How to Fix Common Credentialing Gaps That Dry Up Revenue in Physician Practices

Physician practices are facing a tough reality: shrinking margins, rising administrative burden, payer complexity, and workforce burnout. As if that isn’t enough, credentialing processes are being tested by the ongoing acquisitions and mergers of independent practices into hospital systems, MSOs, and private-equity backed groups. If any of this sounds familiar to you, you’re not alone. 

Credentialing is often a pressure point, but the rapid scaling required during growth, consolidation, and staffing changes will break inferior processes. Some of the most common culprits are when organizations expand to become multi-site or even multi-state, a new mix of payers is introduced, and you’re managing more contracts. This increases credentialing complexities and dramatically increases the workload for teams who were likely already spread thin. The kicker is that credentialing staff numbers don’t always grow at the same rate as the organization. If this is the case for your team, you’re likely dealing with greater onboarding demands, but the same workload bandwidth. 

When your credentialing begins to stall, and missing information slips through the cracks, your compliance program and revenue cycle are both put at risk — organizations lose up to $9,000 per day a provider cannot practice, and the compliance risks stemming from credentialing mistakes can set off a cascade of damage across your organization. 

Fixing these common credentialing gaps that many physician practices are facing right now is the key to making sure your revenue cycle is protected. In this blog, I’ll talk through the most common gaps, how a better credentialing process can help close them, and why investing in a better process will return dividends as your organization continues to grow. 

The 4 Most Common Credentialing Gaps That Drain Revenue

1. Manual Primary Source Verification (PSV) and Exclusions

If you’re still logging into multiple state and federal websites, downloading documents, saving screenshots, tracking exclusions in a spreadsheet, and setting calendar reminders, you could be creating gaps that drain your organization’s revenue. This process is as fragile as it is time-consuming, and it’s not a suitable credentialing foundation for growing practices. 

When verifications and exclusions are handled manually, they’re likely not completed often enough to catch an issue that could cause provider ineligibility and lost revenue. The industry is moving to continuous monitoring and it’s especially important in large or growing practices where even one missed verification can delay enrollment or create compliance risk that impacts reimbursement. 

Fragile manual systems like this create blind spots and are quick to crack under the pressure of increased provider volume or different state regulations, and will surely drain revenue.  

2. Multi-Payer, Multi-State Complexity 

Most physicians enroll with over a dozen different payers to maximize the number of patients they can see. This high volume of payer enrollments combined with a lack of standardization across payers in terms of required documentation, makes it difficult for teams to stay organized and accurate. Practices completing multi-state credentialing face another layer of complexity, because the same payer may have different requirements across different states. 

With this multi-payer, multi-state complexity, even the best credentialers are likely to miss a document or submit an incorrect one, forcing them to reset the enrollment clock. Worst of all, in all this time, the physician can’t see patients. 

Without a system built to handle this credentialing complexity, it becomes all too easy for revenue to slip right out from under your organization. 

3. Lack of Visibility or Standardization Across Sites or Entities

Mergers and acquisitions often put credentialers in charge of  credentialing multiple sites, but don’t provide the visibility into documentation and credentialing status at those other sites. Also, with providers that practice at multiple locations, duplicate work and rework is causing unnecessary delays. Providers are submitting the same documents to multiple locations, credentialers are completing nearly identical applications, and they have no idea because systems are completely incompatible with or cut-off from the systems of other sites. This is a nightmare for credentialing teams trying to manage credentialing across sites, as it’s exceedingly difficult for them to know what documents have been collected, what a provider’s status is, and what’s left to be done.

Credentialing teams need a system that allows for standardization and visibility across sites to ensure the most timely and effective credentialing. 

4. Providers Seeing Patients Before Payer Enrollment is Complete

Credentialing is a notoriously slow process. Providers stuck in a slow cycle of credentialing can feel pressure to see patients before their payer enrollment is complete. This is risky business that can cost both the provider and your organization valuable dollars. When you think about how many patients a single provider can see in a day, those non-reimbursed dollars add up quickly. 

To avoid this sticky situation, you need a credentialing process that enables the fastest time-to-revenue by shortening the enrollment process as much as possible. 

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

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Do These Gaps Sound Familiar? Close the Gaps With Credentialing Software

Closing these common credentialing gaps in your healthcare organization can feel daunting, especially if you’re currently managing credentialing on paper or with a disjointed process. However, implementing a strong credentialing software is an effective way to address them all, and give your organization a competitive advantage with a best-in-class credentialing program. 

Here’s how credentialing software, such as MedTrainer, can upgrade your credentialing process to help you close the gaps that are quietly draining revenue. 

• Get visibility and standardization into multiple sites, while still making it easy to segment workflows, documents, and provider data by location to help you stay organized. 
• Maintain compliance with automated exclusions monitoring run on an NCQA-compliant schedule with notifications when a provider’s status changes.
• Keep provider licenses and certifications up-to-date with automatic document retrieval, expiration reminders, and tracked verification details.
• See progress, status, and timelines at-a-glance with customizable reports and dashboards.
• Standardize processes with controls such as pre-set mandatory documents, pre-built payer rosters, credentialing packet templates by payer, and more.

Credentialing is an intricate process that can easily become a big strain on your credentialing team’s time and your organization’s revenue — especially with the volume required after a merger or acquisition. Credentialing software is the most effective way to close the gaps and create a process that’s repeatable, scalable, and strengthens your organization’s revenue cycle. With MedTrainer, you can quickly adopt a credentialing process that closes common gaps, makes credentialing easier and more efficient, and leverages automation to shorten time to revenue for providers at your organization. 

Ready to see what a better credentialing process could look like at your organization? Schedule a demo today.