Credentialing the First Step to Revenue

The credentialing process is essential to both private practices and hospital-employed provider networks (EPNs) because it’s the key process to getting providers reimbursed for the services they perform. It’s analogous to breath to the lungs; that is,reimbursement is the life blood of the provider organization. In spite its critical role, credentialing is often executed haphazardly and the necessary steps skipped. Many times, whether in health systems or private practices, providers are hired and word of their employment some how seems to fall through the cracks from the point of signed contract to the first day of practice.

Practically, the processes of employing a practitioner and credentialing should mesh seamlessly so that the practitioner participates in most, if not all, of the system’s payer contracts at the time that he or she begins seeing patients.Given the importance of credentialing providers, it’s curious that the process remains a stepchild in the operations of many healthcare businesses. Uncredentialed providers, in the worst situations, create denied and unpaid claims. In its best side of a bad situation, the lack of credentialing requires holding claims and submitting them once the provider is credentialed. With Medicare, for instance, providers can capture charges retrospectively for up to one year before reaching timely filing limits. This inefficiency builds unnecessary burden and weakness into the operations of the system’s revenue cycle. Even when the process runs smoothly, credentialing is a painstaking endeavor requiring months to reach fruition. Healthcare entities should evaluate their credentialing processes, procedures, and people to ensure the addition of practitioners to insurance panels occurs efficiently and timely relative to their contract signing and start dates.

Coker’s credentialing professionals can help systems that seek to outsource or have a flexible adjunct to the credentialing processes.Use of an outsourced solution can provide a practical stop-gap measure when there is a break in employment of credentialing staff (e.g., termination of a staff member, medical or other leave, etc.) and a semblance of continuity to ensure that the process of enrolling providers continues. With quality replacement staff, healthcare enterprises can continue credentialing providers and expedite the protocol to confirm that there is no breach in the continuum. The departure of a staff member, regardless of their skills (e.g., a strong credentialer vs. a weak credentialer),without suitable backup can present significant challenges to on boarding and paneling providers,which negatively impacts revenue. An outside partner can create economies of scale. Companies that specialize or have a service line with a specialty in credentialing should bring to the table efficiency in process and structure due to their volume or specialization in the multitude of steps that comprise the credentialing continuum.

If there is an influx of providers who require credentialing, and insufficient staff to handle the workload, outsourcing to a partner like Coker may help systems through the number of new providers awaiting credentialing. When the immediate demand has waned, or the process is brought to the point where the paperwork had been submitted to payers, and the waiting game ensues, the system might elect to scale back resources (and costs) to manage the remainder of the process in house. Systems should strengthen the credentialing process either through outsourcing or by bolstering internal resources. Evaluation of the best approach, whether pure outsourcing, employing staff, or a hybrid approach, requires analysis and diligence by senior management. The end goal should be a solution that manages costs, strengthens core processes and procedures, and ensures continuity of the on boarding process. While one methodology might appeal to a system, any number of approaches are available to conquer the problem of credentialing. Credentialing may not be a zero-sum proposition.

Healthcare enterprises may opt for a flexible hybrid approach to meeting their needs by supplementing current staff when inundated and then reducing their manpower when the urgency and demand has been satisfied. The key issue in whatever approach is deployed is to ensure accuracy and continuity of process and procedures. Enterprises should evaluate the credentialing processes to ensure that providers are credentialed and can bill (and collect) for their services close to the date they begin rendering care. Health systems should weigh benefits and downsides to their current approach to credentialing to ensure that they are getting the most efficient and cost-effective process possible to confirm that providers are paneled with their payers.

Related Insights