Let’s be real here – the medical credentialing process can be a beast. It’s a tangled web of rules, paperwork, and hoops to jump through. And when things go wrong, it can get ugly quickly.
Think about it. You’ve got doctors, nurses, techs, and all sorts of other medical professionals that need to be properly vetted and approved to work at a healthcare facility. Miss a single step in that process and you could be looking at some serious consequences.
We’re talking potential lawsuits, giant fines from regulators, damage to your organization’s reputation, and even putting patient safety at risk in the worst cases. It’s a credentialers’ nightmare.
So what sort of mistakes am I talking about here? Well, there’s a few biggies that tend to trip-up people. Here’s an explanation…
Inadequately Following the Rules
The credentialing process isn’t some casual suggestion – it’s the law in most states. Healthcare facilities have to make sure their medical staff meets very specific criteria before letting them anywhere near patients.
Things like verifying their education, training, licenses, certifications, work history, malpractice claims, sanctions, and criminal background. If you cut any corners or miss anything, that’s a big no-no that could get you in deep trouble down the line.
Making judgment calls that don’t align with the established policies and processes is just asking for issues. The rules exist for good reasons – skimping on them means putting your organization at major risk.
Failing to Keep Immaculate Records
Documentation is king in the credentialing world. For every provider, you need to maintain detailed, well-organized files spelling out their qualifications and any other relevant info.
If the paperwork is a mess with missing documents or sketchy record-keeping, good luck trying to prove you did things properly if questions ever come up. Sloppy files raise all sorts of red flags and make your whole credentialing program look questionable.
Things move fast in healthcare – keeping meticulous records takes diligence. But it’s a necessity, not an option. Poor documentation has sunk many a credentialing ship before.
Letting Things Slide or Drag On
The credentialing process requires punctuality and good follow-through. Letting things slide by ignoring deadlines, putting off reverifications, or not promptly addressing issues is just negligent.
Maybe a doc’s license is expiring soon and it slipped through the cracks. Or a nurse got disciplined in another state, but the information wasn’t properly reviewed and addressed. Those kinds of oversights, as small as they might seem in the moment, set the stage for much bigger problems down the road. It creates vulnerabilities in your credentialing program that can blow up into front-page scandals if someone drops the ball.
The credentialing process is ongoing – it requires constant monitoring and a commitment to never let things slide. Getting lax or complacent is the quickest way to get blindsided by expensive messes.
Ignoring the Need to Keep Up With Changes
Here’s the thing – the rules, regulations, and industry standards related to credentialing are always evolving. There are constant updates and changes happening at the state and federal level.
If your organization isn’t proactively tracking those changes and adjusting procedures accordingly, you’re setting yourself up to get left behind and fall out of compliance without even realizing it.
Maybe new license verification protocols rolled out, or there was a change to NCQA standards that impacts how you handle certain disciplinary issues. If you’re still following old guidelines without adapting, you’re doing it wrong – plain and simple.
Organizations have gotten torched for credentialing mistakes stemming from being behind the times. Keeping up requires diligence and an eagerness to adapt. The credentialing world stops for no one.
Trying to Cut Corners or Go Cheap
At the end of the day, credentialing is one of those things you can’t afford to skimp on or cut corners with. It requires devoting the proper resources, budget, staffing, and robust processes to get it done right.
Maybe an organization decides to handoff credentialing duties to an overworked team that lacks bandwidth. Or they try pinching pennies by using subpar verification tools and services. Those kinds of half-measure, cut-rate approaches are just begging for issues.
Credentialing done properly requires investment – both financially and from a staffing/operations perspective. It’s never going to be the cheap and easy road. Cutting corners or going bargain-basement is a great way to open your organization up to risks galore.
Those are some of the biggest pitfalls and mistakes I see healthcare organizations stumble into with credentialing. But why does it really matter? What’s the big deal if things get a little messy?
Well, as I mentioned before, the consequences of credentialing screw-ups can get very expensive very fast. We’re talking potential costs and risks that can cripple an entire healthcare system if things really go off the rails. Here’s a quick rundown:
Mega Fines and Sanctions
If a credible accusation emerges that you’ve got major cracks in your credentialing processes, you can bet the government regulators are going to descend on your organization like a swarm of angry locusts.
We’re talking full-scale audits and the potential for fines/sanctions from groups like:
- State medical boards and licensing agencies
- Regulatory bodies like the Joint Commission, NCQA, CMS, DEA, etc.
- Health insurers and payer programs like Medicare and Medicaid
- State attorneys general wielding consumer protection laws
And those fines can get absolutely staggering. Some of the biggest accrediting agencies have the power to hit you with 7-figure penalties for credentialing program deficiencies.
Even if the fines don’t bankrupt you entirely, the costly corrective action plans and increased scrutiny from regulators going forward is a nightmare. Getting back in their good graces could take years of arduous work.
Then there’s the headache of possibly losing certifications, accreditations, and participation statuses with major insurers and healthcare programs. That credentialing-fueled sanctions domino effect could cripple a healthcare system’s revenue streams and operations for a long time.
Disrupted Operations and Revenue Loss
We’ve already covered how credentialing mistakes can trigger crippling sanctions that imperil funding streams and payer participation statuses. But that’s just the tip of the iceberg when it comes to operational headaches and lost revenue.
Think about all the productive time and manpower drained by things like:
- Audits and investigations from regulators picking apart your processes
- Having to re-verify credentials for huge swaths of your medical staff
- Onboarding delays and staffing shortages created by uncertainty
- Lost billable hours from providers tied up in legal battles
- Service line shutdowns if certain practices lose credentials
Credentialing fires act like a drought sapping away at the operational and financial well being of a healthcare organization. It can take a long time to get things flowing smoothly again once that happens.
And we haven’t even mentioned the costs of shelling out potentially millions to overhaul policies/processes, upgrade technology systems, hire consulting help, and implement corrective action plans. It’s a money pit that many healthcare organizations lack the resources to climb out of.
Higher Insurance Premiums
If credentialing issues lead to an onslaught of malpractice claims and lawsuits, you can bet that’s going to do a number on your organization’s malpractice insurance rates going forward. Heck, some healthcare liability policies may drop you entirely if the credentialing problems are bad enough. Those that stick around will absolutely bake huge premium hikes into future coverage as a risk tax. Malpractice insurance is already a massive fixed cost for healthcare operations. Having those premiums skyrocket after a credentialing disaster makes an already tough business model even more unsustainable.
Those are just some of the extremely costly consequences healthcare organizations open themselves up to if the credentialing process goes awry. It has the potential to detonate financial bombs that obliterate even the biggest healthcare systems.
So What’s the Solution?
Well, first and foremost, healthcare credentialing needs to be treated as the utterly vital risk management function that it truly is. It can’t be an afterthought or a silo’ed off responsibility that gets brushed aside. From the C-suite down to the boots on the ground, everyone needs to appreciate how important airtight, consistently executed credentialing processes are. It should be a sacred, non-negotiable priority for any organization that hopes to avoid catastrophic fallout.
That level of cultural buy-in coupled with sufficient budgets, staffing levels, technological resources, and adherence to best practices is how you begin building a credible credentialing program. There’s no cutting corners – it requires total organizational commitment.
Having redundancies, expert guidance, and routine auditing of the processes is also pivotal. Credentialing isn’t a fire and forget task. It requires diligent ongoing monitoring and rapid response capabilities to quickly address any issues. While meticulous and resource-intensive, doing credentialing the right way is far cheaper than absorbing the extreme costs that inevitably arise from letting it become a tangled mess.
Will it require investment? Absolutely. But it’s a critical expense that pales in comparison to the potential bankruptcy-inducing damages that can stem from credentialing going off the rails. So don’t let complacency put your whole healthcare operation at risk. Get credentialing right, or be prepared to pay a price you may never financially recover from.