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How to enhance revenue cycle management with effective provider credentialing

Provider credentialing is pivotal for enhancing financial stability in the complex healthcare management’s complex ecosystem. 

While issues like patient volume, billing errors, inconsistent provider data, and shifting state regulations often take center stage, they account for just a fraction of the $60 billion spent on administrative tasks. 

This spending, 15% of which is attributed to administrative waste (non-clinical costs that don't enhance patient care), is exacerbated by inefficient provider credentialing — from chasing down providers for information to tracking application statuses. The role of effective provider credentialing in revenue cycle management (RCM) is crucial and cannot be underestimated.

Why it's key to address provider credentialing inefficiencies

Provider credentialing — a thorough process that verifies a healthcare provider's qualifications and history — not only protects patients but also ensures your medical practice receives payments from commercial payers, Medicare, and Medicaid.

We spoke with Medallion’s Senior Director of Operations, Caitie Barrett, to dive deeper into the role of provider credentialing in RCM. She emphasized the importance of efficient credentialing practices for patient safety and ensuring timely payments for healthcare organizations.

“Credentialing involves multiple steps — from application receipt, review, data verification, committee evaluations, to approvals. Maintaining this data is really tough, so anything you can do to remove time from the process while still being compliant and doing things well is so important,” Caitie explained.

The power of provider credentialing on Revenue Cycle Management (RCM)

For healthcare establishments, from expansive hospitals to private clinics, a robust RCM is foundational. It covers everything from patient registration to the final payment. Efficient RCM ensures consistent cash flow, which is essential for both operational and clinical functions.

Caitie added, “Credentialing and RCM often operate within different departments in a hospital. So, having accurate data from credentialing is critical to ensure appropriate payments.”

The ripple effects of provider credentialing

It leads to organizational financial stability

Effective credentialing is a linchpin for financial health in medical practices. As highlighted by MGMA, without a strategic approach to credentialing, practices risk fiscal challenges. This can manifest as disrupted cash flow, potentially affecting staff compensation and the procurement of essential medical supplies.

It leads to patient satisfaction

Credentialing plays a pivotal role in ensuring seamless billing experiences, which directly contribute to patient trust. However, the inverse is also true. As reported by MGMA, over half of medical practices noted an increase in denials related to provider credentialing in 2021. Such issues can dissuade patients from revisiting, even if they received high-quality clinical care.

It leads to operational efficiency

Any oversight in credentialing diverts resources from primary care. Over time, such misallocations can compromise service quality. A 2021 MGMA poll highlighted that credentialing issues significantly contributed to claim denials, with challenges ranging from prolonged application processing to inconsistent payer communication.

Strengthening RCM with provider credentialing

Effective credentialing results in:

Fewer claim denials 

Many claim denials stem from provider data inconsistencies. It’s an area where 49% of medical practices are struggling. Efficient credentialing reduces these issues, leading to fewer rejections.

Swift reimbursements

Properly credentialed providers ensure faster claim approvals, stabilizing revenue streams.

Enhanced patient trust

Patients feel more confident knowing their healthcare provider meets insurance standards.

Caitie remarked, “The more streamlined the credentialing process, the more time providers can dedicate to patients. Speedy credentialing also reduces claim denials due to delayed approvals.”

The future of provider credentialing

Embracing technology-driven credentialing can mitigate many challenges. By doing so, healthcare organizations can avoid delays in provider onboarding, claim corrections, and hefty compliance penalties.

“Transitioning from a generic healthcare approach to a more personalized, demand-driven model is the future,” Caitie noted.

By collaborating with a competent Credentials Verification Organization (CVO) and leveraging modern technology, healthcare organizations can revolutionize the credentialing process. Automation and AI have made the process more efficient than ever.

Choosing an effective CVO: Key considerations

Choosing a credentials verification organization (CVO) can greatly enhance your credentialing process. When evaluating potential CVOs, consider the following key aspects:

Provider onboarding:

  • Evaluate the efficiency of the CVO's onboarding process.
  • Inquire about their specific procedures and request evidence of their timelines.
  • Determine if they can integrate providers promptly and seamlessly.

Automated credential file creation:

  • Automation can significantly expedite processes.
  • Assess if the CVO utilizes automation for file creation and how it impacts the overall timeline.

Primary source verifications:

  • Understand the breadth and depth of their source verifications.
  • Determine which sources they verify and the geographical coverage of these verifications.

Manual PSV turnaround times:

  • Speed is crucial in verifications.
  • Investigate their turnaround times for manual Primary Source Verifications (PSV) and gauge if it aligns with your organization's operational pace and growth objectives.

Beyond these primary considerations, go deeper into their offerings and capabilities:

  • User experience: Do they offer intuitive dashboards that simplify the user experience?
  • Multiple solution offerings: Assess the comprehensiveness of their solutions. Do they cater to all your needs?
  • Roster creation: Can they assist in creating rosters efficiently?
  • Payer process understanding: Gauge their familiarity with payer processes to ensure smooth interactions.
  • Customization: Determine if they offer customization options to tailor their services to your specific needs.
  • Client testimonials: Client feedback can provide insights into their efficiency and reliability.
  • Certifications: Check if they are NCQA certified, which can be an indicator of their commitment to quality.

By meticulously evaluating these criteria, you can select a CVO that aligns with your organization's requirements and goals.

Establish these five steps for optimal provider credentialing within your organization

  1. Engage a designated credentialing specialist to ensure efficient application management.
  2. Allocate sufficient time to understand the intricate and time-consuming process.
  3. Regularly update CAQH profiles for swift verifications.
  4. Maintain current contact information and keep provider contact details up-to-date.
  5. Follow up after application submission to stay proactive to address any issues promptly.

Because in the evolving landscape of healthcare management, recognizing the power of effective provider credentialing is undeniable. It transcends mere regulatory compliance — it strengthens the financial and reputational pillars of healthcare institutions. Medallion offers an NCQA-certified CVO solution that enables healthcare organizations to move faster and get ahead — in days, not weeks. With automated verifications and a dynamic platform that optimizes every aspect of your provider credentialing process. Learn more about Medallion CVO services here.