healthcare compliance and credentialing

The statistics are striking: Globally, four in 10 adults have experience with medical errors, either personally or in the care of someone close to them, according to the Institute for Healthcare Improvement. A Centers for Disease Control study found that medical errors are the third leading cause of death in the U.S.  These medical errors—also referred to as healthcare incidents or events—are unfortunate and sometimes tragic. As a result, documenting and analyzing them for cause is paramount, providing hospitals and healthcare organizations with valuable lessons about how to improve caregiver and patient safety.

Some 2,400 years after the Hippocratic Oath addressed protecting the sick from harm and injustice—and decades after healthcare regulations made patient safety a central mission—we’re still asking: Why is achieving and maintaining a safe, reliable patient care environment so difficult? The pursuit of continuous improvement is why we have a highly regulated healthcare industry today, focused on safety, and with steep penalties for noncompliance. 

Vendors and vendor management play a significant role in the operation of healthcare facilities. Healthcare organizations use third-party vendors to handle a number of functions, from providing service for capital equipment to delivering devices for surgeries, helping to ensure the facility’s day-to-day operations run as planned. By partnering with third-party vendors, staff members and administrators stay focused on providing care to patients. However, before third-party businesses can provide supplies or services, their vendor representatives must go through the organization’s vendor credentialing process. One question in particular comes up often whenever vendor credentialing is discussed: Does vendor credentialing vary by state? The answer, broadly speaking, is no: States don’t have regulatory requirements for vendor credentialing. That said, even though states don’t set vendor credentialing policies, those policies can still vary depending on what state(s) the vendor is in.

Ongoing Professional Practice Evaluation and Focused Professional Practice Evaluation (OPPE and FPPE) are standard protocols in healthcare organizations today. They bring together compliance, quality, and safety initiatives in their focus on provider performance improvement. While OPPE and FPPE are The Joint Commission’s (TJC) terms, the ideas they represent are universal. All hospitals and healthcare organizations must evaluate and validate providers’ performance at regular intervals, and under certain circumstances, according to their healthcare accreditation and/or regulatory body’s standards.

No matter what type of healthcare facility you work in, hiring a credentialing verification organization (CVO) is a tried-and-true way to achieve fast, accurate medical provider credentialing and payer enrollment. Organizations of all sizes use CVO credentialing to handle rapid growth and busy times, increase customer satisfaction, and better manage resource capacity. CVOs exist to help healthcare organizations verify licensed medical practitioners’ qualifications (i.e., credential) and enroll them into payers' health plans, in order for the provider organization to be reimbursed for services. CVOs do so by accepting delegated responsibility to gather information on clinicians’ backgrounds, identify gaps or red flags in large volumes of data, and report the findings. They don’t typically make credentialing decisions on behalf of your organization, unless that role is specified in your contract.

Workforce management is an ongoing challenge for healthcare organizations that strive to balance high-quality patient care with financial efficacy. After all, labor costs account for about 60% of hospital expenses, and that number has been rising for the past decade. However, in recent years, a new wrinkle has appeared in the workforce management equation: the move to value-based care and reimbursements that are increasingly tied to patient outcomes. The shift means it's more important than ever for health systems of all sizes to effectively manage their workforces to ensure employees are as productive, effective, and efficient as possible. To aid the efforts, workforce operations tools and automation are delivering positive results like never before.