Claims Copilot ™
Stop Chasing Claims.
Start Preventing Problems.

Credentialing issues in healthcare are extremely common. In fact, the process of provider credentialing has to be a prominent compliance issue for medical practices. It is quite normal for providers to have their applications rejected due to omissions and errors. The consequences can be considerably more disastrous without proper data insight and process oversight. 

Table of Contents

• 1. 5 Common Credentialing Issues
  • 1.1. Keeping Information Up-To-Date
  • 1.2. Time-Consuming
  • 1.3. Staying Compliant
  • 1.4. Challenging to Change Credentialing Program
  • 1.5. Ensuring the Privacy of Healthcare Professionals
• 2. Overcoming Issues with Healthcare Credentialing
  • 2.1. Outsource Your Credentialing Task
  • 2.2. Pay Special Attention to Individual State Guidelines
• 3. We recommend verifying your state’s guidelines for:
  • 3.1. Leverage Credentialing System Technology that Automates the Process
• 4. The Bottom Line

Now, mistakes happen in any process. However, the mistakes in credentialing can be especially punishing. For instance, credentialing issues for nurse practitioners can cost a nurse their career. Moreover, mistakes in credentialing can cost healthcare organizations their hard-earned reputation. Suffice to say, no one can afford the legal and financial complications that follow a poorly executed credentialing process. 

In this article, we would like to shine a light on some of the most common challenges with the medical credentialing system. We hope that being aware of these challenges will make you better equipped to tackle them. 

5 Common Credentialing Issues

1. Keeping Information Up-To-Date

Many healthcare organizations struggle to access relevant applicant information. It is estimated that around 85% of submitted applications suffer from inaccurate, missing, or irrelevant information. It is mandatory to re-attest even minor changes like changes to address and phone number in the CAQH database. 

Missing information or outdated details can quickly derail the already complicated and time-consuming credentialing process. The issue becomes even direr when you consider how frequently individual practitioners change the healthcare institutions they work for. Healthcare organizations must keep pace with the changes as they occur to avoid issues during the process. 

2. Time-Consuming

It is no secret that the medical credentialing process is a time-consuming one. An application review can take around 90 days to complete. When you consider the involvement of additional stakeholders like contract negotiators and insurance companies, the process can easily go as long as six months. That is a long time and most healthcare organizations find their operations stalled because of it. 

3. Staying Compliant

As we mentioned before, compliance issues are most prevalent in the credentialing process. Each state has different standards and policy guidelines that a provider needs to adhere to. Additionally, national organizations like CAQH have their own specific requirements that have to be met as well. This, of course, causes frustrating issues. 

Read More: Credentialing Process Checklist You’ll Need in 2022

The rules, regulations, and requirements for medical credentialing vary from state to state. It also doesn’t help that these rules and regulations are volatile and experience frequent changes. It is important to leverage a reliable credentialing service or system to keep up with varying and changing regulations.

4. Challenging to Change Credentialing Program

As your healthcare organization grows and credentialing requirements become inevitably more complex, you will have no choice but to add integrations or switch to a different assessment system entirely. Migrating information in such a scenario, especially when you have a lot of preset prompts and questions that are not standard compliant, can become almost impossible. 

You will have no option but to lose one or two components to make the migration possible. It is precisely because of this reason that many healthcare organizations get stuck with outdated platforms that are not capable of efficiently undertaking the credentialing process. 

5. Ensuring the Privacy of Healthcare Professionals

Background checks are an integral part of the credentialing process. They are essential to determine that the applicant possesses the skills and qualifications required to provide care to patients. The process entails the submission of crucial documents such as practice license, work history, education qualification, etc. 

As such, privacy become of the utmost importance. The credentialing organization will require information about an applicant’s entire history. Not disclosing this important information can result in the practitioner’s application being rejected. You will need a credentialing service or platform that keeps all of this information up-to-date and secure from prying eyes. Sadly, most organizations don’t have adequate platforms to safeguard such valuable information.

Overcoming Issues with Healthcare Credentialing

1. Outsource Your Credentialing Task

When it comes to hiring someone to overtake your credentialing process, there are two options at your disposal. You can try hiring an in-house staff that is dedicated to managing the process from start to finish or opt to outsource the task to third-party specialists like DENmaar. 

Out of the two, outsourcing is evidently a relatively more cost-effective and time-efficient way to handle credentialing. With outsourcing, you get access to credentialing experts and their technology. Moreover, you aren’t saving money by not hiring personnel on salaries. 

2. Pay Special Attention to Individual State Guidelines

It is important to do your homework with regards to what rules, legislations and policies would be applicable to your healthcare organization. As each state has different requirements, you need help of medical credentialing experts that are aware of policies and can help you with seamless and compliant transition. 

We recommend verifying your state’s guidelines for:

• •     Licenses
• •     Education qualifications
• •     Certifications.

3. Leverage Credentialing System Technology that Automates the Process

There are systems and advanced technology available today that can help your business automate the credentialing process to a good degree. We recommend looking for a credentialing platform that can:

• •     Reduce Credentialing Workload Affecting Your Staff
• •     Reduce Training Time for New Staff
• •     Save time to focus on company growth. 

Implementing such technology can be expensive. However, you stand to enjoy greater benefits in the long run with these technologies managing crucial aspects of your credentialing process. 

The Bottom Line

Credentialing is no child’s play. Most healthcare organizations do not have the staff or resources to handle it with the care deserved. Fortunately, you can save yourself a lot of trouble by simply hiring credentialing specialists like DENmaar. 

We understand how frustrating the process can be, and thus offer services dedicated to relieving you of this unwanted burden. We provide a fully automated system that gives you real-time updates of your credentialing application status. Plus, you get automatically notified by our robust system on the imminent expiration of documents, so your practice continues to legally serve patients with insurance. Moreover, we offer medical insurance credentialing services for sole practitioners as well as huge medical organizations.

Medical credentialing is a complex concept to understand. So it is only natural for one to have several questions about it. In this article, we aim to answer some of the most frequently asked questions surrounding the topic, and in the process, help you understand this complicated but fundamental aspect of our medical world even better. 

Table of Contents

• 1. How Exactly Does Medical Credentialing Work?
  • 1.1. What are the Benefits of Medical Credentialing?
  • 1.2. Can a Provider Allowed to Work During the Credentialing Process?
  • 1.3. What Kind of Facilities Need Credentialing?
  • 1.4. What is the NCQA?
  • 1.5. What is TJC?
  • 1.6. What is CMS?
  • 1.7. What Does Primary Source Verification Mean?
  • 1.8. What is the Credentialing Committee?
  • 1.9. How Long Does a Medical Credentialing Process Last?
  • 1.10. How much will Medical Credentialing Cost You?
• 2. What Do I Look for in a Credentialing Service Provider?

So without much further ado, let’s get started. 

  How Exactly Does Medical Credentialing Work?

Medical credentialing is a process undertaken with the main purpose of maintaining high standards of quality expected from the medical industry. The process usually entails the verification of a healthcare provider’s competency with regards to their educational qualifications, work history, certifications, etc. 

A credentialing authority will contact a provider’s university, certification board and licensing agency to verify whether he or she is capable of providing healthcare. Credentialing is considered to be imperative for all types of providers who engage in providing medical assistance to patients. It needs to be conducted at regular intervals to make sure a healthcare organization or provider is complying with regulatory standards and policies set by bodies like the Centers of Medicare and Medicaid Services, The Joint Commission, National Committee for Quality Assurance, etc. 

What are the Benefits of Medical Credentialing?

Medical credentialing has a plethora of benefits in store for all parties involved with the process. Credentialing provides hospital and clinics with the assurance that their hired staff will offer their services at the level of standards expected of them. Insurance companies can keep their costs down by making sure only competent medical professionals pass the credentialing process. 

Practitioners also benefits immensely from credentialing as they can expand their services to more patients with access to different types of health insurance. However, patients stand to benefit the most out of credentialing. They can rest assured on receiving the highest quality of care from the most qualified providers. 

Can a Provider Allowed to Work During the Credentialing Process?

It is recommended for a healthcare provider to halt their services until the entire credentialing process is complete. This guarantees that all patients receive quality care from only those providers who have verified qualification to offer their services. A healthcare organization is putting itself in unnecessary risk by letting non-credentialed individuals work for them.

That being said, there are a few exceptions to the rule. Medical students, for instance, don’t need credentialing as long as their duties to do not cross the scope of their educational program. They typically don’t need to undergo credentialing as they are working under the strict supervision of superior credentialed providers. 

What Kind of Facilities Need Credentialing?

Aside from practitioners, facilities that engage in the act of providing healthcare need credentialing as well. As such, the following services and facilities need to undertake the process to show they comply with the expected standards of care and competence. 

• •     Dialysis
• •     Ambulance
• •     Home Health Services
• •     Hospice Care
• •     Durable Medical Equipment
• •     Independent Diagnostic Testing
• •     IV Home Infusion Therapy
• •     Laboratories
• •     Prosthetics
• •     Orthotics
• •     Lithotripsy
• •     Urgent Care Centers
• •     Radiology

What is the NCQA?

The NCQA, aka The National Commission for Quality Assurance is an independent non-profit organization. Their job is to evaluate the quality of healthcare provided by medical practices and issues credentials based on their findings. The organizations that go to NCQA for credentialing include managed behavioral healthcare organizations, preferred provider organizations, credentials verification organizations, etc.

What is TJC?

The TJC, or the Joint Commission, is an organization tasked with maintaining high standards of healthcare in the United States of America. They conduct surveys that aim to verify the standards of healthcare provided by the hospitals in USA. Organizations like hospitals proactively answer to accrediting surveys hosted by the TJC every three years. 

What is CMS?

The CMS, or The Centers for Medicare and Medicaid Services is a federal agency that serves under the United Stated Department Health and Human Services. It is responsible for performing a number of functions, which include evaluating quality standards of clinical labs and facilities that have been offering care to patients for a long time. The CMS works closely with state governments to administer and monitor Children’s Health Insurance Program, Medicaid, etc. 

What Does Primary Source Verification Mean?

Primary Source Verification basically means that a credentialing authority will directly verify a provider or organization’s credentials from the source of that credential itself. For instance, a CVO will directly contact the university to verify a practitioners education qualifications. This is usually done to avoid fraud. As such, documents from third-party sources are not entertained. 

What is the Credentialing Committee?

Credentialing committee is responsible for overseeing the entire application review process. They have to make sure that the applicants meet the desired set of quality standards. This committee will include doctors with varying specialties, a liaison with the CVO and a chairperson. If you meet the basic requirements of credentialing, you can appeal a committee’s decision. You will receive all the information needed if it is deemed that you have the right to appeal. 

How Long Does a Medical Credentialing Process Last?

The medical credentialing process can be excruciatingly long. It can take anywhere from days to weeks, and sometimes months. Typically, you can expect the credentialing process to take as long as 90 to 120 days. As such, we recommend starting your application process at least 3 months before you begin your duties as a healthcare provider. 

How much will Medical Credentialing Cost You?

The costs for medical credentialing will vary from CVO to CVO, organization to organization and specialty to specialty. Generally speaking, you can expect to pay around three to four hundred dollars for your application fee alone. You can also anticipate partial reimbursements after your credentialing process has been completed successfully. 

You will also incur costs on periodic and re-credentialing as well. However, you can expect to get this done at a discounted rate. 

  What Do I Look for in a Credentialing Service Provider?

Experience and a good reputation are arguably two of the most prominent factors you must consider when looking for a credentialing service provider. Such service providers are usually home to credentialing specialists who possess the resources, insight and experience needed to handle the entire credentialing and re-credentialing process from start to finish in a quick, efficient and hassle-free manner. 

You will find the above qualities demonstrated perfectly by the credentialing specialists’ right here at DENmaar. With years of industry experience, we’ve helped many providers and facilities get credentialed and can do the same for you. 

Reach out to us at 844-727-3627 to learn more about our services.