“Medical Service Professionals are the first line of protecting patients; they make sure practitioners are qualified to deliver the highest standard of care.
– Angel Mena, MD, Internal Medicine Residency Program Director, TriHealth, and Chief Medical Officer, symplr
Executive summary
Patient safety and healthcare operations rely on a network of credentialed physicians, advanced practice providers, and other specialized professionals to match the supply and demand. A problem hidden under the surface is not supply and demand, but credentialing. A slow credentialing process frustrates practitioners, burns out staff, and delays revenue and patient care.
Credentialing delays can cost organizations $9,000 per physician, per day. ¹
To better understand the biggest roadblocks to provider credentialing, a 2023 State of Medical Staff Services Survey was conducted with medical staff professionals, credentialing managers, and quality managers across health systems, hospitals, and large physician group practices in the U.S. Continue reading to learn about the top challenges and areas for improvement in provider credentialing.
“Significant shifts in healthcare delivery will place tremendous demands on medical staff services, such as recruiting, credentialing, privileging, referrals, and more.”
– Patrick Birmingham Executive Vice President of Credentialing Operations, symplr
Credentialing surge expected with industry shifts
| % | Impact |
|---|---|
| Hospital outpatient, ambulatory surgery, and physician office visits will increase ~ 20% by 2029³ | Medical care will increasingly be provided by mid-level professionals and will continue to be delivered in non-traditional locations as preferred by patients |
| From 2021 to 2031, the projected growth rate for nurse practitioners, physician assistants, and nurse anesthetists is 40%, the highest of all healthcare occupations.5 | These medical decision-making roles will drive greater demand for credentialing specialists and put additional pressure on MSS departments. |
| The U.S. unemployment rate is currently hovering at a 54-year low.6 | An increasing number of MSS departments, provider enrollment departments, and physician practices are short-staffed |
Current challenges in provider credentialing
Turnover – The volume of work often exceeds staff capacity, resulting in unmanageable backlogs and credentialing delays.
Data Overload – Medical Staff Services (MSS) teams struggle to manage data because they toggle between multiple, disconnected systems to complete the provider credentialing and enrollment process.
Poor Processes – Labor-intensive processes lead to credentialing delays that negatively impact the revenue cycle, provider experience, and patient care.
Recommendations to expedite and optimize provider credentialing
To expedite the overall provider credentialing process and optimize healthcare operations, healthcare leadership should consider the following:
Outsource Tasks – Outsource the time-consuming tasks of primary source verification and provider enrollment to a trusted vendor partner. Enable MSS teams to focus on tasks such as privileging, peer review, and the reappointment process.
Automate Workflows – Use automated technology to accelerate workflows and streamline the entire process, from initial application to ongoing monitoring of providers.
Integrate Privileges & Quality – Combine and integrate credentialing and privileging with quality review using a single software system to monitor, benchmark, and report on provider performance (peer review, FPPE, OPPE, etc)
Credentialing survey key results
Nearly 700 medical staff professionals were surveyed earlier this year about the challenges and opportunities for improvement with the overall credentialing and enrollment process.
The MSS department plays a vital role in ensuring high-quality patient care and protecting patient safety. It takes one bad audit for hospital leadership to understand just how critical the MSS department truly is.
The MSS department is considered by many to serve as the “central nervous system” of credentialing, feeding critical provider data to nearly every department of a hospital and healthcare system. As gatekeepers of provider data management, medical staff professionals are under immense pressure to credential, privilege, and enroll practitioners as quickly and accurately as possible.
The cost of turnover
Sixty-four precent of survey respondents reported that turnover is impacting their department.
The volume of work exceeded staff capacity for nearly half of the last 12 months.
Only 17% of respondents solve for staff turnover by leveraging a third-party credentials verification organization (CVO), which can be used to offload administrative burdens to redirect staff focus.
WHAT HAPPENS…if turnover is not addressed?
With the average hospital staff turnover at 26%, losing just one credentialing specialist could double the processing time to 6-8 months.
When physicians are stuck in the credentialing process, they can’t see patients and hospitals can’t collect revenue.
Recommendation:
Consider offloading the most time-consuming tasks of the credentialing process – primary source verification and provider enrollment – to credentialing experts at a CVO.
By doing so, your MSS team can prioritize high-value tasks to speed up credentialing processes.
The impact of data overload
MSS teams use an average of 3.3 software solutions and spreadsheets to manage provider data.
MSS teams report that data managed by their office is used by multiple downstream systems. However, only 25-35% report that data transfer is automated between the credentialing software and other critical software tools.
Nearly 75% of respondents do not have a successful mechanism in place for linking competency measures to privileges for practitioners.
Less than half (48%) of respondents report that the data they need to credential and enroll providers is stored in one place.
Which best describes your facility’s linking of competency measures/quality indicators to providers’ clinical privileges?
- ~25%: “We have a successful mechanism in place for linking competency measures to privileges for all or nearly all our privileged practitioners”
- ~15%: “We have begun to link competency measures for some providers”
- ~14%: “We have had discussions about linking competency measures to privileges, but have not yet implemented a process”
- ~13%: “We have not begun and don’t know where to start”
WHAT HAPPENS…if data overload is not addressed?
From expired certifications to ongoing credentialing requirements and disciplinary actions, a lack of data integration exposes organizations to legal and financial risk.
Uncredentialed, revoked or expired providers are subject to a $5,000 civil penalty for providing services unlicensed. The facility allowing improperly licensed providers is subject to a $10,000 civil penalty.
Recommendation:
An integrated data management platform collects, verifies, stores, shares, and monitors provider data in one automated, user-friendly hub.
Maintaining one source of provider data reduces duplicate data entry, lessening the risk of human error, negligent credentialing, and administrative burden during the overall process.
The cost of poor processes
Confusing, labor-intensive credentialing processes slow everything down, including claims reimbursements and revenue.
Survey respondents indicated that it takes 60 days on average to fully onboard, credential, privilege, and enroll a provider. When teams are short-staffed, processing time can take anywhere from 90-120 days.
Additionally, 86% of healthcare organizations experienced backlogged claims, with a majority reporting weekly backlogs.
How often does your organization experience backlogged claims?
- Daily
- Weekly
- Monthly
- Quarterly
- Rarely
WHAT HAPPENS…if processes are not improved?
When an MSS department struggles with an inefficient credentialing process and is short-staffed, credentialing may take anywhere from 60-120 days, amounting to $500k-$760k in potential lost or delayed revenue.
Recommendation:
Streamline processes and leverage automation to ensure nothing is missed and every detail is captured.
A combination of automated technology and credentialing service experts can lighten the load on the medical services staff and maximize the speed and accuracy of the credentialing, privileging, and enrollment process without sacrificing quality. Streamline processes and leverage automation to ensure nothing is missed and every detail is captured. A combination of automated technology and credentialing service experts can lighten the load on the medical services staff and maximize the speed and accuracy of the credentialing, privileging, and enrollment process without sacrificing quality.
“Our industry needs to hear more about the criticality of credentialing and the level of detail it takes to credential someone to the best business standard.
-Nicole Helmberger Manager of Provider Operations Hennepin Healthcare
Conclusion
Never has it been more important to ensure providers are delivering the safest and highest quality care. Transforming credentialing requires all stakeholders to act on this vision by equipping MSS leaders with better tools, technology, and resources that not only lighten their load but also streamline the entire provider data management process.
Footnotes
¹Merritt Hawkins: https://www.merritthawkins.com/news-and-insights/blog/healthcare-news-and-trends/New-Survey-Shows-Physicians-Are-Key-Revenue-Generators-for-Hospitals/
²symplr Medical Staff Services Survey 2023: Nearly 700 medical services professionals across health systems, standalone hospitals and large physician group practices in the U.S. took the survey.
³McKinsey: What to Expect in U.S. Healthcare in 2023 and Beyond: https://www.mckinsey.com/industries/healthcare/our-insights/what-to-expect-in-us-healthcare-in-2023-and-beyond
4Medscape: https://www.medscape.com/viewarticle/954066
5U.S. Department of Labor’s Bureau of Labor Statistics: https://www.bls.gov/ooh/healthcare/nurse-anesthetists-nurse-midwives-and-nurse-practitioners.html
6 U.S. Department of Labor’s Bureau of Labor Statistics: https://www.commerce.gov/news/blog/2023/02/news-unemployment-its-lowest-level-54-years#:~:text=Today%2C%20it%20is%20just%203.4,they%20were%20seven%20months%20ago
7NSI Healthcare Staffing Report: https://www.nsinursingsolutions.com/Documents/Library/NSI_National_Health_Care_Retention_Report.pdf
8U.S. Department of Health and Human Services Office of Inspector General: https://oig.hhs.gov/fraud/enforcement/civil-monetary-penalty-authorities
