If your medical credentialing is still being done with filing cabinets, paper, spreadsheets, email, and fax, upgrading to medical credentialing software or a total outsourcing solution will save time and effort and increase the accuracy of your credentialing.

The long and arduous medical credentialing process

Before a practitioner can see patients and earn revenue, credentialing and privileging must be performed. To credential a new practitioner requires that the healthcare organization validate their qualifications and experience. This often requires direct communication with educational and training institutions, hospitals, previous employers, licensing agencies, and other entities.

After this primary source verification is complete, medical staff determines which clinical services the physician or practitioner is competent to provide, called privileging. This entire process takes an average of 90-120 days, during which a healthcare practitioner may not practice medicine and cannot bill for services.

Only after credentialing and privileging are complete, can enrollment applications be submitted to insurance plans for the practitioner. Once an application is submitted, the health plan reviews the practitioner’s credentials again and establishes him or her in their appropriate networks. This same application process must be completed for every insurance plan, and with their specific applications, which takes an additional 60-120 days. The opportunity for mistakes with all of these disparate applications is immense and if mistakes are made, the approval process is delayed.

Time is money and shaving days, weeks or months off the credentialing, privileging and insurance approvals amounts to very significant savings – tens of thousands of dollars or more per provider.

Credentialing mistakes lead to slow reimbursements

Medical credentialing requires rigorous attention to detail. Whether 1 person is doing the credentialing for 50 providers or a staff is performing the duties for an entire health system, credentialing specialists must be well-trained, well-supervised, and current with provider information and the unique policies for each payer. The sheer amount of paperwork that needs to be executed and filed for each healthcare practitioner can overwhelm even the most astute professionals and when credentialing mistakes are made (and humans make mistakes), disputes and declines rise for payments for services, which slows cash flow for the healthcare organization.

Credentialing and enrollment also present major operational headaches for providers. Each insurance payer has their own requirements and processes and applications are duplicated. If paper-based applications and communications are still being used, the healthcare organization can experience significant delays in getting new staff credentialed and reimbursed for patient care. This causes delayed reimbursements, longer days in accounts receivable and increased write-offs.

Hospitals and medical practices have two choices to reduce the workload and speed up payments: medical credentialing software or outsource the entire credentialing process. Both solutions offer a paperless workflow, increase the speed of reimbursements and save effort, but there are significant differences between the two.

Medical credentialing software pros and cons

Credentialing software installed on desktops is not a great idea, as the software must be frequently updated and will be “held hostage” by the desktop and operating system it’s installed on. Cloud-based credentialing software is always the best bet, as it can be accessed from any computer anywhere via a secure login, is always up to date, and is formatted for any screen. One must also consider:

  • Cost of the software license per user
  • Return on investment
  • Staff Research and Training (8 weeks – 8 months)
  • The number of paper files which must be scanned and mapped into the software system
  • Software bugs
  • Customer support
  • Frequent updates to the software to ensure that submission forms are compliant
  • Cost may not be efficient for small practices
  • IT department buy-in and support
  • Implementation timeline
  • Which executive will spearhead implementation?
  • Who will manage the project to completion?

Benefits of outsourcing medical credentialing

  • Credentials and re-credentials healthcare providers for you
  • Credentialing staff is free to perform other duties, saving on overhead
  • No burden on the IT department
  • Fast turnaround on payments
  • No need to submit the same information for the same physician multiple times.
  • 100% Compliance with the Affordable Care Act, Medicare, and Medicaid
  • Submit applications only once and have them distributed automatically to every health plan you choose
  • Physician and healthcare practitioner information needs to only be submitted once.
  • Verifications are updated automatically