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Melissa Outlaw

By: Melissa Outlaw on October 14th, 2015

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Accelerate Reimbursement Through Provider Credentialing

Healthcare Provider Credentialing

New federal, state, and payor requirements are increasing the burden of processing on hospitals and physicians seeking reimbursement for services provided to patients. Many of these constantly changing rules, regulation, and guidelines surrounding reimbursement are directly related to the process of provider credentialing – the process in which a medical facility verifies the experience and qualifications of its practitioners.

Practices who seek to contract with third-party payors must collect, verify, and review data which documents a practitioner's education, experience, and qualifications (including information regarding licensure, certifications, malpractice coverage, and employment history – to name just a few items) in order to assign hospital privileges, and complete enrollment with participating providers.

Physician credentialing is a cumbersome, paperwork-heavy endeavor, and can be an arduous undertaking for even the most dedicated facilities. Still, the process is critical to ensuring quality care – and by establishing an effective provider credentialing process, hospitals and medical facilities can streamline costs, mitigate risk, increase revenues, and potentially expedite the reimbursement process.

Haphazard or ineffective provider credentialing can create serious – not the least of which is serious delays in reimbursement, which can adversely affect your cash flow. Fortunately, symplr has provided the below tips, in order to help you streamline your provider credentialing process.

  1. Begin the process as early as possible. Give yourself plenty of time to complete provider credentialing, by beginning as early in the hiring process as possible. Each payor has their own timeline for completing the process – and some can drag on as long as 150 days. Ask your potential hires to submit their information for review as soon as possible, and you'll avoid delays due to slow payor processing.
  2. Check it twice. Many applications are initially rejected or postponed, due to outdated, expired, or incomplete information. Provide new practitioners with a comprehensive checklist, so they can self-review before turning in their applications – and make sure you review each submittal carefully, prior to sending it on. Most delays in provider credentialing can be avoided simply by submitting the right information the first time – so if you have questions, ask – you'll avoid delays, and speed payor processing.
  3. Get certified. Obtaining certification through other organizations can also support provider credentialing. Your organization will learn methods for staying on top of the credentialing process – and your participating medical practitioners will grow accustomed to maintaining the records they need for regular recertification.

    Not sure where to start? The National Committee for Quality Assurance (NCQA) has a well-established, trusted program for credentialing certification.
  4. Leverage technology. There are many softwares and services available today which can help speed up provider credentialing process, and streamline your receipt of payments. For example, the Universal Credentialing DataSource (offered by the Coalition for Affordable Quality Healthcare (CAQH) ) is a free, secure service which helps physicians and healthcare organizations consolidate and update their credentialing information via the web.

    For a more robust solution, symplr offers provider credentialing software which not only consolidates information, it organizes documentation, tracks performance, supports ongoing review, and sends reminders about upcoming renewals and re-certifications – just to name a few features.
  5. Know the regulations. You may be able to accelerate credentialing just by keeping track of your state-specific laws and regulations. For instance, in-state credentialing standards may allow physicians to relocate from one practice to another without performing the full credentialing process – and practitioners who are certified with a payor in one state may be approved to undergo an abbreviated process in subsequent states. Getting clear on the details of your state's standards can help you streamline provider credentialing, saving time and money.

Provider credentialing poses many challenges – but rising to meet them will help you ensure compliance with state and federal regulations, as well as maintain payor approval. Improving your credentialing process will help you reduce costs, increase revenues, and expedite payment – all while improving the quality of patient care, and helping your facility mitigate exposure to risk.

When all is said and done, it's a win-win situation – effective provider credentialing will help secure your hospital or medical facility's success, for years to come.

For more information about streamlining your payor reimbursements through effective provider credentialing, contact the experts at symplr, today. We'll help you determine the approach which best meets your facility's needs.


About Melissa Outlaw

Melissa Outlaw is a Vice President, Customer Success with symplr. Melissa and her team assist clients in learning and implementing our provider management software - credentialing, privileging, peer review, quality and event reporting applications. She supports clients in benchmarking current internal practices, identifying potential efficiencies, then driving the integration of technology with process improvement to reduce time of service and operating expenses. She works extensively with decentralized, multi-facility organizations in transitioning to a shared service center as well as assisting healthcare organizations bridge the gap between procedures performed by a provider and their privileges granted.