Whether you work in private or government healthcare insurance, or both, it’s imperative to partner with clinicians who will deliver on patient safety, satisfaction, and positive clinical outcomes before rewarding them with optimal reimbursement. The payer credentialing process is the starting point to vet qualified, competent healthcare providers who will further your mission to properly measure care costs and compare them with outcomes to make the best healthcare decisions for members.
Automating and optimizing provider data management and credentialing is the only way to achieve the trifecta of:
- Delivering competent, high-quality, and cost-effective care to members
- Supporting large numbers of physicians and other healthcare providers
- Maintaining compliance to be a champion of care
What’s the difference between payer enrollment and payer credentialing?
Enrollment and credentialing are often used interchangeably, but are distinct processes. Payer enrollment—also referred to as provider enrollment—is the act of enrolling providers with your health plan so they are considered “in-network,” or “participating.” For the greatest cost savings, most patients will select a provider from a directory listing of network providers maintained by their health plan. To be listed as in-network, each provider must enroll in the health plan. First, however, payers credential the providers who apply.
What is payer credentialing?
Payer credentialing—also called provider credentialing or medical credentialing—is the process an insurance company uses to obtain, verify, and assess a healthcare provider’s qualifications to join a network. Hospitals and health systems also conduct medical credentialing to evaluate a clinician’s training, certifications, and professional experience to ensure current competence. However, compared with hospitals or health systems, payer credentialing may focus on providers’ utilization data and other factors related to value and cost containment, while also prizing quality.
Why is the payer credentialing process challenging?
Payer credentialing is highly regulated, time-consuming, and labor-intensive, often taking three to six months to complete. Factors that make credentialing complex include these:
- It requires knowledge transfer among a significant number of participants.
- It’s mandatory for the payer to adhere to accreditation (e.g., the National Committee for Quality Assurance) and state and federal compliance standards (e.g., Centers for Medicare & Medicaid Services, or CMS) when handling provider data.
- Meeting contract obligations means continually setting and adjusting the providers in-network to save on costs while delivering the highest-quality care to members.
- It requires tracking minute line-of-business and network details (e.g., provider IDs, date ranges, contract relationships, tax identifiers, services, panel statuses, and directory flags).
As a result, most payers create their own internal credentialing verification organization (CVO) or outsource to a qualified CVO. It’s also impossible to manage the multi-step process of credentialing, including primary source verification, for thousands of physicians, advanced practice professionals, and allied health staff using paper or manual processes, so provider data management software is employed.
Software, preferably delivered as a service (SaaS), makes data gathering, secure access, reporting, and ongoing compliance less burdensome for providers, credentialing staff, and the administrators who assess the provider’s application before including them on a panel. In conjunction with using a provider data management tool, there are proven ways that payers can improve the credentialing process.
Five ways to improve payer credentialing
1. Centralize provider data
Incomplete or inaccurate information regarding a provider’s professional certifications, work history, or malpractice insurance can lead to extensive credentialing and enrollment delays causing member access issues and lost revenue. After providers are enrolled, their information must be updated regularly. To avoid having Medicare billing privileges revoked, providers must report an adverse legal action or change in ownership or practice location within 30 days. All other changes must be reported within 90 days.
Provider data changes frequently; 2-3% of provider demographic data (e.g., addresses) changes each month, requiring it to be updated and reconciled regularly. Even slight discrepancies in an address, for example, can be detrimental. To maintain clean, accurate provider data, use a single source of truth that is consistently reconciled and dynamically validated against primary sources. Centralization of real-time provider data improves data quality, access and transparency, and eliminates duplicative requests for information, reducing provider frustration.
2. Foster data access and transparency
By integrating provider contracting, credentialing, and enrollment processes to share credentials verification data, you eliminate duplication of work, speed up the onboarding process, and reduce the associated administrative costs and burden. Being able to easily share critical provider data is essential for member care access, quality governance and risk management, and patient safety.
At many insurance companies, provider data comes from multiple sources and is stored in numerous systems and departments. Physician contracts may be kept in a file cabinet in the legal department, while onboarding data is stored in the credentialing division or CVO. This lack of communication results in repeated requests for the same information and delays the provider credentialing and enrollment processes.
In addition, when provider data is entered several times into separate systems, you may wind up with inaccurate data. Current, clean provider data is essential for provider directories and compliance with Centers for Medicare and Medicaid Services (CMS) and other governing bodies and regulations.
3. Expedite provider applications
Because payers process huge volumes of applications, they require tools such as batch processing, web crawlers, and form-automation technology to create efficiencies across workflows for primary source verification, credentialing, and enrollment. The use of medical credentialing software for the entire lifecycle of a practitioner fosters the ability to more effectively share data, ensure data integrity and transparency, demonstrate accountability for large volumes of traceable data, and handle rapid growth.
Efficiency and consistency are essential because payer enrollment and credentialing are just the start when a new provider applies to your insurance company. Data management and maintenance continues throughout their lifecycle, including:
- Multiple rounds of applications (one requesting access to provider personal data and others to join plans)
- Verification of primary source data on education, training, and licensure
- Fraud checks
- Internal/external communication of status along the way
- Maintenance of qualifications and recredentialing
4. Eliminate manual steps in processing applications
Human errors can cause delays and increase costs. Conducted manually, medical credentialing is cumbersome for provider applicants and credentialing staff. Many providers still store their paper credentials in a box. When they need to be credentialed by a new payer, providers have to locate and copy the relevant documents. Many providers still complete and sign hard copies of application forms that must be sent to payers.
Further, providers enrolling into payer networks that cover multiple states must be credentialed in each one where they deliver care. The states may have different credentialing requirements and recredentialing time frames, so there’s a lot of information to track, requests to respond to, and documents to share. Credentialing staff may spend hours manually verifying credentials (e.g., calling or emailing medical schools and state licensing boards and searching the National Practitioner Data Bank for malpractice payments or adverse actions).
Failure to submit required documentation on time draws fines and jeopardizes accreditation and compliance. Automating credentialing eliminates errors and inefficiencies rife in manual processes.
Last but not least, providers and members are accustomed to the high level of customer service that automation provides in every other industry, viewing manual processes as outdated and not confidential.
5. Make your credentialing process nimble for the unexpected
To ensure care coverage for members during COVID-19, your health plan(s) likely relaxed guidelines and implemented procedures to expedite credentialing and enrollment processing times. For their part, hospitals responded to the national emergency declaration by activating emergency protocols.
To expedite health plan enrollment, managed care organizations have the option to implement provisional credentialing procedures in compliance with the National Committee for Quality Assurance (NCQA) or Utilization Review Accreditation Commission (URAC). The primary source verification requirements for provisional credentialing require verification of only three things: a current, valid medical license; five years of malpractice history; and a current signed application and attestation. Under NCQA regulations, provisional credentialing can be used on a one-time basis and is valid for only 60 calendar days. Managed care organizations must ensure that all providers are fully credentialed, reviewed, and approved within that time frame. (URAC does not define a time limit for provisional credentialing.)
On October 18, 2021, U.S. Department of Health and Human Services Secretary Xavier Becerra extended the COVID-19 Public Health Emergency (PHE) for an additional 90 days. This means that the credentialing and enrollment waivers and flexibilities that have been implemented during the PHE will remain in effect until at least January 13, 2022. This renewal marks the seventh time the federal government has done so since the public health emergency was first declared at the start of the pandemic last year. The PHE may be extended again.
When the PHE finally ends, providers will need to be recredentialed and re-enrolled with payers. Hospitals, for their part, will need to start identifying and evaluating the status of providers who have been practicing under temporary privileges and enrollment.
Efficiency and accuracy must be the goals when vetting qualified, competent healthcare providers who will make the best healthcare decisions for your members. To learn how symplr Payer works as a single source of truth for healthcare provider data management, request a demo today.