The ongoing credentialing process, as it stands, often feels redundant and creates friction that disrupts providers' ability to manage claims, billing, and collections efficiently. It's not just costly and time-consuming; it often fails to maintain a consistent record that could enhance data integrity throughout the system.

The process involves numerous interconnected parties—from government agencies and verification sources to health systems. It requires detailed validation of board certifications, comprehensive background checks, verification of educational and work history, and thorough assessment of references. This level of detail demands a significant amount of manual effort. For each practitioner, navigating through their network to process an application can consume more than 24 hours of administrative work. Moreover, any day a provider is unable to serve a patient translates to a potential revenue loss of $7,500 for payers. Payers themselves invest heavily in the credentialing process, utilizing advanced technology, databases, and robust operational frameworks to support enrollment and credentialing activities.

A critical issue is the lack of connectivity between various systems and teams. This disconnection, without a centralized records source, results in cumbersome, repetitive, and costly management of disparate databases. Such challenges not only escalate costs but also compromise data quality, ultimately affecting patient safety.

Faced with these complexities, achieving true efficiency in the credentialing process seems daunting. This article explores how to apply best practices to streamline every re-credentialing cycle, ensuring more effective and less burdensome credentialing.

Credentialing and Recredentialing Compliance and Regulatory Requirements

Hospitals around the United States follow a core structure for credentialing and prioritizing medical staff, as outlined in Title 42 of the Code of Federal Regulations (CFR) under the Public Health Service Act. These guidelines, referred to as Conditions of Participation (CoPs), are critical for hospitals seeking accreditation and the ability to take part in Medicare and Medicaid programs.

Although these restrictions primarily affect the Centers for Medicaid and Medicare Services (CMS), their impact extends to the larger, unregulated healthcare industry. Due to the absence of a legislative obligation to standardize these procedures, the fundamental values of patient safety, risk control, and adherence to accreditation criteria remain globally important.

The regulations, particularly sections 42 CFR 482.22 and 482.12, compel hospitals to set stringent credentialing standards. This involves evaluating candidates according to their character, competence, education, expertise, and judgment, to ensure that only competent persons are awarded medical staff participation and benefits. The procedure includes a comprehensive evaluation of each applicant's credentials, including license, education, expertise, and experience, as well as references confirming to their competency.

Key Elements of an Effective Credentialing Process

Healthcare organizations are responsible for verifying the competency of their medical personnel through the credentialing and privileging processes. These processes were once primarily linked to hospitals but are now vital across various healthcare settings, including private practices and specialty groups. They require detailed scrutiny of a practitioner's educational, training, and licensure background, and are crucial for maintaining high standards of care.

The credentialing journey begins with gathering data directly from the practitioners. Practitioners, whether they are freelancers, permanent employees, or volunteers, are required to present their credentials anytime their services or work location changes. They must also re-credential every two years, which entails re-verifying all of their qualifications via primary source verification. This stage also involves reviewing performance evaluations and peer reviews to maintain ongoing professional standards.

To maintain privacy and accessibility, organizations must retain these credentials on file permanently, securely, and apart from other personnel information. After gathering and verifying credentials, the following step is to conduct a comprehensive assessment to ensure the veracity of the claimed qualifications.

Finally, once all verifications and assessments are finished, the acquired information should be examined by a committee or group of stakeholders, who will make a final determination on whether to approve or decline privileges depending on the practitioner's credentials and performance.

Challenges and Solutions in Continuous Credentialing

Re-credentialing can be a difficult milestone that healthcare practitioners must note on their calendars. Just as initial credentialing, the repeated procedure entails a comprehensive assessment of several papers, including malpractice claim data, licenses, Continuing Medical Education (CME) credits, and training certificates. For individuals negotiating both commercial and government programs, this procedure necessitates a thorough awareness of various due dates and regulations, including those established by CAQH.

Most commercial insurance policies need re-credentialing every two to three years. Providers must keep up with these regulations since they can impact reimbursement rates or contract terms. CMS (Centers for Medicare and Medicaid Services), for example, requires re-credentialing every five years to keep billing rights. Typically, providers are alerted three months in advance of forthcoming revalidation dates. Without timely recredentialing, providers could see their billing rights terminated, resulting in no retroactive reactivation and a potential revenue loss for services given during the period of inactivation.

Components of Re-Credentialing

As we see, re-credentialing is vital to ensure the competency and credentials of their medical staff. Recredentialing is equivalent to credentialing. The process typically includes application submission, often supported by documents like proof of ongoing education and certification, verification of credentials such as state licensure, DEA registration, National Provider Identifier (NPI) numbers, board certifications, and committee evaluation.

This ongoing process involves several key components:

  • State Licensure Validation: This first stage confirms that the practitioner's medical license is current and in good standing, validating their legal right to practice medicine.

  • DEA Certification Validation: This confirms if the practitioner is allowed to administer pharmaceuticals, which is critical for professions requiring drug management.

  • Work History Review: By reviewing a provider's career history, companies may analyze their background and professional development, which adds to their fitness for the post.

  • Malpractice History Analysis: This entails investigating previous malpractice claims or punishments against the practitioner. Understanding this past is critical for assessing risk and maintaining patient safety.

  • Board Certification Check: Maintaining any relevant board certifications demonstrates a provider's continued commitment to fulfilling the professional standards of their expertise.

  • Sanctions and Exclusions Check: This confirms that there are no current sanctions that would prevent the provider from taking part in Medicare, Medicaid, or practicing in the state.

This complex data-collecting and verification procedure can be time-consuming and error-prone if not managed correctly. Regular updates and vigilant management are essential to traverse the complexity of diverse state rules and regulations for various types of healthcare practitioners, including doctors, dentists, and mental health experts.

Best Practices for Implementing Continuous Credentialing

To avoid recredentialing concerns and the associated implications, healthcare institutions should document and save documentation of the application in the practitioner's credentials files. They should also create a method to maintain the (ever-changing) information up to date.

  • Proactively Report Adverse Peer Review Actions

Healthcare providers must record any unfavorable peer review actions, such as the revocation, suspension, or voluntary surrender of clinical privileges, state licenses, DEA licenses, or other affiliations. Proactive reporting not just preserves openness, but it also ensures the healthcare provider's integrity with insurers and regulatory organizations. Failure to report such acts may be viewed as deceptive, potentially leading to serious implications such as contractual violations and strained relationships with suppliers.

  • Start the Recredentialing Process Early

Recredentialing can take just as long as the original credentialing procedure. Starting early is critical. Providers should provide enough time to obtain essential papers, fill out forms, and ensure that all licenses and certificates meet current criteria. Delayed submissions can result in expired credentials, requiring providers to repeat the original credentialing procedure, potentially leading to gaps in service permission and lost revenue.

  • Ensure Complete and Accurate Information

Applications that are incomplete are a typical error in the recredentialing procedure. To avoid delays, fill out all credentialing forms completely and precisely, including all relevant information. Incomplete applications may be rejected by credentialing officials, resulting in prolonged delays. Before submitting any documentation, double-check and examine it several times to guarantee its accuracy and completeness.

  • Stay Updated with Credentialing Standards

Healthcare providers must verify that all practitioners in the practice are registered with the appropriate federal healthcare programs, such as Medicare and Medicaid. Each program has its own registration procedure, and differences or errors might hamper the recredentialing process. Keeping up with modifications to these programs and maintaining compliance with their unique standards is critical for smooth recredentialing.

  • Regularly Update Credentialing Files

Maintain a structured process for updating and evaluating credentialing files. This involves keeping updated with credential deadlines and scheduling reminders to renew. An structured system not only speeds up the recredentialing process, but it also eliminates the overlook of expired credentials, which can result in gaps in eligibility to provide treatment under certain health plans.

Preparing Your Healthcare Operation for the Digital Transition

Dataintelo predicts that the worldwide healthcare credentialing software market would develop at a 9.5% CAGR from 2022 to 2030. This trend indicates that a growing number of healthcare businesses are understanding and leveraging the advantages of cloud-based credentialing software.

Cloud-based medical credentialing software provides several benefits to healthcare operations, but it also adds new obstacles and hazards. Thus, equipping your healthcare organization for the digital age is critical, which may be aided by sticking to the essential best practices:

  • Evaluate Your Existing Credentialing Process

It's critical to evaluate your present credentialing practices to identify strengths and weaknesses. This study will help you set goals and expectations for the digital credentialing process, as well as understand if cloud-based credentialing software may help you reach those goals.

  • Choose a Suitable Software Vendor

Research and evaluate several cloud-based credentialing software companies to find one that meets your individual requirements and preferences. It's also critical to check the vendor's credentials, experience, client feedback, and references.

  • Plan and Test the Implementation

It is critical to devote appropriate time and resources to the execution process. Before going live, the program should be evaluated to ensure that it performs as expected and satisfies your needs.

  • Train Your Staff

Inform and teach your employees how to utilize the program and its different capabilities. It is also critical to keep them informed of any changes or alterations to the credentialing process and rules that may result from the software installation.

  • Monitor Performance

Examine the software's performance regularly, as well as its influence on the credentialing process or outcomes. This includes soliciting input from your employees and stakeholders and carrying out any required changes or enhancements.

Credsy can help you establish cloud-based credentialing software for your healthcare company. We are a leading cloud-based system that expedites medical credentialing in hospitals and medical facilities, with features that may streamline your credentialing procedure, such as:

  • Online application forms
  • Alerts and reminders
  • Electronic forms and e-signatures
  • Secure database management
  • Centralized credentialing

Our team of professionals, who have spent over 10,000 hours on licensure and credentialing, understands the procedure for each state and has successfully completed it thousands of times.

To learn more regarding how we can help you transition, arrange a free appointment with us now. We will answer any questions you may have and give unique answers without any commitments.

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