Evading the Pitfalls of Provider Credentialing

Health insurers grapple with many credentialing pain points on a daily basis.

But what if there’s a better way? Health insurers have a common goal: delivering superior, cost-effective care to their members. The process of thoroughly vetting clinicians before permitting them to practice in-network is essential to that mission. But the same process that ensures members have access to high-quality providers also leads to cost, time, and resource inefficiencies that can compromise the integrity of a plan’s performance.

To put it mildly, provider credentialing is a highly necessary, valuable, and expensive slog. But there are also plenty of avoidable hurdles that can be addressed with varying degrees of effort.

The pitfalls of provider credentialing

The credentialing process as we know it took shape 50 years ago, when standards like primary source verification first became the norm. And it has only grown more complicated in the decades since. This is largely due to providers’ expanding scope of practice, the proliferation of accrediting bodies, and the distinct requirements of health plans themselves.

But these factors alone don’t explain credentialing’s unique headaches. There are also procedural, operational, and structural issues at play that compound the problem.

Siloed datasets

First, as the complexities of credentialing have grown, its infrastructure has stayed mired in the past. This has led to a network of provider data that is largely compartmentalized, disconnected, and analog.

The countless institutions that make up the healthcare ecosystem each hold key elements of the credentialing puzzle. But they don’t communicate in a natively digital way. That means the process of gathering and verifying the data needed to satisfy credentialing requirements becomes a series of labor-intensive data requests sent by paper, email, phone call, fax, and web portal. One large insurance carrier purportedly employs 1,500 people focused solely on managing this data.

This tends to be true even when health plans outsource the work to third-party credential verification organizations (CVOs). In fact, CVOs typically lean on large, offshore teams to perform the same manual SOPs an insurer would otherwise follow in-house.

What’s more, provider data silos create endless redundancies. Consider that physicians must maintain up-to-date credentialing data with, on average, 20 health plans (not to mention Medicare/Medicaid, voluntary organizations, hospitals, and other entities they might be affiliated with). That’s 20 distinct credentialing teams operating in vacuums to siphon the same information from a single provider. That provider then shoulders the administrative burden of complying with each individual team’s request. And with each three-year recredentialing cycle, the circus repeats itself.

Stale data

Then, there’s the issue of outdated data. When the data being transferred among silos is static, as is largely the case, health plans and other credentialing bodies run the risk of dealing in inaccurate information. This can pose a risk to their standing with regulatory institutions like the National Committee for Quality Assurance (NCQA), as well as to the health and safety of their members. It can also lead to unnecessary timeline delays as credentialing teams work reactively to fix erroneous data.

Considering this state of affairs, it’s no wonder that provider credentialing takes an average of 90 to 180 days from application submission. The problem may even be getting worse, with some reports suggesting frustrations with the credentialing process have been growing in recent years.

Accreditation surveys and compliance audits

The bandwidth health plans need to comply with evolving accreditation and regulatory requirements presents another source of inefficiency.

For instance, NCQA accreditation is quickly gaining traction. Currently, 31 states require or accept NCQA accreditation to monitor and support quality care initiatives. But earning accreditation status and staying in good standing requires health plans to submit to lengthy biennial or triennial surveys. They must also commit to intermittent audits, ongoing process improvements, corrective actions, and meticulous documentation.

The NCQA includes credentialing and recredentialing compliance among its accreditation requirements. Credentialing teams are charged with rigorously monitoring, interpreting, and practicing those standards and demonstrating strict adherence in preparation for official review. This includes keeping (or unearthing) notes on every action taken on every provider file.

To complicate matters, as the NCQA updates its standards each year, credentialing teams find themselves scrambling to get up to code for implementation and policy updates. This can put tremendous stress on teams that are already stretched thin, diverting their attention from regular responsibilities and disrupting the normal course of business.

Organizations that are ambitious enough to achieve multiple accreditations (e.g., URAC and SOC 2 Type 2) can strain the workloads of entire teams, as it can be quite a complex task to track accreditation and regulatory updates for implementation.

Credentialing committee meetings

NCQA requires all accredited health plans to hold regular credentialing committee meetings. During these meetings, a team of medical professionals gathers to review and evaluate providers’ credentials and decide whether or not they meet agreed-upon credentialing requirements. Their work is especially important in cases where a provider’s file has been flagged for potential concerns.

While critical, credentialing committee meetings can become pitfalls due to management. Running an efficient and effective committee meeting takes methodical preparation on the part of a health plan’s credentialing team. This is even more important when you consider that committee members are providers themselves and thus already time-strapped. Ensuring that meetings go smoothly is paramount to reducing their burdens.

Proper meeting preparation includes:

• Composing clear and direct summaries of all applications
• Systematically organizing all provider files for easy review, with emphasis on the documents needed to support any identified issues
• Removing all identifying information from said documents with regard to name, gender, nationality, race or ethnicity, and spoken language(s) to mitigate the risk of implicit or explicit bias

Without such preparations, credentialing committees may not be able to get through the intended number of files in a given session. They may also mistakenly reject or approve an application due to a lack of clear information. In short, preparing for credentialing committee meetings is time-consuming. When it’s not done methodically, it can further bottleneck an already drawn-out process.

From onerous to frictionless

Identifying the pitfalls saddling the credentialing process is an important first step to remediation. But what can actually be done to resolve them?

The most productive results come from addressing the root cause of credentialing’s worst inefficiencies: broken and nonexistent provider data pipelines. In practice, that means embracing a credentialing model that hinges on real-time connections to primary data sources and automated provider data-sharing among credentialing entities. This approach enables true data interoperability, live data monitoring, and seamless data reporting. It could go a long way toward reducing the $2.1 billion that health insurers, providers, and hospitals spend each year on inefficient and redundant tasks aimed at ensuring the accuracy of provider data.

While this might sound like a pipe dream, one solution already exists. CertifyOS is a first-of-its-kind provider intelligence platform. Powered by API integrations and thousands of data points, it unlocks insights and drives performance for health insurers’ credentialing teams. With one-click credentialing and real-time network monitoring, CertifyOS keeps health plans compliant and hyper-efficient—so they can focus on what matters most to their organization.