Credentialing issues in healthcare can create serious problems for health systems. If you’ve ever encountered a delay in treatment, chances are provider credentialing was to blame. Before a newly hired or contracted healthcare provider can give patient care, they must undergo a thorough vetting process to ensure they are qualified.

This process can take weeks or even months to complete and is often riddled with errors and inefficiencies that cause frustrating holdups in care. This guide will discuss common credentialing issues in healthcare and how to resolve them for smoother operations and improved patient care.

Azulity’s provider credentialing services can help you achieve these goals. Our innovative solution streamlines provider verification to eliminate delays and create a more efficient workflow.

Importance of Credentialing in Healthcare

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How Credentialing in Healthcare Saves Lives

Credentialing in healthcare is essential for patient safety. Hospitals evaluate healthcare professionals’ credentials to identify any past or current issues that may make them a risk to patient safety. This process helps verify education, licensure, work history, references, malpractice claims, and disciplinary action history. By thoroughly assessing these aspects, hospitals can minimize the risk of incompetent or unethical practitioners, reducing potential patient harm and protecting the organization’s reputation. 

How Credentialing Builds Trust and Confidence 

Verifying the qualifications of hospitals and healthcare agencies assures patients of healthcare professionals’ merit and experience. This allows them to place their trust in their chosen providers. 

How Credentialing Prevents Revenue Loss 

Credentialing can help prevent medical practices from losing money in lost revenue from delayed or denied reimbursements. To clarify, paying attention to receiving proper credentialing can result in insurance payers failing to reimburse medical practices for their treatments. 

How Credentialing Lowers the Risk of Medical Errors 

It is estimated that about 98,000 Americans die from medical mistakes every year. This alarming number forces industry leaders to push for better standards of exposure and competency to disciplinary measures against healthcare professionals. Credentialing for healthcare facilities and independent practitioners lowers the risk of medical errors. 

How Credentialing Protects You from Lawsuits 

Having an accurate and complete record of every practitioner’s credentials will be helpful in litigation. For example, you can save yourself if there is a negligence claim against a healthcare professional in your institution. In short, you can save your facility from a lawsuit by confirming that you verified all of their credentials as required. 

How Credentialing with Insurance Networks Works 

The process takes patience and time. First, you have to decide to proceed. Second, you must shortlist the insurance companies you want to work with. Finally, it’s time to take the first step. Knowing that the credentialing procedure may take a few months is crucial.

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10 Common Credentialing Issues in Healthcare

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1. The Challenge of Finding Qualified Credentialing Staff

Healthcare credentialing is one of the most labor-intensive processes in healthcare and relies heavily on qualified personnel. The problem is that finding, training, and retaining credentialing specialists in today’s hyper-competitive employment environment is becoming increasingly challenging. Credentialing is the backbone of the revenue cycle, and any organization’s ability to remain efficient, productive, and accurate depends on qualified personnel to get the job done.

As credentialing processes grow more complex, specialists must navigate many systems, tools, and methods, which takes significant time and energy. Nowadays, many healthcare organizations are looking for knowledgeable and skilled specialists who can understand the complexities of credentialing and ensure the accuracy of all the details and information provided. 

Solution

2. Too Much Data

The amount and variety of data required in the credentialing process are staggering. Over the past decade, many insurance providers, government regulators, and non-government organizations have engaged with healthcare organizations, adding to the volume of data collected and retained in the credentialing process. Nowadays, a significant challenge for healthcare professionals is collecting, assessing, and maintaining this massive volume of data.

Organizations that manually process their data can have up to an 85% error rate due to human errors and oversights. Simple things such as dates, names, and locations can be incorrect or missing, leading to significant delays in processing and achieving accreditation, insurance provisioning, and payments. The right tools and team to tackle this simple but complex issue is essential to an organization’s credentialing success.

Solution

3. Missing Deadlines 

More often than not, credentialing obstructs a healthcare company’s revenue cycle due to its lengthy and labor-intensive process. For most companies, processing an application review can take up to 90 days. However, because the credentialing process involves many stakeholders — like insurance companies, healthcare providers, and contract negotiators — the process can take at least 6 months. This extensive process is drawn out even more when credentialing is done manually, as it is more prone to mistakes, which can further hamper the efficiency and productivity of the healthcare organization. 

Solution

4. Stuck on Outdated Platforms 

As your business grows, so do your credentialing processes. Many companies work with various providers, each with its own credentialing requirements. When these requirements become more complex and elaborate, organizations may need to build and add to their technology stacks or switch technology platforms completely. 

The problem is that if a company has a lot of content on its existing platforms, such as preset questions and prompts, migration, and change can become impractical and complicated — especially if the content is not standard-compliant. Because of this, many healthcare companies can get stuck with an outdated platform that inhibits the efficiency of their credentialing processes. 

Solution

5. Compliance Issues 

Provider credentialing standards, requirements, and policy guidelines vary in every state and every organization. This makes the credentialing process more difficult due to the diverse compliance issues. If your credentialing process cannot keep up with the ever-changing regulations and requirements as they occur in real time, you become more susceptible to fines and penalties. Your organization must regularly review and communicate with the various databases, such as the National Practitioner Database, to ensure that your information, guidelines, and processes are secure and up-to-date. 

Solution

6. Privacy and Security 

Background checks, along with eligibility checks, are among the most critical aspects of the credentialing process. Running background checks guarantees that each candidate abides by the national licensing requirements. Organizations must ensure that all information regarding prospective candidates and applicants is private, confidential, and secure. The organization can be subject to hefty fines and sanctions if information is leaked. Background investigation companies can simplify the process by tightly integrating your tools and methods. 

Solution

7. Overly Complicated Toolsets 

As with any complex process or workflow, multiple tools are involved in credentialing. Credentialing specialists typically need to bounce between various tools to manage their email and other communication channels with their providers. However, using too many platforms and tools can result in miscommunication and delays due to confusion on the specialist’s end. It is essential to try to reduce the number of tools and platforms used during the process to lessen the complexity and error margins of the team. Keeping your specialist on a single screen and central platform is critical to credentialing success, productivity, and efficiency. 

Solution

8. Convoluted Processes 

Tools and processes go hand in hand. When looking at the credentialing process, multiple steps and tasks must be completed simultaneously to achieve an efficient outcome as soon as possible. To achieve maximum productivity, you must streamline your processes and leverage the appropriate tools to ensure nothing is missed and every detail is captured. Missing the most minor information and details can cause significant delays when getting the provider credentialed and ultimately cause compensation fees. 

Solution 

9. It’s All In The Details

Credentialing requires significant personal data and information about a candidate’s background experience and professional credentials. All of this data is very specific and must be correct every time. To obtain credentials efficiently and timely, a specialist must have all the tools necessary to achieve accurate and particular results. A missing birth date or an incorrect date on any credentialing document can lead to significant delays in the production process. Although the traditional credentialing process can take 60 to 120 days, having the right information, tools, and resources can dramatically reduce this timeframe. 

Solution

10. The Right Partners 

Efficient credentialing is not only about getting good tools but also about having great people and solid processes. Finding the right partner is a critical step in credentialing success. Good partners can help you solve many problems and complexities healthcare agencies encounter during credentialing. A great partner will provide you with the right technology, tools, and industry insight to help you achieve success. Not only that, but the right partner will be able to understand your organization’s unique challenges and needs to focus on improving your organization’s efficiency and productivity. 

Solution

How Does Azulity Help With Hospital Credentialing Requirements? 

Azulity specializes in healthcare master data management and provider credentialing services, bringing proven expertise in implementing healthcare data solutions and credentialing across the US. Our comprehensive platform ensures consistent patient, provider, location, and claims data synchronization across all systems and departments.

Key features include healthcare MDM, provider MDM, reference data management, credentialing, and provider enrollment. We serve healthcare technology leaders – from CIOs and CDOs to VPs of data platforms and credentialing – helping them eliminate the costly problems of fragmented data systems. Book a call to learn more about our healthcare master data management services today!

13 Useful Tips for Efficient Credentialing in Healthcare

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1. Streamline Credentialing with Azulity’s Data Platform 

Azulity specializes in healthcare master data management and provider credentialing services, bringing proven expertise in implementing healthcare data solutions and credentialing across the US. Their comprehensive platform ensures consistent patient, provider, location, and claims data synchronization across all systems and departments. 

Key features include healthcare MDM, provider MDM, reference data management, credentialing, and provider enrollment. Azulity serves healthcare technology leaders, from CIOs and CDOs to VPs of data platforms and credentialing, helping them eliminate the costly problems of fragmented data systems. Book a call to learn more about Azulity’s healthcare master data management services today!

2. Start the Licensing Process Early 

For new practitioners, starting the licensing process as soon as possible is critical for a flawless transition from educational programs to practicing. Different licensing processes apply to other providers, and each can take a different time to complete. For example, PAs (Physician’s Assistants) must obtain certification from the National Commission on Certificate of Physician’s Assistants. This certification process can involve several steps, including verifying education and citizenship, and may require peer references. 

3. Keep All Physician Contact Information Up to Date 

Something as simple as a wrong address for a provider or peer reference can cause problems with medical credentialing. Therefore, ensure that all contact information for physicians or other providers is updated periodically. If clear lines of communication are not available for any given provider, this can slow down processes when a provider’s credentials are up for question by a payer. 

4. Outsource Medical Credentialing Services 

Medical credentialing can be a time-consuming process. Additionally, slight missteps in the process lead to frustrating issues later. Therefore, working with a medical credentialing service provider like PrognoCIS may be one of the best credentialing tips you can follow. When you outsource provider credentialing with a service like PrognoCIS, a medical credentialing specialist assesses credentials on file for providers within the organization and ensures everything is recorded as it should be. 

5. Know Your State’s Regulations 

State regulations for medical professionals can vary in terms of credentialing. This is especially important if your organization has providers transitioning from one state to another to provide services. If credentials for that specific state are not updated, this can lead to problems once claims are filed to receive payments from payers for services rendered. 

6. Track Credentialing Applications 

Once credentialing applications are submitted to an insurance company or organization, be sure to track the progress of that application. Don’t hesitate to check in with an insurance company to find out where an application is in the acceptance process. It is not uncommon for payers to set aside applications that are missing information and delay alerting providers promptly. 

7. Avoid Common Errors 

As simple as it sounds, an essential medical credentialing best practice tip is to be mindful of common errors. Standard errors are most likely to disrupt the credentialing process with a provider. Physician’s Practice states that as many as 85 percent of credentialing applications are missing must-have information the payer has to have to process the application. This can include a lack of peer reference contacts or contact information for those contacts, improperly filled-out credential forms or missing information, submitting an expired NPI or DEA number, missing gaps in malpractice history, lack of clinical history documentation, and data entry typos or mistakes. 

8. Keep Digital Files 

Hard copies of credentialing files are important, but keeping at least one digital file where all credentialing documents can be stored is just as vital. This is an essential medical credentialing best practice to remember because it can save time later. When a payer requests credentials, you will have one transparent file where everything is digitally available. Be sure to include diplomas, state licenses, DEA documents, passports, driver’s licenses, and anything else used for credentialing experience or identity. 

9. Obtain a Dedicated DEA Number 

DEA (Drug Enforcement Administration) numbers are mandated for providers to prescribe medication. Providers typically need a number for each state where they intend to provide services, but requirements vary. It can take several weeks for applications for DEA numbers to be processed after applying through the DEA website. 

10. Get an NPI Number 

National Provider Identifiers (NPIs) are assigned to care providers, but the provider must also keep NPI information current. If a provider has an NPI or their information is accurate, this is a common reason for the claim to be denied by payers. Therefore, any time a practitioner’s status changes, the National Plan and Provider Enumeration System (NPPES) must be updated through the NPPES website. 

11. Request Procedure Logs & Clinical History 

Clinical history is a common requirement for proof of work history in healthcare. To prove clinical history for any provider, request procedure or activity logs and keep them on file. Whichever department is responsible for billing for a provider’s services can usually offer an activity log that can be used for clinical history documentation. 

12. Examine Malpractice Claims 

An extensive record of previous claims filed, records of insurers, and policy numbers for malpractice insurance should be kept on file with credentialing information. Make sure new providers have a certificate of insurance on file as well. 

13. Track Progress Using Advanced Software for Monitoring 

A provider’s credential file can involve licenses, numeric identifiers, and forms of identification that face expiration dates. If these documents expire without notice, this can generate problems with credentialing. Be sure to track expiration dates on each provider’s credentials in the organization. This ensures that documents soon to be out of date are updated promptly without disruptions. 

How Has Credentialing Affected US Healthcare

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Credentialing: The Unsung Hero of Patient Safety and Care Quality

Credentialing has a direct impact on patient safety and healthcare quality. This process verifies that healthcare providers meet specific education, training, and licensure standards. Crediting that practitioners are qualified minimizes the chance that unqualified or fraudulent providers will deliver care. For example, hospitals use credentialing to confirm that surgeons have the necessary qualifications and certifications. This reduces errors during surgeries and improves patient outcomes.  

Credentialing Number One Defense Against Regulatory Compliance Issues

Credentialing helps healthcare organizations comply with state, federal, and industry-specific regulations. These include requirements outlined by Medicare, Medicaid, and accreditation bodies like The Joint Commission. For example, credentialing is a requirement for hospitals to maintain accreditation. This enables them to continue operating and accessing government funding.  

Credentialing Reduces Delays in Insurance Reimbursements

Credentialing is essential for healthcare providers to be reimbursed by insurance companies. Providers who are not credentialed cannot bill insurance for services, leading to revenue loss. For example, a newly hired physician must be credentialed with insurers to ensure their services are reimbursed, supporting the healthcare facility’s revenue cycle.   

The Administrative Burden of Credentialing

Credentialing is a labor-intensive process involving extensive data verification, compliance with diverse regulations, and communication with multiple stakeholders. This has contributed to rising administrative costs in healthcare. For example, hospitals and clinics dedicate significant resources to credentialing departments or outsource the process to third-party specialists to manage the workload effectively.  

Credentialing Standards Help Organizations Deliver Consistent Care

Credentialing helps standardize qualifications for healthcare providers, fostering consistency in care delivery. The credentialing processes verify that all providers meet the same educational and professional standards, regardless of their state or organization, promoting uniformity in patient care.  

Delays in Provider Onboarding

Lengthy credentialing timelines can delay the onboarding of healthcare providers, impacting patient access to care and revenue generation. For example, a rural clinic might need more time to offer specialty care due to the prolonged credentialing of a new specialist, exacerbating provider shortages.  

Increased Focus on Data Security

Credentialing processes require handling sensitive personal and professional information, driving the need for robust data protection measures. Organizations must comply with HIPAA regulations during credentialing to protect providers’ and patients’ confidential information.  

Encouragement of Professional Development

Credentialing often requires healthcare providers to maintain certifications and participate in continuing medical education, fostering a culture of lifelong learning. For example, nurses and physicians regularly renew certifications as part of credentialing, ensuring they stay updated with field advancements.  

Reduced Legal Risks

Credentialing protects healthcare organizations from malpractice lawsuits by ensuring providers are qualified and meet regulatory standards. Verifying a provider’s malpractice history during credentialing helps organizations avoid hiring high-risk practitioners.  

Facilitated Collaboration and Credential Sharing

Credentialing platforms have started facilitating data sharing across organizations, improving efficiency and enabling easier collaboration. For example, credentialing networks allow multiple hospitals to access physicians’ credentials, reducing duplication and speeding up the hiring process.

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Book a Call to Learn More About Our Provider Credentialing Services

Credentialing in healthcare is like a double-check on a provider’s qualifications, and it helps ensure that patients receive care from someone qualified to provide it. Credentialing helps verify that a provider has the proper training, experience, and licensure to deliver safe and effective patient care. While this process is vital to patient safety, it has challenges. Many healthcare organizations need more efficient systems for managing credentialing processes and data. These systems often result in fragmented data that lead to costly errors, delays, and gaps in patient care. Some of the most common credentialing issues in healthcare include:  

Data inaccuracies

When credentialing processes are manual or rely on outdated technology, the chances of making mistakes increase dramatically. Data inaccuracies can cause significant problems for healthcare organizations, including delayed patient care and revenue loss. For example, if a provider’s database records are wrong, patients may be unable to access the care they need promptly, or worse, the wrong provider may treat them.  

Delays

The average time to complete the credentialing process is about 120 days. Unfortunately, such timelines can vary greatly, with some processes taking as long as a year to complete. Lengthy delays can have serious repercussions for both providers and patient care. For instance, new hires may only be able to see patients once their credentialing processes are complete. In the meantime, patients may suffer from gaps in care.  

Repetitive tasks

Credentialing processes often involve a lot of paperwork, leading to duplicative tasks and unnecessary repetition. For example, when a provider moves to a new facility, they typically undergo the credentialing process all over again, even if their records are intact. This is because the new facility may need access to their previous records, and even if they do, compliance issues may necessitate a complete review of the provider’s credentials.  

Poor communication

Credentialing processes can involve many different stakeholders, from the providers themselves to department managers, members of the medical staff, and the governing board. Poor communication among these parties can lead to confusion, delays, and mistakes.

What Are the Consequences of Credentialing Issues?  

Credentialing issues in healthcare can seriously impact patient care and organizational revenue. Errors and delays in the credentialing process can lead to inaccurate provider records and gaps in patient care. Patients may need timely access to the right provider, which can worsen health outcomes. Furthermore, credentialing errors can affect a healthcare organization’s bottom line. 

For instance, if a provider needs to be appropriately credentialed before seeing patients, their claims may be denied, resulting in revenue loss for the organization. In addition, the longer a facility takes to credential a provider, the greater the chances that the organization will suffer some sort of financial penalty. For example, claims may be denied if a provider has not been adequately credentialed before an audit. Moreover, if a provider needs to be appropriately credentialed before seeing patients, their claims may be denied, resulting in revenue loss for the organization. 

In addition, the longer a facility takes to credential a provider, the greater the chances that the organization will suffer some sort of financial penalty. For example, claims may be denied if a provider has not been adequately credentialed before an audit. Furthermore, if a provider needs to be appropriately credentialed before seeing patients, their claims may be denied, resulting in revenue loss for the organization. In addition, the longer a facility takes to credential a provider, the greater the chances that the organization will suffer some sort of financial penalty. For example, claims may be denied if a provider has not been adequately credentialed before an audit.

How Does Azulity Help With Hospital Credentialing Requirements? 

Azulity specializes in healthcare master data management and provider credentialing services, bringing proven expertise in implementing healthcare data solutions and credentialing across the US. We serve healthcare technology leaders – from CIOs and CDOs to VPs of data platforms and credentialing – helping them eliminate the costly problems of fragmented data systems. Book a call to learn more about our healthcare master data management services today!

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