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The Importance of a Strong Credentialing Foundation

I have the pleasure of reading a book before its upcoming release called Façade by a friend of mine, Alicia Butler Pierre. Her book describes in detail the importance of a sound infrastructure in small businesses to avoid the traps that success can bring due to lack of preparation and if a successful blueprint is not in place. As I read it, I reflected on the processes and platforms I have built over the years to create and repair many credentialing programs. However, what intrigued me most was the overlapping of functions she highlighted within an organization that could either make or break it, no matter how strong their infrastructure. The same is valid for credentialing or even provider enrollment. In today’s environment, provider enrollment is receiving much more attention and is now being combined with the credentialing process. To me, the two are overlapping functions that require separate, but clear procedures to be followed no matter the volume, no matter the urgency, and no matter the staff. Here’s why:

1. The primary reason is revenue generation. Neither credentialing nor provider enrollment can support an organization if there is no effective timeline in place to meet the organization’s needs. However, the credentialing process affects the onboarding and maintenance of a provider’s credentials to determine if he or she is a good fit for the organization. Therefore, credentialing must be completed before enrolling the provider at the appropriate hospitals or insurers. You do not want to be blindsided if they do not meet the hospital or insurer’s criteria reducing or eliminating the goal of generating optimal revenue.

2. Provider enrollment, though secondary to credentialing, should not be treated as an afterthought with the data collected from the credentialing process. Though the data collected is sufficient for completing enrollment applications, attaching appropriate documentation, and pre-determining eligibility, each insurer or hospital may have additional criteria. Your first reaction may be to encompass the requirement for everybody’s criteria into your credentialing application. However, what about time effectiveness? This includes your internal turn-around-time as well as the external organization’s turn-turn-around timeframe. Is the additional information required during the credentialing process time-sensitive? Will the external organization be performing the redundant credentialing activities done within house? Should one person internally be responsible for onboarding, credentialing, and enrollment? Is the overlap sufficiently defined? What has the potential to fall through the cracks? Yes, this article seems to precipitate more questions, but the most critical element to identify the solution to those questions is your data management. If your data management is tightly structured, the overlap should run smoothly. If not, it is time to reassess.

3. For many organizations, such as hospitals, onboarding is an essential factor that is often overlooked or proven redundant. This function, though it would seem is just another pre-cursor to credentialing is a required overlap. Necessary criteria mandated by Human Resources may not reflect the same requirements for the credentialing and privileging or they may. For instance, education and training, licensing, criminal background checks, OFAC checks, sanctions, and more. The usual problems faced stem from volumes. How many providers must be credentialed before one is hired?

Yes, there are many questions to answer before outlining your organizational structure, your definitive processes to complete each function, and the way you manage these processes to maintain your foundation’s ability to succeed. That’s why, whether you are just establishing your programs, repairing them, or re-assessing them, never fail to recognize how vital a sound infrastructure is to your organization’s success in managing the providers affiliated with your organization to rally a continued success.

Dilsa S. Bailey, CPMSM is the owner and principal consultant for The Right Credentials Network. If your credentialing and provider enrollment programs need assistance, contact The Right Credentials Network. We can help you apply for and maintain accreditation as well as repair your existing program. And, if you or your staff needs additional training, join us for our webinars, training modules, and various events.

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