How to Avoid Exclusions and Sanctions with Credentialing Software

James Smith
18 Jun, 2023 updated

Healthcare organizations are under financial strain as they face rising costs, labor shortages, and razor-thin margins. That’s why accelerating credentialing and payer enrollment is more important than ever. The faster providers are credentialed, privileged, and enrolled, the sooner they can start delivering patient care, billing for services, and generating revenue.

Provider credentialing and payer enrollment are intricate, lengthy processes in healthcare administration, typically taking 90-180 days from application submission to verification and approval. These processes vary significantly across states and organizations, with each payer network having its own set of rules and documentation, leading to extensive paperwork and potential for errors.

This article examines the impact of these processes on an organization's financial health and introduces solutions like Credsy, which aim to streamline these procedures, reduce administrative load, and enhance accuracy, thereby safeguarding the revenue cycle.

The Financial Impact of Credentialing

Merritt Hawkins reports that physicians contribute significantly to hospital revenues, with interventional cardiologists generating the highest at $3.48 million annually. Physician turnover, exacerbated by burnout largely due to administrative tasks, poses a financial risk to healthcare organizations.

The Association of American Medical Colleges predicts a shortage of up to 124,000 physicians by 2034. Physician vacancies can lead to substantial revenue losses, sometimes amounting to $130,000 per month. A one-day delay in provider onboarding can cost as much as $10,122 — a startling figure that drives home the importance of expediting the process. Delays in provider onboarding are costly, and automated systems are essential to reduce errors and accelerate the process. Payer enrollment delays further compound financial challenges. Maintaining efficient tracking of numerous credentialing and enrollment applications is critical to mitigate these issues and prevent delays in care and revenue loss.

Automating the credentialing and payer enrollment process can mitigate these losses by reducing delays and errors. This is crucial, as nearly two-thirds of physicians report burnout, with administrative overload being a key factor. Efficient onboarding processes are vital to prevent these issues and ensure a positive first impression for providers.

A study by Infinity Business Insights projects significant growth in the Provider Credentialing Software market, expecting it to expand steadily in the coming years. The report, focusing on 2023, analyzes global market trends, size, growth, and cost structures. The market, valued at $1.3 billion in 2021, is anticipated to reach $5.6 billion by 2030, growing at a rate of 14.8% from 2023 to 2030. This growth is driven by the adoption of advanced technologies like AI and machine learning, which are enhancing the efficiency of the credentialing process.

In the provider credentialing software industry, there's a notable shift toward cloud-based solutions. These systems are gaining popularity due to their enhanced accessibility, scalability, and robust data security features. Blockchain technology is also making headway as a disruptive force, offering decentralized and secure verification processes that minimize risks of fraud and unauthorized access. Additionally, the surge in telemedicine and remote healthcare services has spurred the development of credentialing software specifically designed for virtual healthcare providers, addressing the unique challenges of telemedicine.

Demystifying Credentialing Software: 5 Common Myths

  • Myth: Credentialing Software is Only for Large Organizations.

Reality: Credentialing software offers significant benefits to healthcare practices of all sizes. While larger entities may have complex needs that such software efficiently manages, smaller practices also reap the benefits of streamlined processes, enhanced compliance, reduced errors, and overall improvement in the credentialing workflow.

  • Myth: Credentialing Software is Excessively Expensive.

Reality: Considering the long-term benefits, the cost of credentialing software should be viewed as an investment. Advanced software solutions come with a variety of pricing structures, catering to different sizes and budget constraints of healthcare organizations. The efficiency and time savings offered by automating repetitive and error-prone tasks greatly offset the initial investment.

  • Myth: Credentialing Software Fully Automates the Process.

Reality: While credentialing software significantly automates and simplifies many aspects of the credentialing process, such as application management and document tracking, it does not completely replace the need for human oversight. Critical tasks, including the final review, gathering electronic signatures, and decision-making, still require human intervention to ensure accuracy and compliance.

  • Myth: Credentialing Software Eliminates Human Involvement.

Reality: Credentialing software is designed to support and enhance the credentialing process, not replace it entirely. Human intervention remains crucial for several aspects of credentialing, including decision-making, qualification evaluation, conducting interviews, and ensuring adherence to industry regulations and standards.

  • Myth: Credentialing Software is a One-Size-Fits-All Solution.

Reality: Modern credentialing software solutions are highly adaptable and can be tailored to meet the specific needs of various organizations. They offer customizable features to align with the unique processes, requirements, and regulatory environments of different healthcare entities.

How to Choose a Provider Credentialing Software

Selecting the ideal provider credentialing software involves navigating a diverse market with many options. While testing every software is impractical, focusing on key features can guide your decision:

  • Prioritize software that is intuitive and HIPAA-compliant, ensuring ease of use while maintaining strict privacy standards.
  • The software should automate the credentialing process, centralizing tasks such as document handling, request submissions, and tracking.
  • Look for systems that facilitate a paperless workflow, consolidating tasks like signing, uploading, and storing documents in one digital location.
  • Choose software that proactively manages credential expirations, sending timely notifications to both the facility and providers.
  • Ensure the system supports straightforward requests for licenses and documents via email and text, streamlining communication with healthcare providers.
  • The software should allow customization to fit your facility's unique needs, enabling modifications and saving at various stages of application processing.
  • Opt for web-based, cloud, or SaaS solutions for greater flexibility and access to real-time updates, unbound by a single computer.

How Credsy Transforms Credentialing and Revenue Cycle Management

Credsy's credentialing software offers a seamless, efficient solution for healthcare organizations, ensuring quick provider licensing without delays. Our platform eliminates paperwork, handling all aspects of the credentialing process and securely storing data in a cloud-based system. We provide personalized support with a dedicated 24/7 account manager for any inquiries. Credsy not only simplifies credentialing tasks but also enhances Revenue Cycle Management (RCM), reducing denials and maximizing revenue potential. Our comprehensive service, backed by years of industry expertise, ensures compliance with all relevant laws and standards, streamlining operations for your practice.

What is the average time for credentialing and payer enrollment?

The credentialing and payer enrollment process typically takes 90-180 days from application submission to verification and approval. The duration varies due to different standards and requirements across states and organizations.

How does efficient credentialing impact healthcare organizations financially?

Efficient credentialing accelerates the onboarding of providers, enabling them to start delivering care and billing for services sooner. This reduces revenue cycle disruptions and mitigates losses that can arise from delays in the credentialing process.

What technological advancements are shaping the credentialing process in healthcare?

Recent advancements include the integration of AI and machine learning to streamline verification, reduce errors, and improve efficiency. Additionally, the shift to cloud-based solutions offers improved accessibility and data security, making these systems more attractive to healthcare organizations.

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