Health care Billing Services A Safe Passage For Denial And Hold off Administration - Small Enterprise

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Provider Credentialing: A Problematic Process Driving Costs And Delays™

On a typical day, the average physician sees about 19 patients for roughly 22 minutes each. That’s a busy day and anything that interrupts that schedule is a problem for them and their staff.

One of the things that does disrupt that rhythm is payer paperwork, which is a significant driver of administrative burden and waste in healthcare. Administrative transactions between providers and payers include a wide range of tasks performed by many different entities, but one piece of the puzzle that stands out as a particular problem area is the credentialing process.

Issues with Payer Enrollment

Credentialing is fundamental to making the payer-provider relationship work, particularly the payer enrollment aspect in which clinicians are credentialed by payers. But, payer enrollment has a few key characteristics that bog down the entire process:

- Fragmented Data: Data is constantly pulled from and verified by a variety of sources - in other words, many sources of truth. This leads to repetition of tasks and exposes the process to error.

- Ownerless Data: Confusion about who actually “owns” the handling of the data results from the variety of ways data is managed and transmitted. Different provider organizations use different roles in the process - larger provider organizations may have in-house medical staff offices or centralized verification offices, while smaller entities will put the burden on administrative staff that’s already handling other vital parts of the practice. Payers also have a variable cast of characters managing collection, verification, and cleansing of data, adding to the number of people and offices who handle a piece of the overall process with no centralized oversight.

- Manual Processes: So much of the work itself is still done by hand - 10% of credentialing applications are still transmitted via paper mail, and many payers still require “wet signatures” from providers. Even for digitized processes, providers still have to print and physically sign forms, then upload and transmit them. All of the manual exercises involved add time and the chance for error.

- Inconsistent Processes: Address changes and other events that prompt an alteration to provider data contribute to a cycle of transactions that are both vital to provider payment and fraught with problems. An estimated 2% to 2.5% of provider demographic data changes each month, triggering added iterations of the data management processes and more opportunities for error.

There are some solutions in the industry that have been designed to help with these problems, but in some cases, they are making the problem worse, not better. A recent HealthStream survey found that 20% of credentialing professionals said vendor solution limitations were “the most challenging impediment” to progress.

Streamlining The Process

While the payer enrollment process continues to be a speed bump in the business of healthcare, it’s actually becoming more important than ever. Value-based care has increased the importance of care coordination, adding another layer of complexity to administrative tasks. Increases in mobility among hospital-related professions are leading to more instances of data change. And, patient expectations are evolving to demand swifter action and information sharing.

At this point, healthcare providers, payers, and everyone in between them require truly digital, bilateral, automated solutions to the problem of payer-provider transactions, which is the source of an estimated $2 billion in administrative waste. A solution that makes credentialing less of a headache for all must include

- Many faces: To solve an industry problem, you must serve the whole industry. Digital solutions must include a provider interface that allows clinicians to input their data and transmit it directly to the organization that needs it.

- Centralized database: With a single venue provider insurance credentialing for data entry, data sharing, and data usage, providers and third parties can review and process the information in one place. Additionally, making all payers’ forms more easily accessible and automatically updated with changes can eliminate time providers spending bouncing from payer to payer.

- Digital signatures: “Wet” signatures are a major barrier to truly digital “paperwork” between providers and payers. Implementing digital signature coordination could significantly reduce administrative waste.

- Continuous data coordination: Credentialing is a process that must be repeated every few years both on the provider end and payer end. Ongoing, real-time, automated data coordination would help decrease manual data retrieval and repetitive data entry.

As providers, payers, and other organizations they work with continue to adopt automated solutions, the industry will see reduced administrative burden and billions of dollars freed up for what’s most important: patient care.

About Jim Dougherty

Jim Dougherty is a serial entrepreneur with nearly 30 years of expertise in bringing automation to manual administrative processes in the financial services and healthcare industries. At Madaket Health, Jim leads the company toward its goal of creating streamlined solutions for the increasingly complicated world of healthcare information technology and data management.