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Credentialing
Compliance
Provider data management is harder than ever. More data is required and there are more hoops to jump through. But, it’s critically important because inaccurate data or poor management is costly — leading to credentialing delays, denied claims, and compliance penalties.
In most cases, poor provider data management is not intentional negligence — it’s a sign of a busy healthcare organization using outdated processes. In a recent MedTrainer poll, 58% of poll respondents said that collecting and managing documents is their biggest challenge. That’s because you have to ask providers for the same document multiple times, there is a lot of tracking involved, and there’s a lot of back and forth with printing or file saving.
Find out why you need to start thinking differently about credentialing.
In this article, I’ll share how healthcare organizations are overcoming bad provider data management practices and the value that technology can bring.
The Risks of Poor Provider Data Management
Failure to maintain accurate provider data puts healthcare organizations at risk for revenue loss and audit deficiencies. Here’s a look at potential risks to your organization:
Revenue Loss
Inaccuracies in a provider’s information, such as an incorrect payer contract effective date, can cause huge issues including denied claims, delayed reimbursements, and the need for write-offs. Since providers see many patients in a day, a data problem is not just for one claim, it’s multiplied across all services.
Regulatory Non-Compliance
Regulatory bodies require organizations to provide accurate and up-to-date records, so when a surveyor asks to find a document that you can’t find, it could lead to regulatory violations, exclusion risks, and potential legal action.
Employing Unqualified or Excluded Providers
Speaking of exclusion risks, employing or having an excluded provider on staff is one of the worst compliance risks a healthcare organization can face. Unqualified providers not only lack the necessary skills to deliver quality care but can also expose your organization to hefty fines and even the loss of accreditation if discovered.
How Bad Provider Data Management Affects Compliance
Accurate provider data management is essential for maintaining compliance with state and federal regulations. Organizations such as CMS, NCQA, and The Joint Commission (TJC) require organizations to prove that all providers have current and verifiable credentials. This means staying updated on expiring licenses and ensuring the organization has a copy that has been verified within a reasonable amount of time from the issue date. Failing to do so can result in audit failures, financial penalties, or even loss of accreditation.
Another compliance risk for healthcare organizations is employing sanctioned or ineligible providers. An organization with bad provider data management may not be checking exclusions regularly, which means that an excluded provider could continue to see patients until the exclusion status is discovered. In addition to the compliance risks, the organization has legal liabilities and will likely lose reimbursements.
Inaccurate provider data management also directly impacts billing and coding, leading to compliance violations and financial losses. When provider credentials, NPI numbers, or payer enrollments are incorrect or outdated, claims submitted to insurers may be flagged as improper billing. This increases the risk of claim denials, delayed reimbursements, and potential fraud investigations.
Revenue Loss from Data Errors
When discussing revenue loss from poor provider data management, it is primarily driven by credentialing issues, billing errors, and enrollment delays. Credentialing-related problems are one of the leading causes of denied insurance claims, as payers require accurate, up-to-date provider information to process reimbursements. When credentialing data is incomplete or incorrect, claims are rejected, resulting in delayed payments and increased administrative work to correct and resubmit claims.
Additionally, billing errors caused by inaccurate provider records lead to inefficiencies and higher administrative costs. Enrollment delays further disrupt revenue cycles, as unprocessed provider applications prevent billing and payment processing.
Without proper enrollment, providers cannot generate revenue, leading to cash flow interruptions. To minimize financial losses, healthcare organizations must ensure accurate credentialing, automate data management, and streamline provider enrollment processes. This can be easier by using an all-in-one healthcare credentialing software, like MedTrainer.
Improving Provider Data Management Accuracy
Many healthcare organizations are turning to technology to improve provider data accuracy. The adoption of new processes and automation can increase efficiency and remove the chance of human error.
Centralize Provider Data
Use software with customizable and comprehensive provider profiles that sync with CAQH to reduce data entry errors and maintain consistency. Having all provider documents saved in the same place makes it easy to verify information. Choose a credentialing system with completion percentages so you can see at-a-glance how much information is missing.
Automated Notifications
Software streamlines credentialing by automating alerts for expired licenses, new exclusions, and document requests. It sends periodic email reminders to providers until all required documents are uploaded, creating a sense of urgency. This improves efficiency and ensures provider data remains up to date.
Surface Missing Data
Ideally, you should have a way to see important certifications and expiring documents in a centralized location. With MedTrainer, for example, color-coded dashboards are there to highlight missing information, saving you and your organization time that would be spent rummaging through paper files or disparate systems.
Harness AI
As artificial intelligence (AI) grows in popularity and capabilities, look for applications that will improve your provider data management. For example, relying on AI to complete forms or enter information based on a verified document will reduce the chance of data entry errors or inaccuracies.
Benefits of Proactive Provider Data Management
Making a change to your provider data management process will take you from reactive (panicking after a claim denial) to proactive (getting an updated license before expiration). It’s driven by real-time visibility that keeps your organization in compliance and reduces revenue disruptions.
Here are some benefits of having a proactive approach when it comes to provider data management:
Faster Provider Onboarding
With software, providers have much better visibility into the healthcare onboarding process. Electronic document requests can be sent to providers upon signed contracts, so you can start collecting documents sooner. If a provider is missing any credentialing documents, for example, they will have consistent alerts to remind them about it, speeding up the process and getting them ready to go.
Reduced Claim Denials
Credentialing-related denials can come in many ways, but when you have reports that identify the most common issues–such as when a provider is out of network or a license is expiring–it can prevent revenue loss before it happens.
Improved Operational Efficiency
The top priority of healthcare organizations should be to deliver quality care, not to spend hours chasing missing documents or building complex PDFs to send for enrollment or privileges. When all your provider data is in one safe location, your whole organization will be less stressed and can focus on what really matters.
Improve Provider Data Management With Credentialing Software
Bad provider data management creates compliance risks and financial losses, which are often far greater than the cost of a solution, such as credentialing software. By updating your processes and implementing technology, you can take a proactive approach that will reap benefits in the long run.
A credentialing platform like MedTrainer includes electronic document requests, comprehensive provider profiles, robust reporting, and more to simplify provider data management. See how MedTrainer could benefit your organization.