In attending various talks and participating in meetings with departmental leaders, it became clear to me that not every professional is aware of credentialing needs beyond their own purposes. There’s nothing abnormal about that, as facilities which separate out credentialing-related tasks often end up unknowingly growing significant information silos, and those departments don’t collaborate nearly as well as they should.
Provider credentialing is all about perspective, and a number of differing perspectives are easily confused, and lumped in as simple “credentialing”. Rather, there are three primary perspectives to consider: those of the credentialing facility, the enrollment specialist, and the insurance company or payer. All three have differing agendas, and all three can have widely varying processes and needs.
The need for these departments to work with some cohesion has become better recognized in recent years. Numerous hospital systems and facilities are looking to combine provider enrollment and provider credentialing departments into a single unit. While this approach is not strictly necessary and, in some cases, detrimental, bridging understanding gaps between these functions is essential.
The credentialing facility is looking in from a patient and organizational safety perspective. Is this provider appropriate to be onboarded to the desired Medical Staff? Credentialing specialists will work behind the scenes to validate that this physician’s past and declared experience are both appropriate and accurate. Along the way, they’ll be looking for signs and red flags, and intuiting as much as they can about the provider. Additionally, credentialing specialists will be looking to participate well within the regulations of their accrediting body, if applicable.
The Enrollment Specialist will be concerned with getting this physician ready to submit claims to payers (federal, state and private). The specialist may perform some credentialing tasks, such as pulling licensure and other documentation to accompany the application. The enrollment specialist will also need to work as closely as possible with the provider to ensure that all applicable information is correct, and that no omissions have been made – regulatory and legal standards are stringent for physicians who omit important disclosures, even if those omissions were made in genuine error.
The payer or insurance company may investigate providers just as fully as a credentialing facility. Depending on the provider type and the policies of the insurance company, the file can be quite extensive. The payer or insurance company will contact the enrollment specialist for any missing documentation or assistance in procuring documentation. This can be a team effort.
For the most part, the work of the payer credentialing system will be silent; therefore, I’ll just focus on the duties of Provider Enrollment Specialists and facility Credentialing Specials.
Here are seven specific reasons to consider putting heads together:
Decrease or Elimination of Redundancies
Here’s the thing: physicians are busy, and have limited time to give to the credentialing and onboarding processes. Oftentimes, enrollment specialists and credentialing specialists consider the time necessary to bring a new physician on staff. For provider enrollment, 60 to 180 days is standard. Depending on the policies of the Medical Staff, it can be the same or longer for a physician to gain privileges.
While the facility is busy preparing for the new physician, the physician is still carrying on their busy practice in the meantime, or in the process of an arduous cross-country move. Extensive paperwork coming at the provider from two different departments ensures that items will likely fall through the cracks, or that the physician may even feel alienated or like his/her time is not seen as important. Schedule time for departments to meet with each other, and determine which paperwork can be eliminated or combined. Physicians will thank you for it.
Engender Mutual Understanding
As mentioned, sometimes the goals of each department can be diametrically opposed. Effort should be made to explain to the other department the processes in play and why they exist. The need to maintain profitability and the need to maintain patient safety are both paramount to the success of a healthcare organization. Employees of each department should understand why the other perspective is both necessary and potentially helpful to their own goals.
Increased Communication = Faster Onboarding
I would be willing to bet anyone who’s been in this industry for any length of time has seen it happen: A new physician is coming; his contract is signed, he’s met his new business partners, he’s had lunch with administration. He’s filled out his Pre-Application with the Medical Staff Office, and he’s working on his full application, and he’s already put in an offer on a house. Things are going great, and it seems like everyone is ahead of the game, weeks and weeks into the process. And then… wait! No one told the Enrollment Specialist. But this physician is scheduled to start working in six weeks, and it takes up to four months to enroll a physician. This will mean a large payment gap for the practice, and more than likely, a great deal of blame will be thrown about.
Departments comfortable with working together better avoid these situations. Their processes are intertwined and, therefore, everyone knows precisely what they mean to the other department. There is a clear process for which employee needs to notify the other department of an incoming physician. It may seem like an obvious step, but it’s missed often enough. It’s important for these departments to keep in touch!
Reduction in Error
The less typing, the less unintentional error. In an ideal world, provider enrollment specialists and credentialing specialists would share the same software platform. This would help streamline the separate processes, help individuals extract the information they need, and help to avoid those pesky information silos. It’s not always possible, but at the very least reduction in error should be an incentive to tighten processes and share information whenever possible.
Better Provider Relations
This goes back to reducing redundancies. Physicians have an appreciation for individuals who make their lives simpler – not more complicated! Payment and onboarding are both very important to physicians, and are often some of the first experiences they have with the new facility. Take advantage, and craft processes which simplify the onboarding process, and demonstrate the savvy of the facility. For example, strive to add no duplication to the state provider credentialing application or new physician application used. The Medical Staff Office can collect the application and send it to the provider enrollment specialist, or vice versa. If licensure and other documentation are available in a central location, it’s unnecessary for the each department to pull documents or inquiry physicians separately.
More Accurate Record-Keeping
If one department is responsible for updating provider demographics, and systems are accessible by both departments, error is easily avoided. An alert system for updated demographics could be helpful to inform the other department when it’s necessary to log in and review updated information, in the event that updates are needed in payer portals or other payer applications.
Safer Privileging Practices
The process of privileging is enormously important, and separate of credentialing. Each facility must perform its due diligence and analyze a practitioner’s ability to carry out each privilege reasonably granted to them, and to identify deficiencies. Depending on the presence of an accrediting body, those standards can be highly delineated and complicated. When there is interdepartmental understanding and action is taken to ensure proper time to vet applicants, those individuals responsible for granting privileges are better able to take time to properly evaluate applicants. Clear communication can help to avoid the “time crunch” and produce a better, safer onboarding experience.
Provider enrollment specialists and credentialing specialists may have differing perspectives, but their ultimate goal should be the same: the onboarding of a qualified physician. Each department has the capability of helping or hindering the other. Processes must be designed to facilitate the sharing of information and responsibilities. Otherwise, experiences within the department and, more importantly, the experience of the physician, may paint an unpleasant picture of individuals and the facility. As in most situations communication is key: How can departments or individuals better facilitate each other and create a dynamite onboarding process?