Putting Your Credentialing on a Diet: How to Effectively Eliminate Non-Value-Added Verifications

This blog post is based on a webinar with Renee Aird Dengler, RN, MS, CPMSM, CPCS, FMSP, Senior Consultant/Independent Contractor for VerityStream, and Renee Zimmerman, RN, MSN, CPMSM, CPCS, Assistant Vice President of Operations at Franciscan Physician Group, Franciscan Missionaries of Our Lady Health System.

“Credentialing takes too long.” This is the consistent feedback of both those processing verifications and providers waiting for them to go through. However, many organizations are trapped in a cycle of doing certain activities and collecting specific documents that may not be required for one reason—they have always done it that way.

In 2016, Franciscan Physician Group and Franciscan Missionaries of Our Lady Health System developed a single department CVO to do all application processing and credentialing verifications for all of their medical staff offices and employed providers for all of their delegated health plans. In order improve their system’s efficiency, they focused on eliminating four things: licensed verifications, peer references at reappointment, malpractice claims histories from carriers for pending claims, and section chief approvals. Change can be challenging and controversial, but if your organization is committed to looking at lean processes and value add, reassessing the importance of the following four items in your credentialing process is necessary.

License Verifications

When reassessing license verifications, begin by looking at your risk assessment and current state assessment and identify where your patients are located. You are required to do license verification from the states where your patients are located, not the states where the practitioner has a current or past license for all practices.

Consider that the state licensing boards are mandatorily required to report to the National Practitioner Data Bank (NPDB). When the NPDB is queried, as required by Joint Commission or other governing body standards, any license actions or adverse actions for other states that you are not querying or doing a verification for will be identified on the report. Let the data bank query do the work for you and only verify licenses in the states where your patients are located, cutting down turnaround time. 

Peer References at Reappointment

Many health systems think that the Joint Commission requires peer references for everyone who is a privileged practitioner on staff at their hospital. However, the actual standard from MS.07.01.03, EP 1 says peer recommendations are required for all new applicants for privileges. This includes all initial applicants and applicants requesting new privileges.  Under EP 2, peer recommendations are required upon renewal of privileges when insufficient practitioner-specific data are available. This means that you only have to conduct peer references at reappointment when the provider is a low/no volume practitioner.

Eliminating peer references at reappointment can be a significant time saver, especially if your organization still uses a paper process instead of a digital or electronic process. When Franciscan Missionaries of Our Lady Health System eliminated this process, they saved 7-10 days of turnaround times for their reappointment applications.

Malpractice Claims Histories from Carriers for Pending Claims

The removal of malpractice claims histories saved an average of fourteen days of initial applicant and reappointment applications at Franciscan Missionaries of Our Lady Health System. Malpractice claims histories can be done for pending claims or for settlements and judgments. Although all settlements and judgments are going to be on a National Practitioner Data Bank query, pending claims will not. Many health systems ask the provider about pending malpractice claims and gather information about any claims.

They decided to eliminate this primary source verification after asking their medical staff leaders about the influence pending claims have on the decision making of committees and governing board. After learning that neither their governing board, medical executive committees, or credentials committees had ever offered an adverse decision based on pending claims, they eliminated this process.

Section Chief Approvals

Many health systems still do section chief approvals before department chair approvals, resulting in a lot of time lost to a process that is not required by any regulatory body. The same  arguments are heard for keeping this layer of approval: department chairs don’t feel like they know applicants well enough and need input from the section chief, section chiefs don’t want to give up this process, or only the section chief can know if they meet privileging requirements.

The privileging process is meant to be as objective as possible, and either the applicant meets the requirements specified on the delineation of privileges or they don’t. The department chair shouldn’t have to have the section chief input in order for them to determine if they should sign off on a file or not, and this is something that medical executive committees should consider removing if they want to increase efficiency.