Speeding Up Physician Credentialing

ApprovedThe physician credentialing process can be time consuming, especially when it is not being managed smoothly or efficiently.  Understanding how to properly complete this process is crucial for outpatient healthcare owners to properly take control and manage their business operation.  The Ambulatory M&A Advisor discusses some of the ways that the credentialing process can be improved in the average healthcare business.

Common Mistakes in Credentialing

We are all human and mistakes will be made in almost any process.  Sharon Kimbrough, CPCS, CPMSM, Manager with Surgical Care Affiliates Medical Staff Services and Credentialing says that there are various areas where mistakes can and will be made in the credentialing process.

According to Kimbrough, one common mistake is not having the right employee in this position.  The employee must have knowledge and training to do the credentialing job well.

Kimbrough says a business should consider someone other than the facility administrator who often has other responsibilities and should be in an oversight, consulting role.The employee assigned to credentialing duties should be someone that is knowledgeable and has training in medical staff credentialing and most importantly has the time to do credentialing. Based on the amount of resources available today, it is suggested that a credentialer have several reference publications or attend a formal course.

“The credentialer must maintain high confidentiality and integrity in their duties and have great communication and organizational skills.  They will work with many different types of people such as attorneys, physicians, outside organizations as well as different employees and providers within their facility.  They also need to have confidence,know what they are doing and why in order to ensure the appropriate information is obtained.  The employee who oversees the credentialing program needs to have critical thinking and analytical skills to determine how much information is needed to meet the facility’s credentialing criteria,” Kimbrough says.

“Some duties of the credentialer would include maintaining the list of active and inactive providers, tracking and keeping items with expiration dates current (there are at least 3 or more per provider), processing initial and reappointment applications, maintaining specialty privilege lists and more.  These employees also interact with the Medical Executive Committee and Governing Body members to ensure criteria is captured appropriately for each application.”

Jon Burroughs, President, CEO, Burroughs Healthcare Consulting Network says that one of the common weaknesses is that it is a relatively recent phenomenon for providers at the ambulatory level to be paying such close attention to the credentialing process, which places it farther behind than other in the rest of the healthcare industry.

“Traditionally, credentialing and privileging was hospital-based, which means it was in-patient based and most people didn’t pay a lot of attention to what went on in an ambulatory setting,” Burroughs says.

“It is only relatively recently, since the proliferation of ambulatory facilities, that ambulatory credentialing has really been taken seriously.  There has recently been serious interest in credentialing doctors in ambulatory settings.”

Another weakness is not verifying all of the information in the application.

“You should not be selective in which information to verify; all information should be verified.  Before an application goes to committee, the information must be reviewed and analyzed.  This step may be overlooked in the rush to get the application to committee.  A component of good credentialing is to compare the application to the verified information for gaps and omissions to determine if additional information is needed from the applicant,” she says.

Process length

Kimbrough says that the credentialing process is laid out in steps.  The first step is sending and receiving the application from the provider.  The second step is credentialing, which is verification of the information in the application.  This step also has many sub steps and may take the most time.  The third step is reviewing and analyzing the information.

“Once all questions are answered and the application is deemed complete by the credentialer, the application is ready for the fourth step which is review by the Medical Executive Committee and final action taken by the Governing Board.  There could also be review by the Medical Director, other facility leadership and the Credentials Committee before the application progresses to the MEC.  It is easy to see how the committee review timeline can add a month or two to processing an application,” she says.

“The entire credentialing process can take 4-10 weeks depending on the amount of information contained in the application and the timing of committee meetings.  Each application is unique.It may take a shorter amount of time to credential Dr. Smith who is on staff at three hospitals versus Dr. Jones who is on staff at 15 hospitals.  Waiting for the return of 12 hospital affiliation verifications could add 2-3 weeks to the application timeline.”

Ronald Duperrior, Principal at The Clarity Companies says there is normally a credentialing technician that assembles a file, pulls all the information together and does the verification and validations. The technician will highlight a lot of things in the file, the good and the bad. If the physician in questions passes all the standards outlined in the medical staff bylaws, they recommend approval. The board then looks at it as a group and makes a decision.

Burroughs says the entry point to improving the process length is that a business has to have a system in place, and most organizations use some type of software.

“You need to have a comprehensive and automatic way to gather data, and you need to have a comprehensive way to process the data, screen the data, and then to do your primary source verification.  You want to have systems in place where you can automate the process and do a comprehensive job each and every time in a timely way.  What you don’t want to do is have to make it up as you go along each and every time.  It is critically important to have a system in place to support your efforts,” Burroughs says.

The goal for a healthcare business is that they should be able to credential someone in a matter of a couple of months.  Burroughs says the process should be 60 days including everything, assuming that the applicant is interested with providing you the information in a timely way.  Usually, the biggest bottleneck is that the person has an application to fill out and they wait months to do that.

“Assuming that once the application is turned in, an application should be able to be processed within 60 days.  I think what you want to have is software applications in place in order to automate the process and enable the system to screen out pink and red flags.  Pink flags are issues that need further evaluation and red flags are issues of potential concern.  You want a software program where if there is a gap in dates, if there are quality issues, malpractice cases, whatever the case, they can screen them out automatically for you.  You don’t want to have to rely on individuals manually going through a record.  They are likely to miss something and it is extremely time consuming and expensive,” Burroughs says.

A healthcare business would want to automate as much as they can, to leave the remainder for human judgement that is required, he says.

Legal Areas Involved with Credentialing

“Basically, increasingly, physicians should only be permitted to do what they are authorized to do.  It has been very loose in the past with the ambulatory setting, where physicians were given privileges to do surgery or to do ENT.  For instance, I am involved in a legal case somewhere in the United States where a little girl had a general ENT physician attempt to remove a cyst from her neck and she had a very bad outcome,” Burroughs says.

“It was because their privileging criteria was way too loose, and the center said the physician could do anything in the neck region that they wanted to do.  What you have to do, whether it is in an in-patient, or ambulatory setting, is be very precise about what physicians are authorized  to do, what age group they are authorized to work with, and what entities they are permitted to treat.  You want to be very specific and not leave it for the doctors to decide.  They will believe that they can probably perform the procedure and put the center at risk by continuing with procedures.”

The whole point of credentialing is to protect patients, protect the organization, and protect the doctor.  That can only be done if your criteria and your scope of practice is very specific so that everyone knows what is in bounds and what is out of bounds.

Another legal concern revolves around how often credentials should be updated for providers in the field.  According to Burroughs whether it is the NCQA or the Joint Commission, the longest a healthcare business can go without re-credentialing someone is two years.

“There are other circumstances where you would want to update the credentials more frequently.  For instance, if a doctor wants to do something new that they have never done before, introduce a new piece of technology, or introduce a new skill, they will need to be re-credentialed for that.  By and large, every two years or so is standard; if there are performance issues, and issues of concern that have been raised, then you may want to do it more frequently to assure that the physician is safe to do what they are going to do,” Burroughs says.

According to Kimbrough, there are two main risks to look out for on the legal front.  One is patient harm or patient death tied directly to physician competency.  The facility should continue to maintain the provider’s credentials after initial appointment and demonstrate their competency to perform procedures requested.Not accomplishing these steps could result in liability for the facility and medical staff as well.

The other risk area is ensuring Federal and State legal (regulatory) requirements are met for provider credentials.  When a facility does not follow CMS Conditions of Participation or their State regulations and allows a provider to practice without current credentials, they are subject to issues. The facility’s credentialing program lacks systematic integrity and again,places the facility and anyone associated at risk.

If you would like to learn more about the concepts covered in this article, want to sell your business or discuss how Ambulatory Alliances, LLC might be able to help you out, contact Blayne Rush, (469)-385-7792, or Blayne@ambulatoryalliances.com.

If you have suggestions for future topics, email Blayne@ambulatoryalliances.com.





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