Credentialing: The gateway to health-care quality

If there’s one predominant theme in the health-care industry right now, it’s quality. Health-care providers are constantly looking for ways to assure that they are providing the highest quality care. Payers are providing financial incentives and rewards for meeting quality benchmarks. Even the recently passed health-care reform law includes elements that are designed to promote quality.While there are many different factors that contribute to quality of care, the most important is the caregiver. It’s not possible for health-care organizations to assure that they are providing the highest quality of care unless that care is being provided by the most talented, experienced and qualified professionals.Unfortunately, it’s not always easy for organizations to obtain background information about their providers. It requires tracking down a lot of information from a variety of sources. And, as any hospital administrator can attest, getting credentialing information can be a nightmare. Even after this information is gathered, important steps like assigning privileges, tracking CEUs and meeting attendance, and monitoring quality and peer data become part of the credentialing process.

Why credentialing mattersObviously, credentialing is an essential part of the quality effort. Before any health-care organization hires a physician, nurse or other caregiver, it is essential to obtain the necessary background information for assuring that he or she has the appropriate education and experience, and that that experience is appropriate to the role that’s to be filled.There have been numerous examples of unqualified people being hired because of breakdowns in the credentialing process. In the worst cases, such situations can have devastating consequences.In one of the most notorious cases, Gerald Barnes was able to practice medicine in California without a license for more than 20 years using another physician’s name. In 1979, through his lack of medical knowledge, Barnes contributed to the death of a 29-year-old patient and was ultimately imprisoned for manslaughter.In another well-known case, Dr. Michael Swango was able to obtain several positions at various veterans hospitals, in spite of the fact that he had served five years in prison for poisoning co-workers. He would ultimately serve time for murdering three VA patients in New York.These are just worst-case examples. However, every day, in hospitals across the country, medical mistakes are committed by caregivers who should never have been hired in the first place.Credentialing continues to be vital even after caregivers are hired. The credentialing process must be repeated every two years to assure that caregivers maintain their qualifications, and that health-care organizations have the most up-to-date information about their caregivers. This also allows the organization to re-evaluate privileges that have been granted.Credentialing also includes licensing, which is equally important for hospitals and large medical practices. Health-care organizations can only expect to be reimbursed for services that are provided by caregivers who have relationships with the appropriate payers. It can be a complicated and time-consuming process to determine whether each caregiver is approved to bill individual payers, including Medicaid, Medicare, private insurance companies, and managed care organizations.

21st century answersWhen it comes to credentialing, most organizations still rely on outdated, time-consuming and potentially inaccurate approaches. In fact, it is estimated that about 70 percent of hospitals and other health organizations still rely on manual approaches involving Excel spreadsheets and individually contacting information sources.Why does this matter? Because it’s impossible to get quick answers relying on pencil-and-paper credentialing approaches. It can typically take anywhere from one to three months to hear back from past employers or schools with essential credentialing information. Long lag times can make it difficult to hire the most qualified staff if more sophisticated competitors are able to complete the credentialing process more quickly and accurately, and move faster to hire the best practitioners.This will become an increasingly critical issue for hospitals as the health reform is rolled out. The addition of 32 million Americans onto the rolls of the insured will increase the need for additional doctors, and the competition for the best of those physicians. Hospitals that are restrained by slow and inefficient credentialing systems will find themselves at a serious disadvantage.These delays can also have serious financial repercussions. Combine the time it takes to manually confirm physician relationships with individual payers with the weeks — or months — it can take to get reimbursed by private payers and Medicaid, and many hospitals and large practices end up waiting many months to be reimbursed for procedures conducted by new caregivers.Moreover, when hospitals and practices are unable to confirm a relationship with a payer, they often end up providing care for free because the payer is unwilling to pay for services that were completed before the provider was approved. Hospitals alone are forced to write off millions of dollars in billings every year because of delays in the approval process.Automated credentialing suites can solve these problems by permitting instant management of the credentialing process. Rather than having to manually track each caregiver and communicate personally with his or her past employers and educators, automated programs can monitor when each caregiver must be re-credentialed, and automatically manage the process, beginning by distributing e-mails requesting the required credentialing or licensing information.Automated credentialing also can provide instant access to national physician databases on which employment and education information is stored, using “Web crawler” technology.The financial advantages are just as significant. By completing the process months sooner, health-care organizations can be reimbursed much more quickly for the services they are providing. Additionally, organizations can save thousands in administrative costs when they no longer have to distribute credentialing requests by hand and follow up individually.At a time when there is more focus than ever on health-care quality, hospitals and other health-care organizations that make their credentialing efforts more effective and efficient can assure that their care is being provided by the most qualified and experienced professionals. At the same time, they can improve their reimbursement rates and assure more timely payment for the services they provide.Mike Melville, president of Nashua-based IntelliSoft Group, can be reached at