Tackling Healthcare Credentialing Challenges

Amanda Marten, MSN, FNP-C
Healthcare credentialing challenges

Providers and healthcare organizations must complete credentialing to bill for medical services. This time-consuming and complex process takes several months but is necessary when onboarding a new provider. Several healthcare credentialing challenges can arise during this process, causing delays in provider onboarding and revenue loss.

Join me as we discuss potential healthcare credentialing challenges, strategies to prevent these problems, and how credentialing software makes the process efficient and effective.

What Is Healthcare Credentialing?

Most healthcare professionals must complete credentialing before starting employment. There are several steps to the credentialing process, two of which are medical and insurance credentialing. Both are vital when billing for patient care services and complying with federal and state regulations and requirements. Although each process is slightly different, both involve thoroughly verifying provider information, including provider background, education, and qualifications. This extensive review requires numerous hours and resources to complete.

Potential Healthcare Credentialing Challenges

Improper credentialing can cause several downstream issues for healthcare providers and organizations. Some potential healthcare credentialing challenges include:

  • Delays and Lost Revenue: Medical and insurance credentialing takes 90 to 120 days. Holdups submitting required documentation will delay the provider’s start date and result in potential revenue loss for the provider and the organization. For example, if a provider has completed medical credentialing but not insurance credentialing, they are not eligible to bill for insurance reimbursement. On average, one physician’s revenue for your organization is ~$2.3M a year, or about $9,000 a day, according to a study by Merritt Hawkins. You’re losing potential revenue for every delay for one provider.
  • Data Integrity Problems: Paperwork errors are significant issues, such as spelling or missing information in required fields. Not validating information through primary source verification is also a quality control issue. If these errors occur, new paperwork is usually necessary. Sometimes, application processing times may reset depending on the organization or insurance carrier.
  • Noncompliance: Providers must maintain specific licenses and certifications to provide patient care services. These include a national provider identification number, state licensure, drug enforcement agency license, and state pharmacy license. Furthermore, new graduate providers obtain these in a specific order, further complicating the process. Noncompliance with federal or state regulations can lead to fines and credentialing issues.
  • Unprotected Private Information: Providers submit personal information during the credentialing process, including their private phone number, address, and Social Security Number. Information leaks or data security breaches can cause massive headaches for providers and healthcare organizations.
  • Inadequate Credentialing Knowledge: Since credentialing is a cumbersome and detail-oriented process, it takes someone well-versed in credentialing to understand the nuances of each provider, organization, and insurance carrier. Having unqualified staff or individuals not specialized in credentialing can pose potential challenges.

Get the tools you need to eliminate delays in your provider enrollment process.

Strategies to Prevent Healthcare Credentialing Challenges

Credentialing issues are pervasive, but there are several steps organizations can take to prevent them. Here are some strategies to I recommend to consider:

Partner with a Credentialing Service

Outsourcing credentialing to a third-party can help organizations save time and money. These services have a wealth of specialized credentialing knowledge and expertise, and their only job is completing credentialing and enrollments.

Hire and Retain Qualified Staff

Whether an organization hires in-house or outside services, having qualified staff is critical. Experienced individuals understand the details and particulars of credentialing. Recruiting and training new staff is time-consuming and expensive. Learning the credentialing process takes several months, so retaining skilled staff is essential to reduce costs. If there are credentialing process updates, staff should be immediately informed and educated on the new process.

Check out 10 attributes to look for in a credentialing specialist.

Use Automated Services

Many credentialing platforms offer automation to streamline processes and prevent data errors. Automated services can verify state and federal licenses and third-party services, like CAQH credentialing, help streamline credentialing since they share provider information with multiple insurance and health networks.

Collaborate with Leadership

Inform executive leadership of credentialing challenges and discuss why qualified staff are crucial to preventing issues. Keeping executive leadership abreast of pertinent information allows them to make well-informed organizational decisions.

Understand State and Federal Regulations

Organizations and providers must understand state and federal laws and regulations. Both should review licensing, insurance billing, and Centers for Medicare and Medicaid Services requirements.

Track and Record Progress

Use tools to track credentialing information and progress. Tools like checklists, logs, and provider enrollment guides help track progress and prevent delays.

Start as Early as Possible

The credentialing process should begin when the provider signs their employment contract. Promptly gather provider information, begin pre-filling applications, and create deadlines. If a provider doesn’t have specific required information, like a state license, consider helping them obtain this. Starting the process early enough reduces the likelihood of delays. Even if there are some delays, it likely won’t push back the provider’s start date.

Quickly Conquer Healthcare Credentialing Challenges

There are many challenges to overcome with healthcare credentialing. But those challenges don’t need to delay a provider’s start date. Credentialing software, such as MedTrainer, offers comprehensive provider profiles, automated license verification and exclusions monitoring, and a proven enrollment workflow.

If you lack resources, MedTrainer Credentialing Services specialists can handle every aspect of your credentialing process, from primary source verification to enrollment.

Learn more about MedTrainer Credentialing in this 3-minute video.