How to Evolve from Manual Provider Credentialing to Automated

The healthcare industry, which suffered from administrative disorganization, is finally changing.

Credentialing, the process of verifying a specific healthcare professional's qualifications, training, educational background, skill set, and experience before allowing them into a network, traditionally used to be a time-consuming and paper-heavy process.

But now, with technological progression, providers and health systems can save their valuable time, money, and legwork by automating the credentialing process.

In this article, we will explore the need for credentialing, a comparison between manual and automatic credentialing systems, and how automation can solve countless credentialing issues and streamline the onboarding process.

Why Do We Need to Do Credentialing at All?

Why can’t we just analyze candidates looking to enter the healthcare field based on what’s on paper and bring in all the help this industry needs?

In simplest terms, the results could be devastating because an error can go beyond financial loss and threaten human life.

There are several reasons why credentialing is an absolute need for the growing healthcare industry:

• Patient Safety. Credentialing helps you verify if the said person is fit for the job. By verifying their education, qualifications, and experience, unqualified individuals are prevented from practicing and potentially harming patients.
• Maintaining Standards. Credentialing establishes professional quality standards that enable healthcare organizations to provide high-quality care consistently and protect patients from getting subpar treatment.
• Minimizing Liability. Credentialing decreases the probability of a financial and legal risk for healthcare providers and health plans since there are fewer chances for malpractice suits and legal repercussions.
• Building Trust and Accountability. Knowing their provider is qualified and carefully vetted enables patients to trust and have confidence in the treatment provided. This also ensures that there is an ongoing concept of accountability—healthcare professionals operate in the best faith, with compliance to Standard Operating Procedures (SOPs) and vigilance, so that they don’t lose their license.

The Need for Automated Provider Credentialing

Credentialing has always been around—ever since ancient times. Around 1000 B.C., Persians developed a process for physicians to earn a licensure before practicing publicly.

Documented proof of credentialing dates back to the 13th century. In the US, CAQH’s (The Council for Affordable Quality Healthcare) credentialing has been an industry standard for more than a decade and is currently used by over 2 million providers and nearly 1,000 participating organizations.

However, credentialing has always been a highly manual process until recently. During a survey by the Medical Group Management Association (MGMA), at least 73% of provider executives said their organizations are focusing on automating physicians’ administrative tasks.

But why was there an urgent need for this change?

The MGMA survey highlighted that over half of medical practices reported an increase in denials related to provider credentialing in 2021. This eventually caused the industry to shift toward automated credentialing systems.

Who Sets the Provider Credentialing Requirements?

The credentialing requirements must stay consistent for provider credentialing to be effective in maintaining a standardized, above-par quality of care across the healthcare industry.

Thus, it’s crucial as to who sets the credentialing requirements. Globally, this responsibility is shared by several key entities:

• National Committee for Quality Assurance (NCQA). The NCQA provides guidelines for healthcare provider credentialing—their major focus is on technical aspects such as written policies, verification, ongoing monitoring, and data reporting.
• Country-Level Regulations. Requirements for complementary health practitioners vary significantly across countries, and their local authorities set the requirements for credentialing systems. For example, the Medical Council of Canada (MCC) oversees it in Canada, the General Medical Council (GMC) manages it in the UK, and the Australian Health Practitioner Regulation Agency (AHPRA) is in charge in Australia.

Benefits of Automation Compared to Manual Provider Credentialing

The global COVID-19 pandemic revealed the limitations of manual credentialing, giving a wake-up call to make the onboarding process of healthcare professionals fast, smooth, and cost-effective—to cater to the rising need for professionals in healthcare facilities.

Moreover, a high increase was observed in the number of provider credentialing denials—not necessarily because of professionals lacking the skill, education, qualifications or experience, but because of the limitations, inaccuracies and inefficiencies of manual credentialing systems.

Let’s look at automated vs manual provider credentialing from a utilitarian point of view.

• Time and Money. Verifying all of a provider's credentials manually is a very time-consuming process—with an extraordinary cost involved.
  The verification process requires contacting multiple sources, such as schools, state licensing boards, and previous employers, to verify information provided by the professional.
  Automated provider credentialing can save us from the staggering amount of legwork and smooths out the onboarding process by verifying provider credentials electronically—saving time, money, and exhaustion.
• Data Security. As the data involved in credentialing is stored in multiple locations, it is challenging to keep track of it all and ensure that every file or document is safe and secure. Since sensitive information is involved, manual credentialing is prone to security breaches and identity theft.
  An automated provider credentialing system typically stores data in a secure, centralized location to protect it from breaches and unauthorized access.
• Margin of Error. There is a very high chance of error in manual data entry, and it can be difficult to keep track of that margin of error when dealing with extraordinarily large amounts of data. That’s exactly why manual provider credentialing is highly prone to delays and inaccuracies in the credentialing process—which results in an increased number of denials.
  Automating the process eliminates all potential mistakes that could happen during manual data entry and verification, ensuring accurate capture and validation of provider credentials from reliable sources.
  Moreover, automation allows us to cross-reference across databases, scanning data from official websites and licensing boards—making the entire process error-proof. With such accuracy, automated credentialing systems can enhance patient trust and increase overall care quality.
• Communication. Manual provider credentialing systems can be a mess—frustrating email threads, unanswered calls, and missed updates abound. As a result, there are communication gaps and delays, as information gets lost in the shuffle.
  With an automated provider credentialing system, there is a more streamlined workflow—keeping everyone in the loop. There’s better communication as a result of automatic real-time updates, helping credentialing bodies monitor application progress, and identify any missing documentation in advance. This allows for timely intervention and resolution of issues—minimizing delays and inefficiency.
• Environmental Impact. As manual provider credentialing relies heavily on paperwork, it’s a wasteful and environmentally unfriendly process. Moreover, manual files are hard to move and access which brings more delays and difficulties in the credentialing process.
  Digital records save both your time and paper—making the entire process environmentally friendly. Also, easy accessibility from any location makes it easier to manage data.
• Tracking. In manual credentialing, tracking deadlines and renewal requirements is a very challenging ordeal since every record is manually maintained. In the case of an expiration, there could be a lot of complications—putting patients at risk.
  Automated provider credentialing systems make it easy to set alerts and reminders for automatic monitoring of deadlines and renewal dates for various licenses, certificates, and other medical requirements. This ensures that all credentials are up-to-date and that there are no lapses in coverage.
• Compliance. Manual provider credentialing struggles to uphold compliance because it can be difficult to keep up with the latest credentialing regulations and requirements. As a result of non-compliance, there is a risk of fines and penalties. 
  Having automated credentialing systems can mitigate these risks and ensure ongoing compliance by offering streamlined verification, simplified workflows, automated alerts and reminders, improved data accuracy, and regulatory compliance tracking.

Does Automation Handle Credentialing Challenges Better Than Manual Credentialing?

Credentialing is a demanding process that faces countless challenges. Let’s look at how automation can address those challenges far better than a manual provider credentialing process:

• Scattered Information. Dealing with information scattered across multiple channels and mediums is chaotic. That’s why credentialing teams waste a lot of time sending requests through paper, emails, and faxes, potentially missing important details due to data inconsistencies and discrepancies.
  An automated credentialing system provides a central hub with secure online access and stores all provider data in one place—with real-time accuracy.
  Also, standardized formats and automated communication almost eliminate manual tasks for a smooth data exchange.
• Old Data. Data in healthcare is time-sensitive—the older it gets, the more unreliable it becomes. Outdated licenses, certifications, and sanctions can put patients in danger—hindering the overall process and compliance drastically.
  An automated provider credentialing system allows you access to constantly refreshed data from primary sources.
  Also, with proactive alerts that notify providers and institutions of expiring licenses, timely renewals happen in real-time.
• Accreditation Surveys and Compliance Audits. With everything happening manually, getting ready for an audit can be extremely difficult.
  Automation delivers well-organized systems that automatically track and record all actions on provider files, creating audit-ready documentation that meets accreditation requirements.
  
• Credentialing Committee Meetings. Bias can be one of the most disruptive elements in provider credentialing, and it’s unavoidable if everything is in human hands.
  Moreover, counterchecking that approvals and rejections didn’t involve any bias can be almost impossible, leading to delayed decisions and mistakes in denials and approvals.
  An automated system allows you to access populated summaries that highlight key information and potential concerns for each application without any bias—redacting identifying information.
  Moreover, electronic voting platforms make decision-making secure and efficient.

What’s the Best Software for Automated Provider Credentialing?

While there’s no shortage of run-of-the-mill credentialing tools, Certify stands out due to its groundbreaking features and ease of use.

Certify is a one-of-a-kind platform designed to simplify and automate key aspects of healthcare provider management, including credentialing, licensing, enrollment, and network monitoring.

Capitalizing on groundbreaking technology and verified data points, Certify helps clinicians, teams, and organizations to work smarter and achieve extraordinary results. The key functionalities include:

• Automated Credentialing: Real-time automation and NCQA compliance, reducing paperwork and administrative legwork.
• Simplified Licensing: Cross-state licensure across all 50 states and license categories, eliminating guesswork altogether.
• Smooth Enrollment: Agile provider onboarding with a payer enrollment process and individual dashboards for progress tracking.
• Network Monitoring: Automated, continuous monitoring of your provider network for ongoing compliance.

Save time, reduce costs, and ultimately deliver better healthcare. Reach out to sales@certifyos.com to chat with a member of our team—or request a demo to see our platform in action.

Frequently Asked Questions

What benefits does automated provider credentialing offer?

There are several benefits of automated provider credentialing, such as saving time, exhaustion, and resources and reducing errors for a faster and more compliant onboarding process.

What is the impact of automated provider credentialing on patient care?

Automated provider credentialing improves patient care by allowing faster access to specialists, ensuring the accuracy of the information, and fostering the development of patient trust.

What steps does the credentialing process usually consists of?

Credentialing starts with submitting an application with detailed information about provider education, training and professional history. This application goes for verification with licensing boards and institutions. The application is reviewed, after which there’s an approval or denial.

Is provider enrollment the same as credentialing?

Provider enrollment involves registering with insurance payers so that you can request payment. Provider credentialing, on the other hand, is verifying a healthcare provider’s qualifications and eligibility.