We’ve got you covered with a handy all-in-one guide to credentialing in 2023! The what, when, where, and how in one place. Fun fact – did you know this practice goes all the way back to 1000 BC?
See how much you really know about credentialing.
What Is Provider Credentialing In Healthcare?
Provider credentialing, also known as practitioner credentialing, is the process of verifying the qualifications, training, and professional background of healthcare providers or practitioners. Traditionally, credentialing is a time-consuming manual process. Healthcare providers submit detailed information about their education, training, licensure, certifications and work history, which is then verified and evaluated by an organization’s credentialing department or team. The credentialing team goes through the application and documents that were submitted, painstakingly validating each of these details, making phone calls, filling out forms, sending faxes and emails with requests for information. They must track the status of all of these requests and follow up, often multiple times, to ensure everything is verified and accurate, before allowing the practitioner to deliver services to the consumers enrolled in their network.
A Brief History of Provider Credentialing
Some form of credentialing–or the verification of a healthcare practitioner’s fitness to provide care–has existed for millennia. The ancient Persian religion, Zoroastrianism, had a process for physician licensure in 1000 BC. To practice medicine, a candidate had to prove that he or she successfully treated at least three heretics. If all survived, the physician was deemed fit to practice medicine in perpetuity; if they all died, the license was denied. Thankfully, the credentialing process has radically improved since then!
In the middle ages, institutions such as the College de Saint Come and the government of King Roger II of Sicily required healthcare practitioners to pass examinations. The requirements further evolved to include specialized medical education and apprenticeships. In colonial Pennsylvania, Benjamin Franklin required physicians seeking to practice at the Philadelphia Hospital, the first hospital in America, to be at least 27 years old, have apprenticed within the city of Philadelphia, have studied medicine and surgery for at least seven years, and pass an examination by at least six physicians of the hospital before being approved to be on staff–a set of criteria that clearly laid the foundation for modern credentialing.
The COVID-19 pandemic has spurred further changes in credentialing compared to practices at the start of the 21st century. In recent years, due to the surge in demand for healthcare professionals during the pandemic, healthcare credentialing processes have had to evolve to meet the so-called “new normal.” Many health plans, hospitals, healthcare facilities, and other organizations have sought ways to speed up their credentialing process to quickly onboard skilled and qualified healthcare providers. Meanwhile, other organizations have initiated emergency credentialing protocols to streamline the deployment of healthcare providers to areas in need. This evolution has highlighted the importance of effective credentialing procedures and prompted the creation of new strategies and technologies to hasten this crucial yet tedious process.
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Why Is Provider Credentialing Important
Provider credentialing is an essential process that serves as a crucial link between health plans, organizations, healthcare providers, and patients, verifying that healthcare professionals meet the necessary standards of competence and ethics to provide safe and high-quality patient care. It establishes the foundation of trust between healthcare providers, health plans, and patients. Practitioner credentialing also serves to safeguard the organization’s reputation, minimize risk exposure, and uphold their commitment to delivering high-quality care to their members. For healthcare providers, it helps to validate their skills, training, and professional background and opens up new opportunities by enabling them to participate in various health plan networks and expand their patient base. Most importantly, credentialing helps give patients confidence that their healthcare provider has met the necessary standards of competence, training, and ethics to provide quality care.
Who Sets the Standards for Provider Credentialing
In order to ensure that healthcare providers in their jurisdiction meet defined standards of training, safety, and quality, regulators and other agencies work in conjunction to set standards and requirements that serve as certifications of quality for credentialed providers. Several entities set these standards, including but not limited to:
- The Centers for Medicare and Medicaid Services (CMS) set standards for credentialing healthcare providers who participate in federal healthcare programs, ensuring both that people who rely on these services receive quality care and that taxpayer funds are spent efficiently.
- State licensing boards define requirements for the licensure of healthcare providers in their respective states to ensure practitioners meet standards for education, training, and ethics.
- Professional organizations set standards for credentialing within specific healthcare professions; for example, the American Medical Association (AMA) sets standards for physicians, while the American Nurses Credentialing Center (ANCC) sets standards for credentialing nurses.
- The National Committee for Quality Assurance (NCQA) is a non-profit organization that works to improve health care quality in the United States. It accredits healthcare facilities, such as hospitals and clinics, and sets standards for credentialing healthcare providers who work in those facilities, serving as a de facto baseline for other organizations’ credentialing standards. In addition to its other responsibilities, the NCQA also certifies credentialing verification organizations, ensuring that they meet rigorous standards and can be relied upon for accurate and efficient credentialing processes
- The Joint Commission is the nation’s oldest and largest standards-setting and accrediting body in health care. As an independent, non-profit organization, the Joint Commission evaluates healthcare organizations and establishes criteria that must be met to ensure high-quality care. By setting these standards, the Joint Commission helps promote patient safety, quality care, and professional accountability within the healthcare industry.
The Provider Credentialing Process from Application to Decision… and Beyond
Credentialing is a complex process in which healthcare providers, health plans and organizations, healthcare facilities, and credentialing verification organizations all play a role. With multiple steps and multiple opportunities for mistakes or errors, provider credentialing can often stretch out over weeks or even months, much to the dissatisfaction of all parties involved. To provide an overview, here are the key steps in the provider credentialing process.
The Provider Credentialing Application
Credentialing can take place at many levels of the healthcare system. An individual may choose to apply for credentialing from a hospital, provider group, or directly to a healthcare network. As an example, health plans credential provider groups or healthcare facilities to ensure they meet the standards of the networks they operate. Once one of these individuals or entities decides they would like to join a healthcare network or system, they complete a credentialing application.
The application provides the organization with information that accurately summarizes their qualifications. In the case of individuals, it will include their education, training, certifications, experience, licensure, and other details that could impact an organization’s decision to approve them, such as any past disciplinary actions, suspensions. In the case of a facility or provider group, the information required will be different, but will serve the same purpose: to assess the entity’s qualifications to provide quality healthcare. This self-reporting task can be complex and time-consuming, but it’s vital that the application be filled out correctly, because incomplete or inaccurate data is one of the most common challenges in the credentialing process resulting in lengthy turn-around-times.
Provider Credentialing Application Review
For individual practitioners, the credentialing entity conducts an initial review of the application to ensure it is complete and includes details such as the practitioner’s education, training, licensure, and work history. If any part of the application is found to be incomplete, it is returned to the practitioner for completion.
In contrast, facility credentialing involves verifying the qualifications of an entire healthcare facility, such as a hospital, clinic, or nursing home. This process ensures the facility complies with healthcare regulations and standards and provides high-quality care. The initial review process includes examining documents such as licensing and accreditation records, quality metrics, safety records, and patient satisfaction reports. Similar to individual credentialing, if any required documents or information are missing in a facility’s application, it is returned for completion.
Thus, the credentialing entity serves as a gatekeeper, ensuring all required information is available and verified before a provider or facility is deemed fit to provide care. This rigorous process is essential for maintaining the high standards of care that patients expect and deserve.
Outreach and Follow-Up
When a provider or facility application is incomplete, the provider credentialing process hits its first roadblock. Providers must be engaged and alerted to submit the missing information before the file can move on to complete primary source verifications. Outreach can take any number of forms, from automated notifications or emails in an online application platform to emails, faxes, and telephone calls from a dedicated credentialing professional. Inaccurate or incomplete information entered into the application, such as contact numbers, emails or addresses, can further delay the process as credentialing teams cannot reach providers to rectify errors efficiently.
Primary Source Verifications
Once the application is complete, it proceeds to primary source verifications (PSVs). This stage can take a significant amount of time, as the source of every certification (e.g., educational institutions, licensing bodies, professional associations, previous employers, etc.) must be contacted and verified against the information reported on their application.
Data aggregation and workflow automation, such as that embedded in the a* platform, can accelerate this process greatly. Using data-matching algorithms, it can provide instant primary source verification against hundreds of data points on over 7.5 million healthcare providers and facilities in the US. The system also identifies gaps in the required information and provides instant alerts flagging potential roadblocks to practitioner credentialing such as malpractice, licensure, or sanctions issues, bringing such issues to the attention of credentialing professionals to make appropriate determinations.
Leveling and Credentialing Committees
Once primary source verifications are complete, applications are moved on to the organization’s credentialing committee, a body of highly qualified clinical professionals charged with reviewing credentialing applications and all relevant reports and information and determining if the applicants meet the standards required to practice in the network. Credentialing Committees make a decision on every provider who applies for participation in their provider network as well as those going through the recredentialing process. Most committees have a process in place where “clean” files do not go through the full committee review process but are reviewed and approved by the Chairperson of the organizations credentialing committee who has been granted the authority to review and approve clean files. With organizations having a process in place for approving “clean” files, it frees the committee to focus its time to review the more complex provider applications that need a detailed and thorough review, and educated credentialing decision.
Provider credentialing applications typically undergo a leveling process, during which they are grouped into tranches of providers with relatively similar levels of merit for approval or denial, along with summaries of any issues that require further discussion. This leveling process allows the credentialing committee to understand the issues, discuss them fully, and make a determination that aligns with the goals of the network’s credentialing policies and procedures, as well as the needs of patients.
One significant event that can impact a provider’s ability to deliver healthcare services is the issuance of a sanction by a regulatory authority such as the Office of the Inspector General (OIG), the System for Award Management (SAM), the Centers for Medicare and Medicaid Services (CMS), or any number of State licensing agencies or Boards. These bodies have the power to enforce sanctions and exclusions against providers or facilities for various infractions, including malpractice, civil judgments, or other disciplinary actions.
A provider or facility facing sanctions not only compromises their professional standing but also risks violating state and federal regulations. This could lead to significant financial penalties, loss of license, operational disruption, and reputational damage for both the sanctioned parties and the organizations they are affiliated with.
Given these potential consequences, organizations must institute stringent continuous sanctions monitoring to ensure that providers in their networks remain in good standing. This includes continuous verification of their status with the aforementioned regulatory bodies, as well as maintaining up-to-date licenses and other required credentials.
Ultimately, through rigorous sanctions monitoring and proactive credential management, healthcare organizations can safeguard their ability to deliver quality, compliant care to their patients.
The initial provider credentialing process offers only a snapshot of a healthcare provider’s qualifications at a given moment. As a network continues to operate, circumstances inevitably change. Licenses granted to healthcare providers or facilities, known as “expirables”, are valid for a specific duration, after which they must be renewed to continue practicing legally.
Expirables encompass not only licenses, but also certifications, insurance coverages, and other vital documents. If any of these documents expire, the provider or entity becomes ineligible to deliver care legally and safely, posing significant risks to patient safety and the organization’s compliance status. Therefore, it’s critical that providers or entities keep their credentials up-to-date and notify the credentialing organization about any changes.
Credentialing Verification Organizations (CVOs), health plans, or other associated bodies can continuously check and monitor various databases to ensure that all providers in their network maintain valid and active licenses, malpractice coverage and other critical credentialing components.
Credentials such as those that grant hospital privileges or participation in health plan networks need to be renewed on a predetermined cadence.Typically, that recredentialing schedule is every three years, but can be as often as every two years, or annually. During the recredentialing process, healthcare providers must provide updated information about their credentials, licensure, certifications and training. Plans, facilities, or CVOs must validate this updated information against the primary source, just as they do during the initial credentialing process. Since recredentialing dates can be anticipated, credentialing bodies can and should seize opportunities to streamline this process and complete it on time.
Healthcare Provider Credentialing Timelines
Practitioner credentialing timelines can vary depending on several factors, including the organization issuing the credential, the type of credential, and the completeness of the provider’s application. In general, the credentialing process can take anywhere from several weeks to several months, but delays in obtaining necessary documentation or verifying the provider’s education, training, and work history can extend these timelines.
When provider credentialing is delayed, health plans, providers, and ultimately patients feel the impact. If enough providers haven’t finished the credentialing process, a network may fail to meet adequacy or patient access standards and consequently be unable to launch, continue, or succeed in a given market. Providers whose credentials have not been approved may not deliver services to patients, frustrating them and impacting their practices’ business. And finally, patients have less options when seeking care, and may either face inconveniences or even fail to receive care they need, causing negative health impacts.
Challenges to the Healthcare Provider Credentialing Process
The provider credentialing process can be complex and challenging, with several potential roadblocks that can cause delays or complications. First among them are data challenges. At the outset of the process, incomplete or missing information can hold up applications before they even enter the primary source verification process, requiring provider credentialing teams to outreach to providers to complete the application. Depending on the responsiveness of the provider, the outreach process may add days or weeks to the credentialing timeline.
This process can be further complicated or derailed by outdated or incorrect provider contact information. Inaccurate or outdated certification, licensure, or other information has a similar impact on the verification process, adding complexity to the credentialing teams or organizations providing primary source verifications when they cannot quickly file or fulfill requests for verification.
The second major challenge occurs at the end of the process, as plans convene their credentialing committees. Credentialing committees must meet to review healthcare providers’ applications and approve them before the providers can render services to individuals. And just like PSVs, for many health plans these committees are plagued by administrative delays – just think about the headaches involved with scheduling several busy physicians to meet for several hours and review hundreds or thousands of credentialing applications!
The sheer volume of applications can compound all of these challenges, as can changing regulations and requirements. As health plans move into more markets, they must credential hundreds or thousands of providers at a time–multiplied by the number of markets they’re entering across counties, regions, and states.
Lastly, regulatory bodies, industry groups requiring credentials, and state governments can change timelines or standards, requiring organizations to adjust their workflows, breadth of verifications, or timelines.
Improving Approaches to Healthcare Provider Credentialing
Traditional provider credentialing approaches require teams of professionals to perform detail-oriented, time-consuming tasks–over and over again, without making errors. They need to validate that applications are complete and compliant, and then contact multiple parties to verify information, all while reaching out multiple times when either applications or verifying entities fail to respond in a timely fashion. All this repeated hundreds and thousands of times annually by each credentialing organization, network, and health system.
No wonder organizations are looking for a better way. Fortunately, there are several options for health plans and other entities responsible for credentialing providers. Some of them include:
Automating Healthcare Provider Credentialing Applications
Any highly repetitive, structured, and detail-oriented task can benefit from automation and optimization. When all the processes involved in practitioner credentialing are performed manually, a number of issues arise, affecting not only health plans, but also providers and ultimately patients. Medical practices spend, on average, $7,000 for each provider credential application, plus 20 hours of administrative time. Since the processes are manual, they are prone to human error. Administrative workers will occasionally enter a telephone number, email, or address incorrectly. This wastes the health plans’ credentialing teams’ time, which leads to delays in approvals for providers, who may spend months on staff before they’re able to see patients–impacting practices’ bottom line and patients’ ability to receive care.
How might automation make credentialing applications easier for providers? What if organizations or providers could start the process through any of a number of convenient ways–by providing their CAQH credentialing data, submitting their own data, through an application programming interface (API) that allows organizations to automate submissions from their proprietary data sources, or using a simple online application? What if the application drew on an industry-leading database of provider data to supplement the application with verified data, reducing the risk of inaccurate submissions?
The andros application system is designed to make providers happy. In fact, most of our credentialing applications don’t require any provider input. Whether we receive data from a client through an API, batch upload, or the provider-filed application, that step triggers the provider credentialing process and alerts andros to validate the providers’ data in its NCQA-certified credentialing process.
Our robust repository of data in the a* platform helps autofill provider information from verified sources, so that it’s nearly impossible for incorrect information to be submitted. In the 20 minutes it takes to complete, the andros application takes the burden off of your team and the providers in your network.
Automating primary source verifications
Once the application is complete and submitted, in a traditional manual credentialing workflow, the professionals begin verifying that the information submitted is accurate and complete by reaching out to the appropriate institutions, employers, and licensing boards. andros automates physician credentialing in two ways: by developing, maintaining, and continuously validating large stores of provider data and by implementing automated, low-touch workflows.
The a* platform, the largest single healthcare provider database in the industry, contains validated data on over 7 million providers across the United States. As andros collects data points from educational institutions, state licensing boards, federal databases, regulatory entities, and more on every provider we recruit, contract, or credential, the a* platform validates the new and existing data, increasing its accuracy and usefulness across the board.
During credentialing workflows, the a* platform uses data-matching algorithms to automate primary source verifications, identify gaps in the required information, and flag potential roadblocks like licensing issues or sanctions. If the a* platform can’t resolve the discrepancies, then it is routed for professional outreach to help resolve any issues. The andros team digs in on behalf of clients, reaching out to providers and facilities at least three times to get to the bottom of any flagged issues and perform quality checks to ensure every credentialing report is up to NCQA standards.
- Primary source verifications (PSVs) tracked by andros include:
- National Provider Identifier
- State medical license
- DEA and/or CDS license
- Board Certifications
- Sanctions and exclusions
- Malpractice History and any disciplinary information
- Education verification
- Medicare opt-out
- Optional PSVs like the Social Security death master, hospital admitting privilegesMedicare and Medicaid exclusions through NPDB query
Automating provider credentialing reporting
Provider credentialing isn’t complete until all the t’s have been crossed and i’s have been dotted. Health plans may require PDF copies as documentation of the process, but in many cases, digital data may be more valuable as it can be transferred from system to system for other purposes.
With andros, after credentialing is complete, clients receive all the provider information in an easy-to-read profile, including vital information like specialty, languages, malpractice information, credentialing status and much more. With comprehensive credentialing reports provided in multiple formats–PDF downloads, the andros web portal, or automated API transfers–clients can move through the final review and approval processes efficiently (or allow andros to manage the Credentialing Committee process as well).
The a* platform is the largest single healthcare provider database in the industry, containing validated data on over 7 million providers across the United States. As andros collects data points from educational institutions, state licensing boards, federal databases, regulatory entities, and more on every provider we recruit, contract, or credential, the a* platform validates the new and existing data, increasing its accuracy and usefulness across the board.
It also uses data-matching algorithms to identify gaps in the required information and flag potential roadblocks like licensing issues or sanctions. If the a* platform can’t resolve the discrepancies, then it is escalated to the appropriate internal expert to resolve any issues.
Improving Credentialing Committee Operations
The key to improving credentialing committee operations is eliminating the issues that pull time and attention away from its purpose: approving or denying applications from healthcare providers looking to participate in a provider network. After all, verifying providers’ credentials isn’t an end in itself; it is simply the means to make the best possible decisions about admitting providers to a network.
One place to start is by leveling providers before the committee meets. One group should contain providers with clean files and no outstanding issues when compared to the organization’s credentialing policies and procedures; the committee can approve these in bulk and quickly grant full network privileges. A second level, containing providers that have been flagged for sanctions or National Practitioner Data Bank (NPDB) alerts, will merit more scrutiny before a decision can be made. More complex leveling systems can allow for even more granular consideration of provider applications.
Other administrative tasks associated with credentialing committees can be outsourced as well, including: schedule coordination, meeting moderation, report preparation and presentation, minutes taking, and even informing providers when their applications are approved. andros committee management can be customized to clients’ needs, allowing internal teams and the committee members to focus on their core competencies.
Credentialing Verification Organizations (CVOs)
A CVO is an independent organization that specializes in verifying the credentials of healthcare providers. Since they specialize in credentialing, they can deliver greater scale and efficiency than in-house teams who are operating without access to the most modern and specialized software, lack data and data infrastructure, and are saddled with management duties. Outsourcing in this manner reduces the administrative burden on client organizations and ensures that the process is completed in a timely and accurate manner.
CVOs are also experienced in identifying discrepancies or red flags in a healthcare provider’s credentials, such as gaps in work history or unverified education or training. This can help to ensure only qualified providers are allowed to participate in the network, which can ultimately lead to better patient outcomes.
andros has transformed the way healthcare companies credential provider networks by leveraging hundreds of points of data collected on over 7 million healthcare providers across the US. Our optimized and automated credentialing workflows dramatically reduce turnaround times, producing complete credentialing files significantly faster than traditional manual processes. With flexible application processes, automated primary source verifications, and validated data, our workflows can deliver improvements of up to 300% compared to fully staffed internal teams using in-house data systems and traditional manual workflows.
To find out more about how andros can help you with your credentialing challenges, book a meeting with one of our credentialing experts.