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Professionals with problematic and tarnished credentials pose serious risk to healthcare consumers and create financial exposure – in the form of CMS fines -- for the institutions that unknowingly employ them. This black cloud now extends to health plans.
A vast number of physicians and other healthcare professionals are currently practicing with expired licenses or questionable issues regarding their credentials. Professionals with problematic and tarnished credentials and qualifications have been discovered working in hospitals, nursing homes, ambulatory surgical centers, and other healthcare facilities. These individuals pose serious risk to healthcare consumers and create financial exposure – in the form of CMS fines -- for the institutions that unknowingly employ them. This black cloud now extends to health plans.
Most health plans credential physicians and facilities before adding them to their list of participating providers and periodically re-credential these providers while they remain in the network.
Credentialing is mandated in accordance with federal and state laws, Joint Commission, and NCQA. Credentialing involves gathering of background information from healthcare professionals in accordance with regulatory and organizational bylaws. Small healthcare organizations may have several hundred healthcare professionals to credential, while large organizations may have hundreds of thousands of staff. The average credentialing application is more than 10 pages long and some can run in excess of 30 pages. The sheer volume of information required to be recorded taxes even a well-staffed credentialing department. In reality, most departments are understaffed and overwhelmed by these burdens.
All credentials information must be archived and accessible when needed for audit or subpoena. To further complicate this situation, this process may need to be repeated continuously as it is the healthcare organization's duty to know the quality of the healthcare professionals practicing within their domain.
Web-based credentialing can address these issues and the many processes surrounding today's medical staff and human resources environments. By combining these processes into one convenient electronic location, online credentialing eliminates the need for paper files and multiple databases. The result is a streamlined, coordinated system that allows health plans and institutions to track credentials on an ongoing basis and take appropriate action in a timely manner.
At the outset, healthcare professionals complete a single online credentialing application, which is centrally stored on secure servers. Every email, correspondence, or other communication can be handled through the system, preserving a complete digital record of all credentialing-related activities. Information can easily be imported from or exported to other operational systems.
This information can be electronically verified against outside data sources. Select service companies now offer proprietary technology on an outsourced basis to acquire practitioner credentials and then electronically verify them against databases including state license boards, Drug Enforcement Administration (DEA), National Technical Information Service (NTIS), and the Excluded Providers Listing Service (EPLS). Stakeholders can log on when convenient and from any location 24/7 to check on the progress of credentialing processes, eliminating unwelcome surprises and ensuring that staff always knows the status of credentialing activity.
Credentialing has been viewed as a necessary evil and regarded as a cost center, extending the legacy of healthcare being administrated but not managed. While credentialing was once perceived as an extremely inefficient and insurmountable challenge, it is now being resolved by the advent of Web-based services. Currently, more than 5 million U.S. practitioners are credentialed by 150,000 healthcare organizations in accordance with 52 individual state requirements, federal requirements, as well as Joint Commission, NCQA, URAC, CMS, AAAHC, and others every two to three years. Thanks to Web-based credentialing, provider data can now be monitored on a continuous basis in accordance with relevant accrediting organizations and government agencies.
Health plans and acute care settings will require careful monitoring of credentials including contracting, pay-for-performance programs, enrollment, member services, risk mitigation, certification, and provider reporting. As patients are empowered with online provider directories, specialty selection criteria, and geographic considerations, those charged with supplying provider data should consider Web-based credentialing as a solution.
Matthew Haddad is president and CEO of Medversant, a provider of Web-based healthcare practitioner management applications.