The lesser-known process affecting healthcare quality: Credentialing

By Mark Hirschhorn

March 15, 2022

Over the last two years, we’ve gained more insight into the inner workings—and over-burdening—of the healthcare system than ever before. However, most people are still unaware of how much time-intensive administrative work is involved in the healthcare they receive.

This work which takes countless hours of healthcare workers’ and administrators’ time, on top of other responsibilities, includes one of the most important, and least visible, facets of healthcare: credentialing.

What is credentialing? (And why does it matter?)

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Credentialing is part of the process by which healthcare providers join health plans, and receive privileges to practice with or at specific healthcare facilities.

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A practitioner who has been credentialed/approved to work at one facility might not have the necessary credentials to practice medicine at a facility across the city.

If you’ve ever wondered why some healthcare providers are covered by your insurance and others are not, it comes down to credentialing. If a provider is credentialed to work with your insurance plan, you can have some or all of their fees covered by that plan.

The credentialing process is meant to take into account the various factors that determine how qualified a certain practitioner is to provide care to the people on a given health plan. These factors can include considerations like:

What kinds of qualifications they have,
Whether they’ve kept their knowledge up-to date with continued training,
Whether other institutions they’re associated with can corroborate these facts.

All of this information, and more, should be a part
of a health plan’s decision about whether or not to
credential a doctor.

If this seems complicated, that’s because it is. The
healthcare system—already not the most efficient
structure—loses time and money every year to
the paperwork and red tape and hours that the
credentialing process involves.

When credentialing breaks down

Inefficient credentialing can approve providers who are unqualified to practice in a particular context, and stall qualified providers’ ability to see patients.

In a complaint originally filed in 2017 and updated earlier this year, a whistleblower alleged that massive insurance network Aetna was including deceased doctors in its network of providers supposedly available to treat Pennsylvania children whose healthcare was covered by Medicaid.

According to the whistleblower, nurse and former Aetna quality management consultant Carol Wessner, Aetna was also listing providers who had moved out of state, and those who didn’t specialize in pediatrics, as available to care for kids in PA. The result was hundreds of kids going without everything from check-ups to specialized care. The company then kept the money paid out by Medicaid as compensation for services never rendered.

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Proper credentialing would’ve weeded those providers out of the network.

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And while this case may seem like an isolated situation, the reality is that similar issues affect healthcare access and efficiency all over the country. In Ohio, where the state government has recently awarded Aetna a $1 billion contract to create a program for coordinating care for children with complex needs, the consequences could be particularly immediate.

When dangerously incompetent neurosurgeon Dr. Christopher Duntsch (the subject of several lawsuits, as well as ample media coverage) was practicing medicine in Texas, records of the harm he’d caused patients piled up before he was finally stopped. More efficient credentialing could have been a key component in stopping him earlier along his path of destruction by preventing him from avoiding the consequences.

Before dozens of people were wounded or killed and hundreds of kids went without care, smarter credentialing practices might have saved the day by both reducing human error and making it harder to hide deliberate fraud.

How good credentialing protects patients

Poor and inefficient credentialing practices
directly affect patient care, which is why solutions
that reduce the burden on those who handle
credentialing are so important. A credentialing
process that’s up to the challenge of building,
expanding, and managing provider and payer
networks help connect qualified, available
providers with as many patients as possible.

When you’re seeking healthcare, you’re often at
your most vulnerable. Many people work to become
fierce advocates for themselves and loved ones
in the face of a complicated and overwhelming
system. While their efforts are admirable, they
shouldn’t be necessary.

Good credentialing removes a layer of uncertainty from healthcare, by ensuring all practitioners you may come into contact with are qualified to treat you. Listing a provider on a health plan’s network is like giving them a stamp of approval. When these networks are properly screened and maintained, they expand access to high-quality healthcare. When they’re not, unqualified practitioners can wreak havoc, and people can’t connect with vital healthcare.

Equitable credentialing = equitable care

While this wave of information may seem intimidating, understanding credentialing is empowering. When you’re deciding on a new health plan, ask about their credentialing processes and how they vet new providers. As about the lines of communication between the health plan, and the medical facilities where its providers practice.

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Credentialing is empowering

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Credentialing may seem overly complicated, or too bureaucratic to have an immediate effect on patient wellbeing. The reality, though, is that when it’s done improperly or ignored altogether, patients can end up being treated by unqualified doctors, or they can end up not being treated at all. Credentialing is one of the almost-invisible processes that make the healthcare system run and ensuring that it works as efficiently and effectively as possible can help remove one more barrier to high-quality care.

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