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Top 5 Challenges in Medical Credentialing and Strategies to Overcome Them

Medical credentialing rigorously verifies healthcare providers' qualifications and competencies. Medical credentialing is crucial, posing challenges for healthcare. In this post, we discuss credentialing challenges and best practices to overcome them.

The Expansive Scope of Credentialing Data

Credentialing requires collecting and verifying vast practitioner information. It includes:

1. Academic Records

Credentialing requires verifying practitioners' education, training, and credentials from primary sources.

2. Licenses

Collecting active medical license details for every state the provider will practice in. It includes license numbers, issue/expiration dates, and disciplinary status. Licensure must be re-verified on an ongoing basis.

3. Specialty Certifications

Board certification is verified through specialty boards. Details like certification status, expiration dates, and any disciplinary actions must be gathered. Recertification is required on a regular basis.

4. Hospital Affiliations

Verify hospital privileges, including dates and restrictions. It often requires coordination across multiple facilities.

5. Work History

Typically, document a 5-year work history with location and responsibilities. Employment details are verified through the Human Resources departments.

6. Malpractice Insurance

Verify malpractice coverage details, including claims history. Minimum coverage amounts are usually mandated.

7. Ongoing Education

Track CME credits, specialty training course completion, and other ongoing education credentials. Minimum annual CME requirements must be met.

8. Sanctions

Screen government sanction lists for disciplinary actions.

9. Peer References

Require letters of recommendation vouching for competencies and character. The number of peer references varies by organization.

10. Criminal Background Checks

Performing county/state/federal-level criminal record checks to identify any exclusions.

Credentialing data collection and verification is extremely expansive. Managing this carries major compliance risks and resource burdens. Automated credentialing systems are critical for healthcare organizations today.

Challenges in Medical Credentialing

1. Struggles With Data Accuracy and Integrity

Maintaining accurate and current credentialing details is paramount but challenging. Most healthcare organizations rely on manual data entry and spreadsheet tracking. Such antiquated systems are prone to errors like:

Missing or outdated documents lead to compliance gaps. A 2022 survey found that 9% of providers had expired licenses on file.

  • Inaccurate personal and practice information disrupting directories. One study showed that 18% of doctor directories had the wrong location or specialty data.
  • Duplication of effort across departments handling provider data. Credentialing teams spend 21% of their time re-verifying details.
  • Lack of audit trails proving due diligence.

Inaccurate credentialing data can disrupt patient care. It also poses compliance risks with steep penalties.

2. Constantly Evolving Compliance Standards

Compliance is one of the toughest challenges as standards continually evolve. Key requirements include:

  • NCQA regulations demand complete and current credentials. New 2022 standards require tracking of 10 separate provider details.
  • Timely re-credentialing every 2-3 years. AMA data shows that 60% of providers miss re-credentialing deadlines.
  • HIPAA mandates the protection of personal data. Breaches increased by 30% from 2020 to 2021.
  • Medicare conditions of participation. Violations can lead to exclusion from federal health programs.
  • Individual payer requirements. Top insurers have added over 200 new credential fields since 2018.

Oversights, like missed re-credentialing deadlines, can occur. Manual tracking of changing policies is burdensome and error-prone. Organizations need automated systems to guarantee compliance readiness.

3. Intensive Time Requirements

Credentialing workflows devour time when collecting, verifying, auditing, and updating data. Staff must chase down documents from various sources while juggling multiple provider files.

Despite large credentialing teams, backlogs often occur due to constant hiring needs. A 2022 survey found credentialing departments were understaffed by 35% on average.

Slow credentialing hampers provider onboarding and practice growth. It takes 102 days on average to credential a provider fully.

By automating administrative tasks, healthcare organizations can accelerate the process. Electronic data exchange with insurers and federated databases also helps curb workload. Automation can reduce credentialing time by 45%.

4. Specialized Expertise Needed

Recruiting and retaining qualified credentialing staff is difficult, given the specialization required. Key needs include:

  • Meticulous attention to detail and organization. Credentialing has up to 200 checkpoints per provider file.
  • Superb communication skills for corresponding with providers. 72% of providers complain about a lack of communication during credentialing.
  • Expertise in compliance protocols and standards. Only 23% of credentialing applicants have relevant certification or accreditation.
  • Commitment to credentialing as a profession. The average tenure of credentialing staff is less than 2 years.

Limited relevant training coupled with high turnover hinders many healthcare organizations. Without experienced teams, accuracy and compliance suffer. Resources must be dedicated to specialist staff recruitment, education, and retention.

5. Optimizing Solutions

Addressing these challenges is crucial through solutions like:

Credentialing Software

Automates data tracking and monitoring for accuracy. It can reduce errors by up to 57%.

Document Management

Streamlines attachment handling with online profiles. Improves accessibility to records by 65%.

Instant Credential verification

Checks credentials in real-time via digital networks. Accelerates the verification process by weeks.

Alerts and Notifications

Prompt for expirations and missing items to avoid lapses. Decreases re-credentialing deadline misses by 75%.

Reporting and Analytics

Provide insight into bottlenecks. Allow targeted workflow improvements.

Staff Training Programs

Invest in continuous learning opportunities. Linked to 38% better staff retention.

Outsourcing Assistance

Partner with external experts to supplement resources. Can improve throughput by over 50% during peak periods.

Optimizing workflows, staff, and automation can transform medical credentialing. It enables them to concentrate on providing high-quality patient care with minimal disruptions.

Final Words

Medical credentialing requires robust processes due to its direct patient impacts. Challenges like limited resources, data volume, compliance risks, and changes threaten efficiency & quality.

Automation, specialist staff, and education enable transforming credentialing. Investing in productivity and optimization solutions is crucial for overcoming the obstacles. Fast, accurate, compliant credentialing allows providers to focus on quality care.

Struggling with Medical Credentialing?

See how AltuMED's automated credential management platform can help

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