8 Healthcare Credentialing Challenges and How To Overcome Them

Credentialing is one of those unavoidable tasks that people want to talk about. It’s a necessary but often cumbersome part of running a healthcare organization. With endless paperwork, time-consuming verification processes, and ever-changing regulations, it’s no wonder why so many organizations struggle with the healthcare credentialing challenges of provider credentialing.

This guide will offer valuable insights to address their goals, like allowing healthcare organizations to use innovative data management. Azulity’s solution, provider credentialing services, is designed to make provider credentialing easier and more efficient. By leveraging innovative technology and data management, Azulity can help reduce the burden of credentialing on your organization.

8 Healthcare Credentialing Challenges and How To Overcome Them

man on a laptop - Healthcare Credentialing Challenges

1. Challenges of Obtaining Accurate Provider Information for Credentialing

Keeping up with the latest information during the credentialing process can be challenging. Most medical organizations need help to obtain important applicant information. Over 85% of filed applications are claimed to contain faulty, missing, or inaccurate information. Even slight modifications, such as residence or contact information changes, should be re-attested inside the CAQH system.

Missing or inaccurate info can easily jeopardize the complex and highly time-consuming healthcare credentialing process. The problem becomes much more serious when you consider how often healthcare professionals switch organizations for which they work. To avoid issues during the procedure, healthcare organizations should keep up with the modifications as they happen.

2. The Prolonged Nature of Healthcare Credentialing

The healthcare credentialing procedure is time-consuming. An application will be reviewed in a maximum of 90 days. If other players, such as contract negotiators and health insurers, are involved, the procedure can take up to 6 months. This is a lengthy period, and as a result, most healthcare organizations’ operations are halted.

3. Compliance Concerns During the Credentialing Process

As previously stated, compliance problems are most prominent throughout the credentialing procedure. Providers are required to abide by the laws and guidelines of every state. Furthermore, national organizations such as CAQH follow their own rules that must be met. Which, of course, creates complications.

Healthcare credentialing policies, regulations, and standards differ from state to state. These rules and guidelines are unpredictable and constantly change. A trustworthy credentialing service provider or system is crucial to comply with diverse and evolving laws.

4. The Challenge of Transitioning to New Credentialing Programs

As your medical organization grows and credentialing needs become more complicated, you will also be forced to add connections or switch entirely to a new testing system.

5. The Importance of Safeguarding Provider Personal Information

Background checks are a required step in the credentialing procedure. They must establish whether the candidate has the skills and credentials to provide patient care. The procedure necessitates the submission of important papers such as practice licenses, job records, educational credentials, and so on.

As a result, privacy becomes extremely important. The certification body will require an applicant’s whole background. Failing to provide this key info can result in the physician’s application getting refused. You’ll need a healthcare credentialing solution or system to maintain every piece of this updated data and protect it from watchful eyes. Unfortunately, most firms lack sufficient platforms to protect such essential information.

6. Data Accuracy and Integrity Issues

Maintaining accurate and current credentialing details is paramount but challenging. Most healthcare organizations rely on manual data entry and spreadsheet tracking. Such antiquated systems are prone to errors, such as Missing or outdated documents, leading to compliance gaps. A 2022 survey found that 9% of providers had expired licenses. Inaccurate personal and practice information disrupts directories.

One study showed that 18% of doctor directories needed the correct location or specialty data. Duplication of effort across departments handling provider data. Credentialing teams spend 21% of their time re-verifying details. Lack of audit trails proving due diligence. Inaccurate credentialing data can disrupt patient care. It also poses compliance risks with steep penalties. Fines for HIPAA violations can be over $50,000 per record.

7. Evolving Compliance Standards

Compliance is one of the toughest challenges as standards continually evolve. Key requirements include: NCQA regulations demand complete and current credentials. New 2022 standards require tracking of 10 separate provider details. Timely re-credentialing every 2-3 years. AMA data shows that 60% of providers miss re-credentialing deadlines. HIPAA mandates the protection of personal data.

Breaches increased by 30% from 2020 to 2021—medicare conditions of participation. Violations can lead to exclusion from federal health programs—individual payer requirements. Top insurers have added over 200 new credential fields since 2018. Oversights, like missed re-credentialing deadlines, can occur. Manual tracking of changing policies is burdensome and error-prone. Organizations need automated systems to guarantee compliance readiness.

8. The Need for Specialized Knowledge in Credentialing

Recruiting and retaining qualified credentialing staff is difficult, given the specialization required. Key needs include Meticulous attention to detail and organization. Credentialing has up to 200 checkpoints per provider file. Superb communication skills for corresponding with providers. 72% of providers complain about a lack of communication during credentialing—expertise in compliance protocols and standards.

Only 23% of credentialing applicants have relevant certification or accreditation—a commitment to credentialing. The average tenure of credentialing staff is less than 2 years. Limited relevant training coupled with high turnover hinders many healthcare organizations. With experienced teams, accuracy and compliance improve. Resources must be dedicated to specialist staff recruitment, education, and retention.

13 Tips for Efficient Healthcare Credentialing

1. Use Azulity

Azulity excels in healthcare master data management and provider credentialing services. Their extensive knowledge in executing healthcare data solutions and credentialing across the U.S. eases the burdens of fragmented data systems. Their comprehensive platform consistently synchronizes patient, provider, location, and claims data across all systems and departments.

Key features of Azulity’s platform include healthcare MDM, provider MDM, reference data management, credentialing, and provider enrollment. They serve healthcare technology leaders from CIOs and CDOs to VPs of data platforms and credentialing. 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 smooth 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:

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
Data entry typos or mistakes

8. Keep Digital Files

Hard copies of credentialing files are essential, 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 out of date are updated on time without disruptions.

Basic Process of Healthcare Credentialing

1. Identify the Required Credentials

Understanding and identifying the necessary credentials is crucial in ensuring healthcare professionals meet the qualifications for their roles. This process involves determining the specific education, training, licensure, and other requirements needed to practice in your healthcare organization.

Common qualifications and credentials include

Education: Degrees from accredited medical schools
Training: Completion of residency programs
Licensure: State medical licenses
Board Certifications: Certification in relevant specialties
Work History: Previous employment verification

Ensuring these credentials are accurately identified helps maintain your organization’s high standards of care.

2. Gather Necessary Information

Collect all required documentation and verify the healthcare professional’s work history, licensure, education, and board certifications. Having complete and accurate information is essential for a successful credentialing process in healthcare.

3. Verify Primary Sources

Checking primary sources is crucial for verifying the accuracy and reliability of a healthcare professional’s information during credentialing. It involves obtaining information directly from primary sources such as licensing boards, medical schools, and previous employers.

4. Use a Centralized System

A centralized system for the medical credentialing process ensures all necessary documents are received on time and deadlines are met. It provides a streamlined approach to managing the entire process and allows for efficient communication between all parties involved.

5. Adopting Technology

Incorporating technology can automate parts of the credentialing process, reducing the time required. Electronic verification of licensure and board certifications, for example, can significantly speed up the provider credentialing process steps.

6. Prioritize the Process.

For example, electronic verification of licensure and board certifications

Giving the credentialing process the necessary attention and resources ensures it is not delayed by competing priorities. Prioritizing the process helps it be completed promptly and efficiently.

7. Follow Up Regularly

Regular follow-ups with healthcare providers and relevant parties are crucial for maintaining smooth communication and addressing any issues quickly. This step should be noticed, leading to delays in the credentialing workflow. Additionally, regular check-ins are essential for communication. They help resolve problems quickly and keep the process on track.

For many healthcare organizations, this step is the biggest culprit when it comes to delays. Office workers need to be more relaxed with their tasks. They cannot be responsible for scheduling and conducting regular check-ups like police officers.

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!

Importance of Healthcare Credentialing

Credentialing: Vital to Patient Safety and Quality Care in Healthcare Organizations

Hospital credentialing is crucial for maintaining patient safety and quality care within healthcare organizations. By evaluating healthcare professionals’ credentials, hospitals can ensure that only qualified individuals are granted privileges to practice medicine. Credentialing 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.

Credentialing Increases Trust Among Patients

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

Prevent Losing Revenue with Credentialing

Credentialing can help prevent medical practices from losing revenue due to delayed or denied reimbursements. Neglecting to receive proper credentialing can result in insurance payers failing to reimburse medical practices for their treatments.

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.

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.

Understanding Credentialing: Navigating The Insurance Network Process

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 essential.

Book a Call to Learn More About Our Provider Credentialing Services

Credentialing is essential for healthcare facilities and professionals, as it helps ensure patient safety and care quality. However, the process can be tedious and time-consuming. Healthcare organizations often need help with fragmented credentialing data spread across multiple systems, resulting in slow, manual processes that can lead to costly errors.

Azulity specializes in solving these types of healthcare credentialing challenges precisely. With its robust healthcare master data management (MDM) platform, Azulity helps organizations eliminate the costly problems of fragmented data systems to streamline credentialing processes and boost operational performance.

How Azulity Tackles Provider Credentialing Challenges Head-On

Provider credentialing verifies that medical professionals have the qualifications, training, and experience to deliver safe, effective patient care. The process involves collecting extensive data on providers and cross-referencing that information with multiple databases to ensure accuracy.

This data-driven approach helps organizations avoid hiring individuals with medical errors or malpractice histories.

Azulity’s provider credentialing solutions accelerate this process, reducing dependency on manual approaches that often result in incomplete or inaccurate information. With our platform, healthcare organizations can automate data collection and verification to eliminate human errors and reduce the time it takes to onboard new providers.

How Azulity Improves Healthcare Operations for Better Patient Outcomes

For many healthcare organizations, the primary focus of tackling credentialing challenges is to improve operational performance. Slow, manual credentialing processes create expensive bottlenecks that hinder overall organizational efficiency. By improving the accuracy and speed of provider credentialing, Azulity helps healthcare organizations eliminate costly delays that impact their bottom line and patient care. Ultimately, our solutions help organizations boost their operational performance to focus on what matters most — delivering quality care to patients.