Andrew Resnick, MD: Credentialing may be a time-consuming administrative task, but savvy chief medical officers (CMOs) know it’s one that greatly impacts organizational resilience and high reliability. If the organization isn’t performing credentialing well, it can overburden providers, and leaders miss the opportunity to leverage it toward improving quality. My colleague Sally Pelletier, CPMSM, CPCS, Chartis’ Chief Credentialing Officer, explains how CMOs can help optimize the credentialing process and leverage it to achieve strategic goals.  

With more than 30 years of credentialing and privileging experience, Sally advises clients in the areas of medical staff accreditation and regulatory compliance, Medical Staff Services Department and centralized credentialing operations, and privileging redesign. She has a passion for mentoring others, baking, reading mystery novels, and spending time with her dog. 

Chartis: What do CMOs need to understand about the role of credentialing in today’s dynamic healthcare environment? 

Pelletier: On the surface, credentialing is a checklist. However, when you dig more deeply, you realize this process affects so many aspects of a healthcare organization’s operations. For example, consider quality and patient safety. High reliability care—a strategic goal for many organizations—requires a credentialing process that goes beyond minimal compliance to include steps such as a criminal background check, validation of the past 10 years of malpractice claims, verification of 3 peer references who have recently directly observed the clinician, and more. By advocating for stringent, criteria-based credentialing processes that are clearly documented through bylaws and standard operating procedures, CMOs bring organizations one step closer to accomplishing this goal. 

During this time of healthcare workforce shortages, credentialing also affects a healthcare organization’s ability to attract and retain top clinical talent. Organizations can’t afford to lose potential candidates because of a broken, burdensome, or inefficient credentialing process. CMOs can position their organizations for success by advocating for automation that reduces duplication and promotes alignment with critical workstreams (such as recruitment and enrollment). This technology can augment the role of the Medical Staff Services Department and ultimately help reduce burnout in your workforce.  

Physicians and other healthcare practitioners are working extended hours and putting their own well-being in jeopardy to ensure high-quality patient care. The credentialing process should not add another layer of stress. 

Finally, credentialing affects revenue. Each additional day required to complete the credentialing process translates to thousands of dollars of lost revenue for practitioners who are not able to bill for services rendered, not to mention the salaries already being paid to employed physicians. Again, it goes back to having a well-documented, efficient credentialing process in place.

Chartis: Given the frequency of mergers and acquisitions, is there anything CMOs should keep in mind as it pertains to credentialing?

Pelletier: Yes, CMOs need to know whether acquisition targets have a compliant and risk averse credentialing practice. In the absence of a compliance practice, they will need to mitigate potential risks. Doing this successfully while embracing systemness means CMOs need to manage disparate cultures, revise existing policies, and revamp existing workflows to establish a consistent methodology that promotes compliance and scalability.  

There is considerable danger in overlooking credentialing as a part of due diligence during a merger and acquisition: namely, the potential for a negligent credentialing lawsuit in the wake of a poor patient outcome and underestimating the challenges in integrating the two cultures.

Chartis: What can CMOs do to make credentialing more of a priority in their organization? And with whom should they partner to accomplish this? 

Pelletier: First, CMOs need to openly model compliance by not bending the rules—that is, the bylaws, policies, and procedures—under any circumstances. To do this, they need knowledge of established policies, a solid backbone, and effective conflict resolution skills. With that said, CMOs should also be open to rule revisions when necessary.  

They also need to be mindful of best practices, such as credentialing by proxy or an expedited governing board approval process, that have been adopted without corresponding policy updates. Outdated policies are ripe with opportunities for CMOs to remove non-value-added activities that are founded in a “we’ve always done it this way” mentality. CMOs should support removal of dated practices, such as interviewing every initial applicant, requiring copies of unnecessary documents (such as a medical school diploma), or over adaptation of initial focused professional practice evaluation requirements. 

Second, they should advocate for adequate resources. This includes competitive salaries for knowledgeable medical services professionals and championing the optimization of automation by adequately resourcing the “lift” it takes to appreciate the full functionality of a software platform. 

CMOs should emphasize that credentialing is not a paperwork exercise but a key contributor to achieving and sustaining a high reliability organization and minimizing legal risk. Partnership with the Medical Staff Services Department, organized medical staff leadership, and administrative leadership is paramount. 

Chartis: How can CMOs better leverage their Medical Staff Services Department? 

Pelletier: Medical services professionals are an important resource for CMOs because they can help them navigate regulatory, accreditation, and internal requirements. These professionals can also alert CMOs to potential red flags in a clinician’s file. The best way to leverage this relationship is through open communication and trust.  

Together, the CMO and medical staff professionals can drive policy content and hold practitioners accountable for compliance. CMOs combine their managerial and clinical expertise with the Medical Staff Services Department leadership’s managerial and operational expertise to drive policy content and hold practitioners accountable for compliance. 

Chartis: What else can CMOs do to promote a robust credentialing program? 

Pelletier: CMOs must walk the talk about the importance of credentialing in providing quality patient care and bring into being measurable results. Following are a few suggestions: 

  • Ask the Medical Staff Services Department to provide routine educational sessions to the credentials committee, medical executive committee, and the governing board so they fully appreciate their roles and responsibilities related to credentialing and avoid decision errors. 
  • Produce an annual credentialing report in concert with the medical executive committee and Medical Staff Services Department that displays volume of activity and KPIs, such as number of instances of unprivileged practitioners who exercised privileges, number of fair hearings, number of negligent credentialing claims, number of initial applicants, and number of reapplicants not approved. 
  • Facilitate direct communication between legal counsel and the Medical Staff Services Department.  
  • Meet with the director of the Medical Staff Services Department weekly and the full department at least monthly or more often when needed to reinforce mission, vision, and values, address strengths and opportunities, and provide a clinical perspective to processes, such as FPPE and privileging. 
  • Provide mechanisms for physicians to voice kudos, concerns, questions, and frustrations related to the credentialing process toward the goal of continual performance improvement. 

Chartis: Any final words? 

Pelletier: CMOs who emphasize the importance of credentialing are doing a huge service to their patients, physicians, other practitioners, and organizations. The direct and indirect links between credentialing, strategic goals, and the revenue stream are clear.  

CMOs are well positioned to take the lead on credentialing best practices and compliance. And they can help their organizations promote high-quality patient care through assisting medical staff leaders in carrying out their board-delegated responsibilities and promoting the importance of the responsibilities administered by the Medical Staff Services Department. 

Optimizing Provider Enrollment With Payers

Tied to internal credentialing, provider enrollment also plays a significant role in finances, patient and provider experience, and even bringing in new patients.

Most Enrollment Delays Stem From Data Issues 

At the heart of an optimized enrollment process is data integrity.  

While physicians and other clinicians usually must go through credentialing at your organization first and then through enrollment with your various payers, they may also need to go through credentialing a second time—this time on the payer as side as part of that enrollment process. Following or exceeding industry best practices for data integrity will benefit both your internal credentialing process and allow your contracted payers to process it efficiently for enrollment. 

The quality and timeliness of the data your organization submits can dramatically slow down the length of time it takes the payer to complete the enrollment process. It also has downstream impacts on things like the accuracy of the health plan provider directory accessed by patients. Best-in-class enrollment occurs in 45 days, but the enrollment process takes an average of 120 days for many payers.  

While many internal factors could also contribute to delays on the health plan side, an optimized credentialing process at your organization can prevent much of the back-and-forth requests and clarifications that occur when the data submitted is incomplete or not fully accurate. Strong practices for data quality and standardization not only enable greater streamlining and reliability in your organization’s internal processes and databases. They also are essential for seamless integration with payer processes, including state and federal systems, such as the Medicare Provider Enrollment, Chain, and Ownership System (PECOS). 

Work Toward Alignment to Smooth the Way: 4 Considerations 

In addition to ensuring the accuracy and timeliness of your data submissions, aligning expectations with your payers can help pave the way for smoother enrollment. Your organization should align with the payer on who will conduct credentialing and the process, format, and frequency in which to submit data. Payers credential clinicians during enrollment and then recredential each clinician every 2 or 3 years.  

These 4 considerations can help facilitate greater efficiency: 

  1. Optimize internal processes for data standardization and validation. Remember that data integrity is essential for both your own credentialing and for efficient processing on the payer side. 
  2. Appropriately invest in a modern provider data management platform. The right software platform can help automate the credentialing process and also offer built-in validation and standardization tools. It should also provide sophisticated interoperability capabilities. 
  3. Understand the format or structure your contracted payers need. Typically, if a payer is asking for data in a specific format or structure, submitting your data accordingly allows their systems to process that data most efficiently. That translates into fewer delays.

    Several vendors offer centralized data submission for multiple payers. Engaging with organizations like the Council for Affordable Quality Healthcare, Inc. can facilitate consolidated data management between you and your contracted payers. 
  4. Leverage a payer relations function for enrollment guidance. Many provider organizations have an internal team with subject matter expertise on how specific payers work. When appropriately resourced, they should be able to provide advice on what course of action to take when issues arise. 

    Additionally, establishing a reliable point of contact at your organization and with each payer can also ensure the enrollment process isn’t unduly slowed down when questions arise. 

Internal Optimization and External Alignment Facilitate Desired Results 

Ultimately, coupling this alignment with an optimized internal credentialing process will pave a smooth external enrollment process with payers. 

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