Common Challenges in Medical Credentialing and Solutions

Medical Credentialing: Common Challenges in And Solutions
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If you had to make a list of some of the most important resources that medical providers have when working with patients, “trust” would undoubtedly be right at the top.

According to one recent study conducted by NORC, people tend to trust individual medical professionals more than they do the healthcare system in the United States as a whole. Yet at the same time, trust in those professionals decreased noticeably during the COVID-19 pandemic. As a result, rebuilding trust is essential.

The more patients trust medical providers, the more likely they are to embrace things like preventative care. This leads to better outcomes and healthier communities, as a whole.

Medical credentialing is one of the many resources that is used to help build and maintain that trust. In an over-arching sense, this is the process that is used to verify that a healthcare professional is certified. It makes sure they’ve gone through the training needed and are therefore qualified to treat patients. It’s also a big part of how they’re able to accept payment from certain insurance providers.

Of course, Medical credentialing experts agree that this process is not without its fair share of challenges. If you truly want to enjoy all the benefits of healthcare credentialing services with as few of the potential downsides as possible, there are a number of important things to keep in mind.

Overview of the Current State of Medical Credentialing

Even as recently as a few years ago, medical credentialing was something that was seen as merely a recommendation by most healthcare professionals. If you’re trying to get your practice off the ground, there are obviously more pressing short-term matters to concern yourself with.

However, the shifting healthcare landscape in the United States has made it less a recommendation and more a requirement – particularly in an increasingly competitive landscape. According to one recent study, more than half of all practice reported credentialing-related claims denials in 2021 alone.

Because of this, it is more important than ever for medical professionals to remain vigilant. Not only does medical credentialing help improve trust among the patients they serve, but it also helps make sure that claims are processed as quickly (and as accurately) as possible to keep revenue flowing in the door.

What Are the Challenges in Medical Credentialing?

By far, one of the biggest challenges relating to medical credentialing has to do with notoriously long delays in processing new provider applications. Because the process is very precise and there are large volumes of providers attempting to get credentialed by insurance companies, wait times are regularly increasing.

The issue is that a lot of practices don’t find this out until claims are rejected due to credentialing-related issues like those outlined above. This is why it’s so important to be as proactive as possible about this process.

Another major challenge that many face in terms of medical credentialing has to do with requirements that seem to change on a regular basis. Many fight a lack of standardization across providers – what one company requires may be considered woefully inadequate by the next. This can make it difficult for the medical professionals themselves to stay organized to the point where the entire process becomes unnecessarily convoluted.

Solutions to Overcome Medical Credentialing Challenges

For most healthcare professionals, the solution to these and other medical credentialing challenges involves outsourcing the work to a trusted third-party with specializes in these precise tasks.

When a private practice attempts to handle everything in-house, it requires a vast amount of time and energy to “get right.” You need to compile all necessary documentation, which can include but is not limited to things like:

  • Malpractice claims history, including information about suspensions, revocations, and more.
  • Medical license information and history.
  • NPI numbers.
  • DEA licenses.
  • Work histories.
  • Degrees and education transcripts.
  • Insurance information.
  • Board certification information.
  • And more.

Not only can the requirements vary depending on the provider, but things can also change depending on which state you’re operating in. It’s also often difficult because the process requires collaboration between not only the healthcare provider, but also the organization they work for, the payer, and other entities.

All this, and you still have to spend time responding to any requests for corrections or additional information. Then, you need to start the process all over again as re-credentialing deadlines creep up.

But when you outsource this work to a third party with expertise in this field, they can help things go as smoothly (and as quickly) as possible. All the responsibilities that would normally be handled by a medical professional or their team are instead looked over from start to finish by a partner. All throughout this process, collaboration is still welcome. Applications are completed, due diligence is performed. Many providers, with PrognoCIS being a primary example, will even give you updates on credentialing status within just 24 hours to make sure you’re always in-the-loop at all times.

In the end, you relieve a lot of the common challenges inherent in medical credentialing while still maintaining your ability to deliver critical services to patients. Truly, that in and of itself is the most important benefit of all.

How Does PrognoCIS Medical Credentialing Help the Healthcare Industry?

PrognoCIS Medical Credentialing

At Bizmatics, Inc., we believe that nothing should stand in the way of medical providers and the accurate, actionable information they need to make the most informed decisions possible. That’s why we’ve designed our PrognoCIS EHR platform to be the centralized point of truth that you need to increase efficiency and offer the highest level of care that you can.

Medical credentialing services are certainly no different. PrognoCIS is a tool built to assist both small and large practices with provider enrollment, making the process of becoming an in-network provider a straightforward process, thus making it easy to receive necessary reimbursements for patient care from every carrier.

The process begins by working directly with our credentialing team, who will go over the list of insurance carriers that you believe it is in your best interest to participate in. We will then perform a careful analysis for both your service area and your general specialty, providing you with a clear road map of the steps you have to follow to help achieve those goals.

Even if you’re an existing medical practice, PrognoCIS can still help. Medical credentialing is something that should be done every three to five years and our team can proactively notify you when documents are going to expire, can help maintain your CAQH profile, and more. All this means you can spend less time worrying about re-credentialing so that you can focus more on running the most effective practice that you can.

Note that PrognoCIS’ medical credentialing services are also available in all 50 states.

Key Takeaways

  • Medical credentialing involves verifying a provider’s qualifications to help make sure they can provide an acceptable level of care to patients.
  • This is required by the vast majority of healthcare providers in the United States.
  • Medical credentialing is time-consuming because it involves verifying all of a provider’s documents to make sure they are both valid and correct.
  • Medical credentialing services like those provided by PrognoCIS can verify not only a provider’s medical license and malpractice insurance status, but also medical school information, residency and fellowship information, and more.
  • This makes medical credentialing, along with becoming an in-network provider, easier than ever.

If you’d like to find out more information about the common challenges in medical credentialing, or if you’re eager to learn about how a solution like PrognoCIS can relieve this burden for your own organization, please don’t delay – contact us today.

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