Medical credentialing: More to good health than meets the eye

July 19, 2011
Complex and evolving regulatory reform renews the importance of automated solutions.

Many patients know little more about their doctor's qualifications than what they see hanging from an office wall. While they can access detailed qualification information about their mechanic or lawyer, it is when they are at their most vulnerable, trusting their family's health to a qualified healthcare professional, that they must hope that there's more than meets the eye behind the confusing abbreviations listed across those medical school diplomas.

Medical credentialing is increasingly important because it is the one procedure that allows patients to confidently place their trust in their chosen healthcare providers. Through a standardized process involving data collection, primary source verification and committee review by health plans, hospitals and other healthcare agencies, patients are assured of their healthcare professional's merit and experience. With the advent of Web services and other technology innovations, credentialing is therefore a prime area for increased efficiency and process improvement.

Generally, physicians need to engage in a tedious, paper-based credentialing process before a health plan can contract with the provider or a hospital can grant affiliation. However, this burden can be greatly reduced. Electronic credentialing processes offer organizations efficiency, thereby reducing the burden on all stakeholders and positively impacting quality.

Make no mistake: The need for electronic credentialing
Medical errors are responsible for the deaths of 98,000 Americans each year and, by and large, this statistic impels industry leaders to fight for enhanced standards of competency and greater disclosure of recorded disciplinary actions against healthcare workers.1 Yet organizations continue to use slow, manual and paper-based credentialing processes that will never truly guarantee transparency of providers' credentials.

With one simple human error in handling the current clutter of paper documentation necessary to credentialing, a nurse can be authorized to perform services beyond his experience, or a physician with an expired license can be allowed to continue to practice. This can have serious negative ramifications to patient safety, a physician's professional survival and an affiliated institution's reputation.

Hospitals and other healthcare organizations have traditionally viewed credentialing as a check-the-box regulatory burden and have largely overlooked the benefits of a streamlined approach. Without an understanding of the cost benefits, risk mitigation and general efficiency of an electronic credentialing system, it's no wonder that most healthcare organizations only check credentials at the time of hire and then once every two or three years. More continuous monitoring is neglected because of the time and cost involved with manually validating employee records against various primary sources. In many cases, manual data acquisition and verification on a single provider can take anywhere from several days to several months to complete.

The good news is that complex and evolving regulatory reform has placed renewed importance upon healthcare organizations to invest in automated credentialing that expands access and meets benchmarks for improving the quality of care while reducing overall costs.

Outsourcing as an option
Credentialing verification organizations (CVO) utilizing robust Web-based software platforms that integrate provider data collection, verification, reporting, etc. can be an effective turnkey approach to achieving electronic credentialing. This allows healthcare organizations to immediately reduce fraud and eliminate waste by centralizing provider data for enterprise-wide use and meeting ongoing compliance requirements for verification of crucial staff qualifications.

Such CVOs must, however, deliver a robust package to make this option viable. At a minimum, the solution must provide for electronic data capture to collect and manage provider data, constantly verify background information, generate online reports and statuses, and complement all aspects of credentialing while following regulatory requirements offered by NCQA, URAC and the Joint Commission.

In response to the challenges of manual processes, electronic credentialing eliminates errors and reduces labor costs by allowing organizations to screen practitioners in real time.

Now, more than ever, healthcare organization leadership is expected to ensure greater patient safety, protect their institutions from financial harm and reduce costs. Real-time electronic credentialing can be a significant factor in achieving these goals.

1. “U.S. Markets for Acute Care Clinical Information Systems 2007,” Millennium Research Group; December 2007;; Accessed May 31, 2011.

About the author
Matthew Haddad, J.D., is president and CEO of Medversant Technologies, LLC. He is also a patent holder of Medversant's AutoVerifi technology (US Patent No. 7,529,682).
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