4 tips to prevent a credentialing crisis

From small private practices to large health systems, healthcare organizations must navigate the constantly evolving requirements and regulations surrounding provider credentialing, payer enrollment and privileging. These functions are necessary to run a profitable practice and deliver quality patient care. However, credentialing can be a complex, tedious and time-consuming process, especially when handled manually.

For more than 30 years, Microsoft Excel has been the standard for credentialing. Document acquisitions, verifications and payer enrollment applications are completed by hand, all progress is tracked in a spreadsheet and re-credentialing deadlines are set as calendar alerts in Outlook.

While some continue to maintain a competent system using this old-school method, it can be a struggle for independent primary care practices with limited administrative resources. In my work with healthcare organizations across the country, I’ve encountered several common scenarios that can trigger a credentialing crisis and leave practices overwhelmed, including:

• The long-term credentialing expert has left. The practice now lacks experienced staff who can handle the complex credentialing process. The practice is left without the ability to conduct ongoing or new credentialing, which can lead to delays, cash flow issues and noncompliance risks.

• The practice is expanding. Organizations with an aggressive growth strategy, such as those taking over or merging with other practice groups, suddenly may find they lack the resources to support the greater number of practitioners who need to be credentialed.  

• Physicians are entering private practice for the first time. When doctors start their own practices, credentialing can quickly become a burden as they try to balance all the other requirements needed to run a business successfully.

Instead, practices can take the following four steps to streamline and safeguard the credentialing process. These steps also allow practices to stay on top of their current credentialing needs and increase their capacity for future organizational growth.

1. Leverage technology to alleviate administrative burden

Unlike a large hospital system that typically has the resources to staff an entire administrative department, an independent practice may rely on a small team - or even just one administrator - to piece together the entire credentialing puzzle.

A practice administrator also may juggle a number of other duties, including front-end office management and back-end functions such as human resources and billing. Even if the administrator is highly efficient, there may not be enough time in the workday to actually execute all those tasks.

By replacing spreadsheets and email alerts with automated credentialing software, administrators can complete each step of the credentialing process quickly and turn their focus back to other critical tasks. And if an administrator leaves the practice, it will be much easier to train a new staff member into the credentialing role since much of the heavy lifting is automated.

2. Organize all documents in a centralized system

One major challenge across all healthcare organizations is keeping track of the necessary credentialing paperwork pertinent to each physician. More than 500 data points must be collected for a typical physician to complete the credentialing process, including licensure, completion of residency, board certifications, work history and continuing education.

If any of this documentation is missing, it can cause major delays in moving forward with payer enrollments and may even put annual or semiannual audits at risk.

This is why it is crucial for practices to have one system that can store and track all required documentation and reference links. Credentialing software removes the burden of organizing this paperwork by eliminating most of the actual hard copies and creating electronic versions that are automatically filed, securely stored and easily accessible.

Administrators can quickly pinpoint any items that are missing or expiring soon. This level of organization also ensures audits from accrediting bodies are painless and successful, since they can go directly to any document that needs inspection, rather than sifting through thousands of physical files.  

3. Automate payer enrollment to save time and frustration

Insurance payer applications are often the longest step of the credentialing process and are a major source of frustration for most practices. More than 5,000 payers operate in the United States, and each one has different requirements that can change from year to year.

Once an application is submitted, it can take anywhere from four to seven months for it to be processed and may require additional follow up. Applications must, therefore, be submitted quickly and with 100 percent accuracy. Any missing information could result in a rejection, causing further delays.

Choose a software solution that allows for universal population of enrollment forms. With this capability, the system can fill out and submit application after application for multiple practitioners - much faster and more accurately than the practice could handle manually. Once applications are submitted, their statuses can be tracked from within the system, which eliminates the need for time-consuming follow-up phone calls.

For growing practices, automating payer enrollment applications results in faster application submittal times. The faster practitioners can get enrolled with payers, the sooner they can see patients and be reimbursed for their services.

4. Consider outsourcing to a trusted specialist

Small, independent primary care practices may benefit from outsourcing all credentialing responsibilities to an experienced third party. A credentialing management partner can be more cost-effective than hiring an in-house team and can bring many more resources to the table.

For instance, I worked with an independent practitioner based in New York who had just branched out into private practice. She was not very well versed in credentialing, and more importantly, just didn’t have enough time to dedicate to it. The practitioner outsourced all credentialing responsibilities so she could focus her efforts on marketing, logistics and obtaining quality providers to build her new practice.

The practitioner was able to get all providers credentialed and enrolled with payers so they could begin seeing patients immediately and build a solid revenue cycle foundation.

Whether you are a brand new practice tackling credentialing for the first time, a growing facility that needs the capacity to expand or an established organization simply looking to master the process, credentialing technology can help you get it done fast and done right, helping you avoid a potential credentialing crisis and set your practice up for success.

Ted Gottis is senior vice president for MedTrainer, a provider of software and services for streamlined physician credentialing and compliance.