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Credentialing: More than applications and checklists

October 3, 2019

Think back to 2015 when the healthcare community frantically prepared for the implementation of ICD-10 and try to remember how many workshops, meetings, training sessions and vendor calls you had to participate in. It was all a bit overwhelming, wasn’t it? Well, credentialing and network management are replacing ICD-10 at the top of our list of operational challenges facing practices in 2018.

Why is credentialing so important? 

We’re glad you asked. Credentialing is the first step in a laundry list of events that must go smoothly for a provider to be reimbursed for their work by third-party payers. There was a time when we all thought CAQH was going to save us from the burden of paperwork for multiple credentialing applications. It sounds great in theory, but unfortunately, it hasn’t turned out that way.

After reviewing our own processes for provider enrollments, we determined there are an average of six steps to add a provider for each contracted payor, in addition to the completion and quarterly updates of the provider’s CAQH profile.

The process to initiate a provider credentialing application is different for every payer: some direct you to a web form, some want you to email a specific email address and others request a phone call to open an application.

If that’s not confusing enough, those with online forms and application links can change them at any time without notice, so you are out of luck if you’ve mapped templates or created detailed guidelines.

Once you’ve managed to successfully navigate the credentialing labyrinth, you are probably also seeing frequent and repetitive requests from payers to confirm your provider data for their online directories. If we are already attesting that our CAQH data is accurate on a quarterly basis, why do we need to do it in multiple places? Much of the urgency is due to CMS reviews of Medicare Advantage Organization (MAO) provider directory information. In their prior studies, CMS found that over 50% of the MAO data reviewed contained inaccuracies, including phone numbers, locations and whether the provider is accepting new patients. These data deficiencies have costly implications, including negative impacts on access to care.

With the threat of fines looming for inaccurate provider lists, some of the major insurers are piloting a program to use the decentralized nature of blockchain technology to share provider demographic data. Let’s hope UnitedHealth Group and Humana are successful in their study and make strides to eliminate waste in the system for patients, providers and payors.

To summarize, thank your credentialing specialist today!

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