Medical Credentialing Helps Ensure Patients Receive Highest Level of Care

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By Priyankar Bhattacharya

Today’s payer and provider organizations are increasingly focused on physician credentialing for outcomes such as cost savings, quicker turnaround time and improved accuracy. It originated in the 1960s with the Darling v. Charleston Community Memorial Hospital case, which established the obligation of hospitals to verify their physician and other provider competencies. This landmark ruling led to the creation of credentialing as hospitals and other organizations sought to protect themselves from lawsuits.

Credentialing in Today’s Healthcare Market

Credentialing is commonly defined as the process of examining, reviewing, and verifying that a candidate’s professional licenses or certifications, education, and experience are in order and related criteria are met. It is also used with medical groups’ closed panels to determine the eligibility of a prospective provider. While credentialing appears a straightforward process, it can actually be a difficult and often confusing practice, since many healthcare practitioners require different types of education and certifications.

The act of credentialing exists along with other administrative actions that occur once a physician or clinical practitioner completes his or her education and clinical training. Newly graduated and trained practitioners are often in contact with recruiterswho  initiate the administrative process by guiding them through the contracting, credentialing, privileging and provider enrollment process. This ultimately results in a thoroughly vetted clinician who is approved to deliver clinical care and who can be reimbursed by insurance payers for the associated clinical services.

A Critical Component to Delivering Care

In today’s litigious society, even the smallest medical misstep can cost hundreds of thousands in legal and medical costs. Healthcare organizations are increasingly targets of lawsuits, especially when the problems are the result of failure to fully verify the professional credentials of the practitioners. For smaller practices, this is an especially difficult position, as staffing, time, and other limitations can increase the chances of failing to perform a thorough check of a new associate’s background.

It might seem like credentialing is just a paperwork task, mundane and not as important as patient care; however, it’s an essential task that cannot be taken lightly. It not only protects an organization from potential lawsuits; it’s also a way to ensure practitioners are qualified to do their job. It’s a safeguard put in place to protect patients by providing qualified, high-quality providers.

Credentialing is not to be confused with “network contracting” or “enrollment,” although it is necessary for insurance companies to also verify professional credentials before adding a new physician to the organization’s or group’s coverage. Many provider networks use the services of Council for Affordable Quality Healthcare (CAQH) to acquire credentialing data from a centralized location and therefore, require that their participating providers have a complete updated profile on file. Hospitals and managed care organizations, as well as individual practices and healthcare staffing companies, must perform strict credentialing due to the possibility of a malpractice lawsuit against a staff member or hiring organization.

Addressing the Pain Points

Credentialing can bring new challenges associated with the people, process and technology and create an administrative burden for health systems. Some of the industry-level bottlenecks that are associated with credentialing are:

  • Low Portability: Lower portability (or, interoperability of data among existing silos) affecting the process workflow and data management tasks in credentialing—translating to less traffic and lag time while seeking response
  • Manual Process: A paper-based and manual credentialing process affects the speed and efficiency of credentialing
  • Data Management:  Inefficient management of data storage, data segmentation, and data security for better credentialing
  • High Error Ratio: High error ratio in the credentialing process due to manual and paper-based systems
  • Noncompliance: Inability to maintain National Committee for Quality Assurance (NCQA) compliance for seamless and secure credentialing process
  • Credential Expiration: Inability to manage and control healthcare credentialing process without proper reminders

By working with a partner, providers can engineer credentialing tracking software to address many of these pain points.

With a dedicated credentialing focus, organizations can ensure that patients receive the highest level of care from professionals who have undergone the most stringent scrutiny regarding their ability to practice medicine. Providers can rest assure that colleagues are being held to consistent standards, with the right priority in place: the quality of patient care.

About Priyankar Bhattacharya

Priyankar is a Senior Manager of Provider Network Operations at HGS Healthcare. He has more than 13 years of U.S. healthcare experience spanning policy management, claim adjudication, network operations and procurement, pre-authorization, and customer service operations. He has worked for major U.S. and middle east global healthcare payers. 

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