Credentialing Problems? We Can Fix Them!

Let’s examine the most significant problems:

1. Manual, Paper-Heavy Processes

Despite technological advancements in virtually every other aspect of healthcare administration, credentialing often remains trapped in manual workflows that rely heavily on paper forms, physical signatures, and document shipping. Each provider application can involve hundreds of pages of documentation that must be meticulously reviewed, organized, and stored.

2. Redundancy and Repetition

Healthcare providers frequently practice at multiple facilities, yet each organization typically requires its own separate credentialing process, often requesting identical information in slightly different formats. This means physicians and other providers must repeatedly submit the same documentation, creating unnecessary duplication of effort.

3. Complex Verification Requirements

Primary source verification (the process of directly confirming a provider’s credentials with the original source) is both necessary and notoriously time-consuming. Credential verification organizations (CVOs) must contact educational institutions, previous employers, licensing boards, and other entities individually, often waiting weeks for responses.

4. Ever-Changing Regulations

Credentialing requirements continuously evolve based on changes in state regulations, payer policies, and accreditation standards. Keeping up with these changes requires constant vigilance and adaptation, placing additional burden on already-stretched credentialing departments.

5. Recredentialing Cycles

The work doesn’t end once a provider is initially credentialed. Most organizations require recredentialing every two to three years, creating a perpetual cycle of verification activities that must be managed across the entire provider roster.

6. Payer Enrollment Delays

After organizational credentialing comes payer enrollment. The process of getting providers approved to bill various insurance companies. Each payer has unique requirements and timelines, further extending the overall onboarding process and delaying revenue collection.

These issues aren’t merely administrative inconveniences, they represent significant operational and financial problems:

For Healthcare Organizations:

• Lost revenue during credentialing delays (potentially $7,500 to $30,000 per provider per month)
• Increased administrative costs for credentialing staff
• Compliance risks from inadequate verification
• Delayed service implementation and practice growth
• Frustrated physicians and staff

For Healthcare Providers:

• Income loss during waiting periods
• Professional frustration and decreased satisfaction
• Career advancement delays
• Redundant paperwork requirements
• Confusion about application status

For Patients:

• Reduced access to needed specialists
• Longer wait times for appointments
• Potential care discontinuity
• Higher healthcare costs passed along from administrative inefficiencies
  

Here’s what an ideal approach includes:

1. Centralized Digital Data Management

Modern credentialing requires a secure, centralized platform where provider information can be stored, accessed, and updated in real-time. This eliminates redundant data entry and creates a single source of truth for provider credentials.

2. Automation of Routine Tasks

Many verification activities can be automated through integration with primary sources, including license verification, OIG/SAM checks, and National Practitioner Data Bank queries. Automation reduces both human error and processing time.

3. Intelligent Workflow Management

Advanced credentialing systems can track application progress, automatically assign tasks to appropriate team members, and flag exceptions that require human intervention, ensuring nothing falls through the cracks.

4. Document Management Capabilities

Digital document storage with OCR (optical character recognition) capabilities allows for quick retrieval and analysis of provider documents, eliminating paper files and enhancing security.

5. Integration Capabilities

Modern solutions should seamlessly connect with existing healthcare systems, including EHRs, HR platforms, and practice management software to ensure data consistency across systems.

6. Analytics and Reporting

Robust reporting provides visibility into process bottlenecks, credentialing timeframes, and upcoming renewal requirements, enabling continuous process improvement.

Medwave’s comprehensive credentialing solution tackles the traditional pain points head-on through several key capabilities:

Streamlined Digital Application Process

Medwave’s platform eliminates paper-based workflows through a user-friendly digital application system. Providers can complete applications online, upload documents directly to the secure system, and track their application status in real-time. This transparency improves provider satisfaction while dramatically reducing initial processing time.

Intelligent Automation

The platform incorporates intelligent automation throughout the credentialing workflow. Their system can automatically verify certain credentials through direct integrations with primary sources, trigger follow-up communications for missing information, and manage re-credentialing cycles proactively rather than reactively.

Customized Workflow Management

Understanding that every healthcare organization has unique requirements, Medwave offers customizable workflows that align with specific organizational policies and procedures. This adaptability ensures compliance with internal standards while maintaining optimal efficiency.

Comprehensive Provider Data Repository

At the heart of Medwave’s solution is a secure, centralized provider data repository that serves as the single source of truth for all credentialing information. This repository supports not only initial credentialing but also ongoing monitoring, privileging, and re-credentialing activities.

Integrated Payer Enrollment

Medwave extends beyond organizational credentialing to streamline the payer enrollment process as well. By managing both processes in a coordinated fashion, they help reduce the overall time-to-revenue for new providers.

Regulatory Compliance Monitoring

The healthcare regulatory landscape is constantly evolving. Medwave’s platform stays current with changing requirements from accreditation bodies, state licensing boards, and federal regulations, ensuring organizations remain compliant without dedicating excessive resources to regulatory tracking.

Analytics and Performance Insights

Through robust reporting and analytics capabilities, Medwave provides organizations with actionable intelligence about their credentialing operations. These insights help identify bottlenecks, measure process improvements, and quantify the return on investment from credentialing optimization.

Organizations that implement modern credentialing solutions like Medwave’s typically experience significant improvements:

• Reduced Credentialing Timeframes: Processing times often decrease by 50% or more, allowing providers to begin practicing, and generating revenue, much sooner.
• Lower Administrative Costs: Automation reduces the staff time required for routine verification tasks, allowing credentialing specialists to focus on exception handling and more complex cases.
• Improved Data Accuracy: Digital systems with built-in validation reduce errors in provider data, enhancing compliance and patient safety.
• Greater Provider Satisfaction: Streamlined processes and transparent status updates lead to higher satisfaction among physicians and advanced practice providers.
• Enhanced Compliance: Systematic tracking of expiring credentials and automated alerts ensure timely re-credentialing and reduce compliance risks.
  

For healthcare organizations considering a transition to a modern credentialing system like Medwave, several best practices can help ensure success:

1. Conduct a Thorough Process Analysis

Before implementing new technology, thoroughly document current workflows, identifying pain points, redundancies, and manual processes that could benefit from automation.

2. Establish Clear Success Metrics

Define what success looks like with specific, measurable targets such as reducing credentialing time from 120 days to 45 days or decreasing credentialing-related provider complaints by 75%.

3. Engage Stakeholders Early

Include representatives from all affected departments (medical staff office, provider recruitment, compliance, IT) in planning discussions to ensure the solution meets diverse needs.

4. Plan for Data Migration

Develop a comprehensive strategy for transferring existing provider data and documents to the new system, with careful attention to data validation and quality control.

5. Invest in Training

Thorough training for all system users is essential for realizing the full benefits of new technology. Budget adequate time and resources for initial and ongoing education.

6. Start with Quick Wins

Identify high-impact, relatively simple improvements that can demonstrate value quickly while building momentum for more complex changes.

Forward-thinking organizations like Medwave are already exploring advanced capabilities:

Blockchain for Credential Verification

Blockchain technology offers the potential for immutable, instantly verifiable credential records that could dramatically accelerate verification processes while enhancing security.

Predictive Analytics

Advanced analytics can identify potential credentialing issues before they occur, allowing proactive intervention and further reducing delays.

Unified Provider Passports

Industry initiatives toward standardized credentialing data sets could eventually lead to “provider passports” that eliminate redundant verification across organizations.