5 Ways To Improve Credentialing

Credentialing is critical for hospitals and health systems, as it validates a provider’s qualifications, board certifications, work history, and references.


The term usually comprises two separate processes. One, called privileging, involves approving an individual provider to perform a specific procedure or specific set of privileges. The other, provider enrollment, ensures providers are enrolled with all of their organization’s insurance plans, so they receive correct payment.

The credentialing process is a major hurdle for hospitals, ambulatory surgery centers, and physician offices. The process can cause significant delays in getting new clinical staff onboard and reimbursed for the services rendered.

survey of 500 healthcare industry leaders revealed that two in three credentialing processes (67 percent) are taking longer than five to six weeks to privilege a physician. Sixty-two percent of respondents said it takes from one to three weeks for peer references to respond to traditional privileging requests, according to SkillSurvey.

Additionally, the provider enrollment portion of credentialing can take 90 to 120 days and sometimes longer, according to Lynbrook, N.Y. based Newport Credentialing Solutions.

Scott Friesen, CEO of Newport Credentialing Solutions, says credentialing is often a lengthy process, both on the privileging and provider enrollment sides. On the privileging side of credentialing, regulatory agencies require that disparate data sources are validated prior to granting a physician privilege to provide a particular clinical service. Similarly, on the provider enrollment side of credentialing, insurers have different enrollment forms and applications — paper, online and delegated agreements — that need to be processed prior to accepting a provider into their panel for reimbursement. Some insurers process enrollments faster than others, but on average, a provider can expect the process to take 90 to 120 days, he says.

Mr. Friesen says an enterprise platform that connects the hospital, provider, and insurer into one unified platform that shares one data set would help speed up the process. “There are so many data points required on the privileging side, as well as on the provider enrollment side, and there’s no enterprise-wide platform that allows hospitals, providers, and insurers to streamline the process by sharing a single, interoperable dataset. It’s just a highly fragmented process that is yearning for an enterprise-wide solution. It makes absolutely no sense that in today’s technological age, hospitals, providers, and insurers can’t share an interoperable data set,” he says.

Becker’s Hospital Review recently spoke with Mr. Friesen and Jacqueline Lam, CPCS CPMSM, director of medical staff services at Mineola, N.Y.- based Winthrop University Hospital, about streamlining the credentialing process. Here, they outline five improvements that could be made to the process.

1. Utilize an enterprise-wide cloud-based technology platform. Utilizing the benefits of the cloud, an enterprise-wide platform will allow hospital privileging and provider enrollment staff, medical providers and administrators to access provider data at any time and in any location, Mr. Friesen says. A lot of technology systems are client server-based, making it difficult to access and share data. For example, a health system that has recently merged may have five hospitals with five separate credentialing systems. Further, these systems are not interoperable and do not aggregate provider data in a way that is easy to access, manage and report on. Mr. Friesen says hospitals need to have an enterprise-wide platform, allowing all of the parties to access data at the same time and in real-time.

2. Ensure data is accurate and current. Mr. Friesen says its critical to ensure data that is entered into a credentialing system is correct. On the provider enrollment side, data that a hospital or medical group has in their credentialing software may be different than what the insurer has in their credentialing system, Mr. Friesen says. So he encourages hospitals and medical groups to follow policies and procedures that ensure their data matches what the insurer has. Mr. Friesen recommends conducting quarterly provider roster reconciliations to ensure that the information in the provider credentialing system is the same information that’s in the insurer credentialing system. If this doesn’t occur, the result may be lost revenue for the hospital or medical group.

3. Understand the impact of delayed processing on revenue. On the privileging side, hospitals and health systems lose money if they hire a physician and it takes six weeks or more to grant privileges. “Investing in technology and services that generate faster and more robust responses will have an impact on the quality of information received as well as reducing the turnaround time for the privileging process,” Ms. Lam says. The same goes for the provider enrollment side. Every day that process is lengthened, the provider may lose revenue because the provider isn’t accepted by the insurance company and the insurance company isn’t going to pay them for services. “so on both sides, hospitals have to have technology that allows them to look at the financial impact of the processes they have in place because if they don’t they’re losing revenue,” Mr. Friesen says.

4. Streamline operations surrounding enterprise-wide technology. Mr. Friesen says hospitals and health systems should have enterprise-wide policies and procedures on how to process provider data, regardless of whether it’s on the privileging or enrollment side. Additionally, they must have key performance indicators in place to track performance. “There hasn’t been a lot of focus placed on standardized key performance indicators in provider enrollment, so developing KPIs that track operational and financial performance is critical so that providers can measure their performance and therefore improve upon their performance,” Mr. Friesen says.

5. Communication is key. “Credentialing is a team effort,” says Ms. Lam. Therefore, it’s important that all areas involved in the credentialing and privileging process work together. “Resources from IT, finance, risk management and human resources all need to work closely with medical staff and provider enrollment in order to coordinate a smooth transition with minimal to no loss of revenue,” she says.