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5 Proven Tips to Improve Provider Credentialing

Posted by Matthew Smith on Aug 15, 2014 9:11:00 AM

Credentialing, Provider Credentialing, Outsourced Managed CareProvider credentialing is often thought of as a routine business office task. Everyone assumes it will get done but only a few people actually know how it happens. However, as hospitals and health systems employ more physicians, they are paying more attention to the function.

The concept of provider credentialing is relatively straightforward. A healthcare organization sends information about a physician’s or provider’s qualifications—work history, education, certifications, licensure, and so on—to a payer for review and verification. After thoroughly vetting the information, the payer confirms the provider and begins reimbursing him or her for services rendered. Every two years, the process repeats.

Note that credentialing is different from the more nuanced process of privileging, where an organization assesses physician competency and authorizes practitioners to provide specific services to patients. The focus of this article is on the physician credentialing effort.

Simple in Theory, Challenging in Practice

Executing a consistent and reliable credentialing program is not always easy. “The volume and variety of information payers need make this a detail-heavy job that can easily go off track,” says Beth Tanner, accountant at Cameron Memorial Community Hospital. “For example, Payer A may require original documentation and the physician’s signature in black pen, while Payer B may need slightly different documentation and no physician signature. If you send the wrong thing to a payer, they don’t automatically let you know. If you don’t follow up, you could be in a situation where the provider is ready to start and the payer has cancelled his application because of a missed detail.”

In many cases, healthcare organizations do not allocate full-time resources to the credentialing effort and, as a result, an already busy staff person is tasked with managing the process amidst other priorities.

If the person hiring a physician forgets to communicate with the person in charge of credentialing, it can further delay the already time-consuming task. “Credentialing can take between 30 and 120 days depending on the provider and payer,” says Tanner. “If you don’t find out about a physician starting until a few days before his or her first day, you already are behind the eight ball and you will be late.”

The Consequences of a Poor Process

In addition to the malpractice and regulatory risks, a weak credentialing effort can have serious financial ramifications for a hospital or physician practice that employs physicians. “If a physician is not credentialed before he or she starts to see patients, then the physician may not be reimbursed by the payer for his or her services depending on the patient’s out-of-network benefit,” says Sabrina Burnett, vice president of Health Directions, LLC. “If the physician has already started receiving a salary from the hospital, then the organization is paying money out without taking any in.”

There are also potential patient satisfaction impacts. “If a provider sees a patient before being credentialed, the patient may receive an estimate of benefits from the payer indicating the patient went to an out-of-network provider and needs to pay a higher copay, deductible, or the entire bill,” continues Burnett. “This can cause patient dissatisfaction and may even affect an individual’s decision to stay with a provider long term.”

5 Strategies for Improving Credentialing

While credentialing has many moving parts, there are a few key strategies for systemizing the process and supporting better accuracy and efficiency.

1. Develop policies and procedures. These should address the who, what, when, and where of commercial and government payer credentialing. For example, a policy should describe how staff obtain accurate credentialing information.

“Organizations may want to require providers to maintain a current profile in the not-for-profit Councils for Affordable Quality Healthcare (CAQH) database,” says Tanner. “This database houses most of the information needed for credentialing. If a physician keeps his or her profile up to date, then the credentialing department can access information from one central location, limiting the need to hunt down items from various sources.”

Organizations also should outline the credentialing steps for commercial versus government payers. Medicare has described its process on its website.

“Enrolling providers in Medicare and Medicaid is usually a little easier than the commercial credentialing process, but there are some unique nuances that providers should fully understand,” comments Tanner.

It can also be useful to outline payer follow-up times, says Burnett. “For instance, you may want to state that for all commercial payers, you will follow up at 30 days and then every 15 days after that.”

2. Create a centralized credentialing function. For organizations that hire a large number of physicians and/or have multiple sites, it can be beneficial to centralize the credentialing process.

“Having one department focusing on credentialing helps with efficiency and eliminates duplication of work,” says Burnett. “It can also enhance provider satisfaction. For instance, if a three-hospital system has separate credentialing departments with different people working on commercial payer and government payer credentialing in each department, then the provider could receive multiple phone calls asking for very similar information. Having a centralized department limits provider contact and prevents frustration. It also gives the provider one source for asking follow-up questions, heading off the possibility of miscommunication or information getting lost.”

3. Allocate sufficient staff. Even if centralizing is not a possibility, organizations should try to dedicate specific staff to the credentialing effort instead of lumping the job with other responsibilities.

“I am a staff accountant and in charge of commercial payer credentialing as one aspect of my job,” says Tanner. “Since we are a small hospital and don’t credential a lot of providers at one time, I have been able to manage the work. However, if we start hiring more physicians this may become difficult. In the ideal situation, you would have people dedicated to this work and some redundancy. It’s not always easy to step into a credentialing professional’s shoes because of all the details, so it is helpful if there is trained back up.”

When looking to hire an individual or individuals to spearhead physician credentialing, look for people who are organized, detailed-oriented, and proactive. “This job requires someone who is comfortable juggling a lot of details and is not afraid to follow up with payers,” says Tanner.

A number of hospitals and health systems choose to outsource credentialing. “Depending on your organization, this could be a good approach,” says Burnett. “You don’t have to recreate the wheel, and it can be seamless with the rest of the business office. An outside firm can also weather fluctuations in physician hiring, allowing you to scale up when the organization is bringing on a lot of new physicians and reduce the effort when hiring slows.”

4. Leverage technology. Some organizations choose to create their own technology tools to facilitate the credentialing process. “I rely on multiple spreadsheets to keep track of effective dates, provider status, and payer requirements,” says Tanner. “By having a cheat sheet for each commercial payer, I can manage the different requirements and make adjustments as things change.”

Others opt to use specific credentialing software. “A solution that is especially designed to support credentialing can trigger action through automated reminders and alerts, ensuring providers don’t fall through the cracks,” comments Burnett. “You can also pull up a provider record and see the status for all payers in one location.”

5. Build relationships with payers. While technology can enable an efficient process, healthcare organizations cannot ignore the human element when it comes to credentialing. “Strong relationships with payers are key,” says Burnett. “That way if there are problems or issues with a provider’s application, you can pick up the phone and resolve them in real time, instead of waiting for a letter or, even worse, receiving no communication at all.”

Good relationships can also allow an organization to be more proactive. “Having a strong rapport has been helpful on many levels,” comments Tanner. “First, the reps give me the heads up when things are changing so I know ahead of time instead of after I send all the information. Second, if we have a situation where we need to expedite approval, they can sometimes move the process along. In particular, if there is a hold up on their end, they can work to get to the bottom of it.”

A Little Work Goes a Long Way

While improving provider credentialing may not be a top priority for every organization, having a streamlined process can ensure timely reimbursement and prevent unnecessary delays that could impact revenue and patient satisfaction. Developing consistent policies, allocating the appropriate resources and technology, and building relationships can help your organization onboard physicians faster and smoother.


Originally published Tuesday, July 22, 2014 by HFMA. Kathleen B. Vega, author.

Topics: credentialing, Provider Credentialing, Managed Care, Outsourced Managed Care

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