The National Committee for Quality Assurance was founded in 1990. For almost four decades, practices have been required to maintain, and regularly submit to carriers, credentialing data for their clinicians. So how is it, nearly forty years later, practices still treat this process as an afterthought?

The reality of “the re-cred firedrill” is not limited to smaller single clinician practices. The idea that a large health system, with fully staffed Medical Staff offices, whose responsibility it is to perform credentialing and privileging pursuant to the requirements of the TJC, could be equally challenged by a re-credentialing request from a carrier, is mind blowing. The reality, however, is that both initial and re-credentialing continues to be a challenge that practices face, and an afterthought the rest of the time.

The rationale for why this seemingly mundane reality goes unaddressed ranges from excuses about lack of staffing resources to the siloed nature of many large institutional providers. Regardless of the excuse, the outcomes are the same, reduced clinician productivity, reduced practice cash flow, the inevitable finger pointing exercise between payer and provider, and a likely group of patients that are caught in the middle.

In the age of value-based care, additional realities surface. The foundation for caring for a population is the identification of that population. While attribution methodologies may vary from health plan to health plan and even vary between product offerings within a health plan, in all cases a member is linked to a clinician, who in turn is linked to a practice entity (Group, ACO, CIN, etc.). Weak credentialing processes result in misattribution of members and at best lost opportunities for PMPM revenue, at worst significant challenges to the care coordination of that member.

The current processes employed by many practices are very much akin to a “pile of dirty laundry approach”. If you keep letting the laundry pile up until you reach the point that you no longer have a clean shirt to wear, you will find yourself having a rough morning. Doesn’t matter if you have a 1980’s style top loader, or the latest and greatest “Smart Tech” front loader. Maintaining your practices credentialing is no different than sorting your whites, lights, and darks, and then doing a load of laundry periodically.

If you are a small practice, this can be as simple as setting up a folder structure on your PC accompanied by a tracking spreadsheet. If bringing on new clinicians into your practice is a rare occurrence, make sure you have a checklist for on-boarding that includes all of the credentialing information needed for submission to the carriers. Be proactive, not reactive. If you are the type of person that prefers not to do your own laundry, make a call to the IPA/ACO/CIN that you participate in. They are equally incented to ensure your credentialing is well maintained, despite not having the Fee-For-Service reality your practice faces.

Large groups and faculty practices may require more robust system solutions for data maintenance, however in most cases a solution is relatively easy to implement. In the case of faculty practices, it is often as simple as breaking down the silos between practice administration, medical staff administration, the managed care office and the Human Resources department of the facility/system. In most circumstances, privileging is a prerequisite to employment. Creating a feedback loop between departments is critical. When a credentialing package is compiled and submitted for medical staff approval, it should also be submitted to carriers with an expected future start date. If, for some reason, the clinician does not join the practice, they can be terminated in the carrier record with a phone call. By waiting until the clinician starts, or as often times is the case, the discovery by the managed care team that a clinician began a month or more in the past, forcing that managed care team to compile the credentialing data separately and on their own, and then waiting for a carrier decision, the hired clinicians productivity has just been delayed by 3-6 months at best. That’s 3-6 months of panel building loss, 3-6 months of Fee-for-Service revenue, and 3-6 months of potentially attributable members lost. The only other alternative is to impact your existing clinical staff by forcing them to oversee and sign off on all of the work of that new clinician, impacting their individual productivity.

It’s easy to blame the payer community for protracted credentialing decisions, however, more likely than not, submission delays and incomplete submissions are the root cause of the problem. Maintaining a comprehensive process with strong controls will alleviate most of these concerns and create an environment that is defensible for your practice when a carrier is to blame for delays in credentialing.

Contact info@copehealthsolutions.com or 213-259-0245 for a quick gap assessment and to implement a process that may help you alleviate concerns in credentialing.