Top Five Changes in Credentialing Due to the Increased Numbers of Employed Providers

All of us who work in healthcare have seen and experienced the many changes that have occurred as a result of the shift of organizations to increasingly employ/contract with providers. It is not unusual for an organization to employ/contract with 50% or more of their providers. The numbers keep rising and it doesn’t appear that there is a downturn in this trend any time soon.

What impact has this had on the individuals who work in credentialing (and provider enrollment)? Here are the top 5 impacts that I’ve observed:

1. There is a need for credentialing departments to find out what a provider has been hired to do – because of the impact on the privileges that should/should not be requested.

It is becoming fairly routine in some organizations to provide a privilege delineation to an employed/contracted provider – only to return it to him/her and ask that it be resubmitted because the provider asked for privileges not covered by the contract or – conversely – didn’t ask for privileges that he/she is expected to provide. This often does not occur until the decision-making process when the privilege delineation is reviewed by someone who is responsible for the services that the applicant will be providing once credentialed – an awkward situation at best that requires rework and can add length to the credentialing process. Organizations need to provide better guidance to the providers who are asked to complete privilege delineations or have a process in place to have someone review them immediately upon submission.

2. Employed physicians are likely to work in multiple organizations within a health system. There is a trend within health systems to standardize privileges across the system to help more easily facilitate the ability for providers to provide services across the organization.

Standardizing privileges within a health system used to be something that CMO’s and others from the C-suite would talk about wistfully. I’ve had many conversations about this with CMO’s who indicated that they were not willing to expend their political capital on something (like standardizing privileges) that they did not believe could or would be successful. The word is out, however, that this can be successfully achieved and more and more organizations are initiating privileging standardization projects. Is it easy? Not usually – but there are tremendous benefits for organizations that persevere. 

3. The need to successfully integrate the recruitment/credentialing/enrollment process (i.e., the onboarding) has become acute.

Organizations that want to streamline their onboarding processes must determine processes that can occur concurrently rather than consecutively. There must be a defined time during the recruitment phase/contracting when information is made available to the credentialing department so that the credentialing/privileging process can begin. Each organization also needs to determine when enrollment activities can begin so that when a provider is credentialed, there is no big lag time between the credentialing approval date and the date on which services can begin to be provided to patients. This sounds easy – but it obviously isn’t.

Tackling these processes – and determining what can be done concurrently versus what must be completed prior to the next process beginning takes a lot of discussion, willingness to change, some willingness to give up some control and a huge dose of cooperation. However, organizations that have successfully transformed their onboarding process have found it to be well worth the time and effort that it took to get there because of increased provider satisfaction and increased revenue.

4. As the numbers of employed/contracted providers increase, there are more providers for whom enrollment with health plans must be managed.

Additionally, there is also a trend for organizations that employ/contract with providers to also manage their credentialing process with organizations outside of the health system.

This item is pretty obvious – as the number of employed/contracted providers increases, so will the numbers that need to be enrolled with payers. Additionally, I’m seeing that many of these enrollment or “credentialing” departments are also responsible for facilitating the credentialing process for hospitals/facilities that are not part of the healthcare system. For example, let’s say that we have a group of providers that needs to be credentialed at a hospital in the geographic area that is not within the system. Perhaps the hospital provides a service that is not provided by the healthcare system or takes care of specific types of patients. The employed/contracted physicians must be credentialed by the hospital and the “credentialing” department of the health system obtains, facilitates completion of and sends applications, documents, etc. to the hospital so that the physicians can be credentialed there. This adds an additional layer of complexity to the work that someone or some department is providing.

5. Finally, proliferation of files – there is now a big need to clearly identify what information is located in the credentials file vs. the “HR” file.

This is an issue that needs to be tackled by many health systems. I see much duplication between documentation and data collected by the Human Resources department and credentialing. There is usually no need to duplicate documentation in the HR file. This is an issue that can and should be tackled when the onboarding process is analyzed. It will usually require some advice from legal counsel about what goes where. HR files should not contain “peer review” documents – those should be contained in the credentials file. There is no need for both departments to verify licensure, etc. Elimination of duplication of activities will help streamline the onboarding process and will also protect information that should not be discoverable in legal proceedings.

We can be certain that credentialing and privileging will continue to evolve and that there will be new and constant challenges that those of us who work in this field will need to tackle. The challenges are one of the reasons why I’m never bored!