A streamlined physician credentialing process is essential for patient safety, compliance, and operational efficiency for healthcare organizations. However, the process is extensive, complicated at times, and can take months to complete. Healthcare organizations can benefit from streamlined processes that heed best practices.
What is Physician Credentialing
Essentially, physician credentialing refers to the process of verifying a physician’s education, training, and licensure to confirm that they are capable of providing the standard of care required by license-granting healthcare organizations.
Importance of Physician Credentialing
The physician credentialing process is necessary to maintain patient safety, and because of that, healthcare organizations, networks, and insurance plans require it. Without credentialing, a physician cannot see patients or bill insurance plans.
Standards of Care
Physician credentialing helps to establish a level of care that is standard across all healthcare organizations, facilities, and practices. This makes it safer for patients because they know they can expect physicians to have the proper training, licensure, and knowledge to practice medicine.
Risk Management
Imagine if physician credentialing didn’t exist. Healthcare organizations would have no way of knowing what level of care they would be providing to their patients. The legal and financial risks a facility would take would destroy the organization because physicians could be practicing medicine with subpar skills. Physicians who’ve had their medical license suspended or those who never passed their licensure exams could be scamming patients and the healthcare organization they’re representing.
The risk of not conducting physician credentialing would create far too high of a risk for any facility to take on. By verifying credentials, healthcare organizations effectively manage their risk while having peace of mind that their physicians are providing quality care. While there is always a risk that mistakes could happen, there is a baseline level of care that is established that helps prevent instances of fraud or malicious malpractice from occurring.
Regulatory Compliance
The last piece of the physician credentialing puzzle is that it’s mandated by several organizations and laws (state and federal). Physician credentialing is required to ensure that physicians meet the state and federal licensing requirements, that they meet the healthcare organization’s accreditation standards, that the physician is not blacklisted on the federal OIG exclusion list, that the physician is following the Affordable Care Act, and the Physician Payment Sunshine Act, that they comply with insurance requirements including Medicaid and Medicare, that they have met the continuing education requirements, that they have not been subject to disciplinary issues. Finally, it also verifies that the physician has not violated anti-discrimination laws for healthcare organizations.
Healthcare organizations could lose accreditation if they have physicians on staff who have not been properly vetted. Physicians cannot practice medicine without passing a state medical board review, and the credentialing process allows healthcare organizations to confirm that. Compliance with federal mandates, such as the Health Care Quality Improvement Act (HCQIA) of 1986, requires healthcare organizations to check a physician against a database to find out about past malpractice cases. Additionally, Medicaid and Medicare also require credentialing before a physician can bill for services.
Actions Healthcare Organizations Can Take
While most healthcare organizations do their best to manage the physician credentialing process as best as they can, there are some common pain points for all organizations, large or small, that could be improved. The biggest issue is that the process isn’t streamlined! There are so many aspects to physician credentialing that it can be overwhelming for staff to handle internally, especially when it is not a short, simple, or quick process. Your healthcare organization can streamline the physician credentialing process in a number of ways.
Educate Your Team
The most important part of managing the credentialing process is to make sure your team understands what needs to be done, by whom, and on what timeline. By having a clear protocol for the steps that your organization prefers to take in the physician credentialing process, your staff won’t be scrambling and won’t miss pertinent steps, causing delays or duplicating credentialing efforts. Having a physician credentialing checklist of what mandatory documents you need can help. Keep the lines of communication open among departments so everyone (human resources, compliance, and the medical director) knows what’s going on. Assign leaders who will be responsible for keeping track of the entire process.
Use Credentialing Software
Even if you have individuals in charge of managing different aspects of the credentialing process, having a centralized credentialing software or platform will help your team be more efficient. At a glance, your team can check the status of a single physician’s credentialing verification and know where they are in the process. Credentialing software can also help reduce errors, which results in a more streamlined process.
Automate & Data Integration
If you can, take advantage of automation! Automating the process of checking your physician’s license, querying the National Practitioner Data Bank for past issues, and other compliance checks can save time and money for healthcare organizations by creating a more streamlined process.
Data integration is also an easy way to make the tedious physician credentialing process more efficient, especially when it is integrated with other systems within the healthcare organization. There’s no sense in duplicate processes, so make sure that all team members are on the same page regarding the physician credentialing process. There are a number of tools that make online verification a breeze.
Best Practices for Healthcare Organizations
Healthcare organizations wishing to improve the physician credentialing process at their facility should implement the following best practices.
Streamline Processes
Streamlining practices should be a priority for healthcare organizations. By taking action to identify the steps of the credentialing process to make it more efficient, automate when possible by implementing credentialing software, and by educating staff and opening inter-department communications, healthcare organizations are taking a step toward improving their physician credentialing process as a whole.
Track & Audit Credentials
Another best practice for healthcare organizations is to stay on top of credentialing for physicians on staff. Facilities can eliminate renewal delays and avoid interruptions by staying ahead of expirations, such as with malpractice insurance or licensure dates. This is a great practice to automate using software.
Check for Errors, Audit Internally
Having a dedicated team to review the work of others in the credentialing process is an important step because it is so complicated, time-consuming, and important. This isn’t something that should be done as punishment or to undermine the work of others, but rather, it should be implemented as a best-practice safety net. Internal audits can make sure all credentialing information is current and accurate and identify inconsistencies or missing documentation. This can resolve any issues or discrepancies, which keeps everyone in compliance, including the healthcare organization.
Preparation is Key: Keep Current with Regulatory Changes
By continuously monitoring state and federal mandates and staying abreast of upcoming compliance changes, you can help streamline the credentialing process by being trained and ready for any changes, whether they relate to accreditation standards or insurance requirements. Healthcare organizations can stay abreast of changes by attending conferences and webinars, reviewing industry news, and staying on top of the latest licensure updates to get ahead of changes that would impact credentialing down the line. By implementing changes in advance, healthcare organizations can work out any issues or delays before they are required.
Get Help With Physician Credentialing
Do you manage a healthcare organization and are interested in getting help streamlining your organization’s physician credentialing? Look no further. Contact Credence Global Solutions today to learn more about how we can improve your process.
