Assessing the ROI of Automated Credentialing

How modern provider data solutions optimize the efficiency, accuracy, and costs of healthcare’s most critical process.

Provider credentialing plays a vital role in ensuring clinical excellence for every healthcare organization—but when it’s not carried out efficiently, it can also lead to heavy administrative workloads, lengthy application processing delays, and avoidable costs.

This is a timely problem. Recent reports suggest that healthcare administration costs are rising in the U.S., jumping $18 billion in the last year alone. In addition, over half (54%) of medical practices have reported a recent increase in credentialing-related denials, leading to even greater losses.

All told, automating critical processes like credentialing could save the U.S. healthcare industry up to $25 billion a year—or 41% of its current $60 billion in administrative spending.

That led us to wonder, just how much money do healthcare organizations stand to save by leveraging fully automated credentialing solutions? Let’s take a closer look.

What is automated credentialing?

At its core, credentialing is an essential step when onboarding a new provider. It involves verifying a provider’s academic qualifications and clinical practice history and evaluating their ability to deliver quality care. Health insurers routinely credential new providers as part of the enrollment process, while health systems, provider groups, and digital health companies may also run their own internal credentialing program for a new hire.

Provider credentialing is an age-old process—arguably spanning more than 1,000 years—but it’s grown more complex and work-intensive over time as new regulatory bodies like the National Committee for Quality Assurance (NCQA) and more formalized requirements have emerged. 

Automated solutions aim to ease this complexity by using technology to verify primary-source credentials through real-time data sharing and connectivity. That means, unlike manual, in-house systems, automated credentialing places little to no administrative burden on time-strapped team members already shouldering full-time responsibilities, and it helps avoid the human biases that can cloud approval decisions.

Automated credentialing is also distinct from traditional third-party credential verification organizations (CVOs) and other legacy credentialing solutions, which still rely on outdated human automation methods and outsourcing to verify and manage provider data. Generally, these options involve lengthy turnaround times that can cause critical delays and lost revenue, and they often result in needless provider data errors and omissions.

Instead, truly automated credentialing is API-led and uses direct integrations to primary sources to streamline verifications and provider network monitoring from end to end. This not only increases administrative efficiency, it ensures 100% accuracy and effortless compliance.

How does automated credentialing lead to
cost savings?

There are several ways that automated credentialing can help healthcare organizations secure savings across the board.

1. Shorter onboarding timelines

Put simply, API-first, automated credentialing tools dramatically improve onboarding timelines, which can have a direct and substantial impact on revenue cycles.

Without automated credentialing, it can take up to 180 days for a provider application to be approved, and the costs associated with this drawn-out process accumulate over time. In fact, according to recent estimates, a provider who is uncredentialed and thus unable to perform reimbursable services can cost a medical group as much as $10,122 per day in forfeited revenue. 

Taken together, these figures suggest that extended credentialing timelines and delays can cost a medical group over $1.8 million in lost revenue per provider.

Here’s where automated credentialing can really move the needle. A properly streamlined, API-based credentialing process can reduce credentialing timelines up to 97%—think, five days to approval, rather than 180—recouping more than $1.75 million per application.

Automated solutions like CertifyOS also help shorten onboarding timelines by preventing missing and erroneous provider data points. Research shows that up to 85% of provider credentialing applications are missing required information, which adds to timeline delays and triggers time-consuming rework processes. But with CertifyOS, thousands of relevant and accurate provider data points are streamed in real-time straight from the source.

2. Fewer claim denials

Accelerated credentialing timelines allow providers to get reimbursed for their services faster. But efficient provider network monitoring with a solution like CertifyOS also ensures that they stay in good standing with payors, preventing reimbursement denials in the long run.

Claim denials are often a result of credentialing issues. Data analyzing roughly 102 million claim remits from 2020 show that the total denials rate is up 20% since 2016 and that roughly $400 million in claims were denied in 2020 due to provider eligibility issues.

Additional sources show that common reasons for denials include payor verifications that don’t match what’s documented on the provider application, demonstrating how inaccurate provider data can cause significant roadblocks in the credentialing process.

API-based, automated credentialing helps keep provider data up to date, reducing claim denial rates and other critical KPIs like the number of days claims spend in A/R and volume of aging claims. Automated credentialing can also increase clean claim rates, which can positively impact an organization’s revenue.

3. Reduced administrative burden and increased productivity

Automated credentialing enables healthcare organizations to minimize administrative workloads and increase efficiency. They do this by offering a fully automated data infrastructure that integrates with hundreds of primary sources and provides instant and continuous updates to provider directories.

This not only allows administrative teams to spend less time (or no time at all) performing manual verifications, it helps optimize credentialing committee meetings and simplify NCQA survey preparations.

With a solution like CertifyOS at their back, companies can operate with leaner, more agile teams, potentially reducing hiring and payroll costs and freeing up time and resources to focus on innovation and growth.

The bottom line

Inefficient and inaccurate provider data continues to hinder the credentialing process and drain the time and resources of modern healthcare organizations—but new data solutions like CertifyOS are primed to reverse this trend.

By leveraging fully automated credentialing, today’s teams can save millions of dollars per provider and spare the U.S. healthcare system billions each year in needless administrative costs, giving the industry the transformation it so desperately needs.

Save with CertifyOS’s automated credentialing solution

CertifyOS is a first-of-its-kind provider intelligence platform, with API-first integrations that connect to hundreds of primary sources and deliver thousands of verified data points in a matter of seconds. We unlock insights and power performance to help healthcare organizations rapidly scale their business while keeping up with the latest industry demands.

To learn more about our one-click, automated credentialing solution—and how it can unlock 38% lower admin costs and over 90% faster turnaround times—reach out to sales@certifyos.com or schedule a live demo to see our platform at work.