Think provider credentialing is a modern concept?
The current set of checks and balances that clinicians undergo as employees or contractors of a health system is just decades old, having emerged as healthcare organizations became the extensive enterprises they are today. But traces of what medical services professionals (MSPs) do date back thousands of years. In fact, as early as 1000 BC, the Persian cult of Zoroaster had a physician “licensure” process that could be considered a precursor to medical credentialing.
Today, MSPs are gatekeepers of nearly all provider lifecycle data in health systems and health plans. They’re responsible for medical credentialing, including licensure verification, of course. But more complex tasks related to provider data management are being funneled to them.
Multiple factors are expanding the MSP role, including:
- Technology and innovation in the healthcare industry: Previously manual and paper-based administrative methods have become digital and automated. This makes MSPs’ role one of maintaining software and workflows that support providers’ initial affiliation with the health system as well as co-managing (with the quality department) their ongoing performance via peer review, including focused professional practice evaluation (FPPE) and ongoing professional practice evaluation (OPPE).
- Centralization and alignment of tasks in health systems: Credentialing and payer enrollment have merged in many health systems to save resources, spurring the need for MSPs to learn how to manage payer relationships.
- Mergers and acquisitions creating mega health systems: More employed and contracted physicians are processed through medical staff services (formerly known as the medical staff office or MSO). More non-physician providers are being credentialed and privileged than ever before, too, as their scopes of practice expand.
Essential traits of the medical services professional (MSP)
As a result of healthcare industry changes, the medical services professional's job description is vastly different than it was even five years ago. The role has evolved from a primarily clerical position decades ago to one that requires leadership and critical decision-making skills. Medical services professionals are required to possess stellar organizational and communication skills. They also need specialized knowledge of legal matters; an understanding of healthcare financing, payer relationships, and health networks; and a command of the ins and outs of credentialing, privileging, and payer enrollment; among other knowledge.
Perhaps most importantly, MSPs are considered to be participants in the ongoing effort to keep patients safe. According to the National Association Medical Staff Services (NAMSS), the professional organization for medical services professionals, their gatekeeping role ensures that only currently qualified, licensed medical professionals are allowed to care for patients within their facilities and for their health systems at large (e.g., via telemedicine).
Their expanding scope is significant—and not one medical services professionals are taking lightly. With so much at stake, healthcare organizations are turning to software solutions that streamline and simplify provider data management, making the workflows more manageable, optimized, and transparent. This in turn enables MSPs to do their jobs at the highest, most efficient level possible.
Allowing medical services professionals to operate at the top of their profession means giving them tools that eliminate manual and repetitive tasks. We must capitalize on their knowledge, experience, and skills to analyze data and make high-level recommendations to committees and medical staff leaders.
For example, a highly functioning MSP works in conjunction with leaders to:
- Research and recommend criteria for clinical privileges for all specialties and subspecialties
- Review credentials files and recommend action on providers' initial appointments and reappointments
- Participate in data collection for provider peer review and performance improvement activities
- Assess and expand the hospital’s universe of potential payers, form delegated relationships with payers, and potentially negotiate for better terms with payers if provider volume allows
Provider data management changes
Let's take a look at six big changes to provider data management that have shaped the MSP role in recent years.
1. Healthcare organizations are more complex
Historically, where physicians worked and who they worked for was cut and dry: Most were in private practice, and affiliated with a local hospital (or multiple facilities) by joining the hospital’s medical staff and/or applying for privileges there. This way, they could conduct rounds on their patients who were admitted to the hospital. A few were employed directly by hospitals.
Today, things are vastly different. Some physician groups have banded together to own and operate their own hospitals. Other physicians might work at—and may or may not be employed by—the hospital, while also providing care at outpatient or urgent care facilities, retail clinics, and via telemedicine. Each of these providers must be credentialed, privileged, and enrolled, but doing so manually is time consuming and error prone.
Automated tools make MSPs' work easier and more efficient by removing the pitfalls of the manual and paper-based methods that used to be standard for medical staff services. For instance, the tools interact with CAQH for fast provider profile updates and use web crawlers to automatically obtain practitioner data.
2. There are more clinicians to process
Gone are the days when the MSP managed only a handful of physicians being onboarded. More physician specialists need privileges (including temporary privileges) at many more facilities. Plus, increasing numbers of non-physician providers require credentialing and privileging as a result of their expanded scopes of practice. This is occurring as multidisciplinary care teams are responsible for patient outcomes. For example, in addition to the advanced practice registered nurses, certified registered nurse assistants, and physician assistants who have been processed like physicians for more than a decade, new types of allied health providers (e.g., speech-language pathologists, dietitians, and social workers) require privileges. Formerly, the HR department in hospitals onboarded and monitored these providers.
Handling the credentialing and performance improvement data for so many providers makes relying on paper-based records risk prone. Paper records are harder to gather, store, and organize. They’re cumbersome to maintain and nearly impossible to share securely. It's too much for any single person—or even a team of people—to handle manually. After all, credentialing “done well” helps eliminate risk, secure patient safety, and improve quality.
Instead, MSPs can use databases that easily gather and store practitioner data in a single-source-of-truth location while simultaneously eliminating duplication and repetitive tasks.
symplr's secure, cloud-based tools also perform primary source verification, maintain years' worth of records, distribute information organization wide, and more—making handling data for so many providers simpler.
3. Speed and turnaround time (to reimbursement) matter more
MSPs historically would wait weeks or even months for manually completed provider applications to be processed. On the other end of the spectrum, the reappointment process was similarly manual and slow. Today, waiting too long for either process is a costly risk your organization shouldn’t take. symplr's digital end-to-end provider data management solution creates alerts, reminders, and automated workflows that speed the back-and-forth communication that’s a hallmark of credentialing applications. Providers are better able to self-serve by securely uploading their own data and documents.
Digital tools also ensure that MSPs don’t miss a single step in the credentialing or enrollment processes. For instance, if a healthcare provider has items that are about to expire, the medical staff services team will know immediately, providing sufficient time to respond before it's too late and before compliance is jeopardized.
Similarly, streamlining the payer enrollment process makes step-by-step tracking of practitioner applications easy for medical services professionals while also allowing your organization to receive reimbursements faster. In addition, the provider data management tools allow tasks to be done on a larger scale rather than one by one, such as sending applications in batches and verifying multiple facilities, providers, and verification types. These features save time and maximize efficiency for MSPs.
4. The “dotted line” from medical staff services to patient safety solidified
Only a generation ago, physicians were protected from negligence or malpractice claims if something went wrong while they were caring for a patient. Today, things are very different, but there still isn’t any federal standard for credentialing and privileging. That means healthcare organizations must be scrupulous when it comes to ensuring their providers are qualified and currently competent. Doing so fosters patient safety and protects the hospital or health system’s accreditation status and bottom line.
Such important tasks are a big burden for medical staff services to take on without the help of automation. symplr's provider data management tools take the stress out of this process in several ways. With these tools, medical services personnel can perform primary source verification for provider credentialing and access a comprehensive, customizable privileging forms library maintained by a team of expert researchers. There are even tools for gathering, analyzing, and reporting data for peer review purposes—including OPPE and FPPE—to automate processes, provide insights for improvement, and enable organizations to track the quality of care their providers deliver.
5. Data security is more complicated
Part of working in and managing an medical staff services department is having and granting access to countless files of sensitive data and information. When your organization relies on paper-based systems—or electronic systems that are backed up by paper—data security gets more lax. Without the aid of digital files, there are just too many administrative, physical, and technical entry points for breaches to occur, which puts security at risk all the time. That puts an additional burden on medical services professionals, who should be focused on patient safety and provider management.
On the other hand, MSPs’ whose organizations use cloud-based software from symplr can rest easier because of extensive privacy and security features. The software tools address concerns like activity tracking, auditing, and encryption; applying administrative permissions; and adding security features to meet specific federal, state, and board regulations.
6. There are many more professional opportunities for MSPs
As the MSP role has become more extensive, so too, have the opportunities for additional education, training, and professional development. NAMSS notes that its membership includes more than 6,000 medical staff and credentialing services professionals from medical group practices, hospitals, managed care organizations, and CVOs. This professional organization provides education and advocacy for the medical services profession, which spans an incredibly diverse number of healthcare settings—from traditional hospitals to payer organizations, rehab centers, telehealth companies, locum tenens firms, law offices, and more. NAMSS also offers educational programs and resources, including the Certified Provider Credentialing Specialist (CPCS) and Certified Professional Medical Services Management (CPMSM) designations.
The MSP role will continue to evolve as healthcare and provider data management become more complex. As a result, healthcare organizations must ensure that their technology grows with the needs of the industry. One step health systems can take today is to implement an automated, end-to-end provider data management software solution to aid these invaluable professionals in their critical mission to support providers and to ultimately help keep patients safe.