7 Credentialing Mistakes to Avoid and Improve Clinician Turnover
And what you should do instead
Credentialing is an integral, but sometimes inefficient, part of any healthcare organization. Incomplete applications, outdated workflows and limited resources can mean longer delays and decreased turnover.
Ensuring that every one of your clinicians and providers are actively licensed and have the proper certifications can be the difference between providing quality patient care and legal action. Additionally, proper credentialing is required by payers to receive reimbursement for services rendered.
What is credentialing?
In its most basic sense, credentialing is the process of establishing the qualifications of a licensed medical professional to assess their background and legitimacy. It is essential to ensure high standards of safety and is required by payers, including Medicare/Medicaid, in order to obtain reimbursements for provided services.
The process is done through primary source verification (PSV). This is when the organization who is doing the credentialing reaches out to the primary, or original, source to verify that all the documentation and information provided is correct.
Seven ways to improve improve clinician turnover
An inefficient and error ridden credentialing process can mean slower vetting and longer wait times. Below are common bottlenecks and mistakes telehealth and healthcare organizations make when credentialing.
1. Incomplete or inaccurate provider enrollment application
It’s important to thoroughly identify and collect the information your clinicians are required to provide. Below is a general list of requirements you should expect and communicate to your clinicians. Depending on the organization and payer, these may vary or other requirements may be needed.
Proof of Identity: This includes a valid government-issued identification document, such as a passport or driver's license.
Medical License: Clinicians must provide their current and valid medical license, which demonstrates their authorization to practice medicine in a specific jurisdiction.
Board Certification: If the clinician has obtained board certification in a specialty, they will need to provide the relevant certification documentation from the appropriate certifying board.
Educational Degrees: Clinicians must submit documentation of their educational degrees, such as medical school diplomas or certificates, to verify their educational background.
Residency and Fellowship Training: If the clinician has completed residency or fellowship training programs, they may need to provide certificates or other documentation to validate their training.
Work History: A detailed work history, including previous employment positions, dates of employment and job responsibilities, helps establish the clinician's professional experience.
Curriculum Vitae (CV) or Resume: A comprehensive CV or resume provides an overview of the clinician's professional achievements, publications, presentations and other relevant information.
Professional References: Some credentialing organizations may request references from other healthcare professionals who can vouch for the clinician's skills, competence and character.
Malpractice Insurance: Proof of malpractice insurance coverage is often required to ensure that the clinician has adequate liability protection.
Continuing Medical Education (CME) Credits: Documentation of completed CME credits helps demonstrate ongoing professional development and commitment to staying up-to-date with medical knowledge.
After collecting all the above documentation, ensure all information is present and correct before submitting for credentialing. If there is an error or omission in any of the required paperwork, the credentialing process will be stopped and forms will have to be resubmitted with the correct information. While the task may seem tedious, it can cut weeks off of the credentialing process caused by going back and forth, allowing providers to start seeing patients sooner.
The solution:
Some organizations use credentialing software to archive the information and securely store it for future licensing and credentialing needs. Another option is to outsource the credentialing to a third-party vendor. They will have dedicated credentialing experts, technology and proven frameworks already put in place.
2. Inconsistency of application criteria
In addition to having incomplete or inaccurate information, a mistake telehealth and healthcare organizations often make is inconsistent criteria across clinician credentialing. While the documentation required for credentialing does vary across organization, practice and state, it's important to have consistent standards for each.
Without it, individual evaluators may interpret requirements differently, leading to unfair evaluations and inconsistency in the quality of credentialed clinicians.
The solution:
If credentialing in house, be sure to prioritize and document standard credentialing criteria. Document every procedure, checklist and template and then build a standardized training for each credentialing specialist on how to properly follow them. If your resources are limited, outsourcing is a great time saving and cost-effective alternative.
3. Relying on limited staff and resources
Credentialing with limited staff and resources can lead to miscommunication, errors and delays. Having a dedicated licensing and credentialing team within a healthcare organization can offer several benefits:
Expertise and specialization: A dedicated licensing and credentialing team brings specialized knowledge and stays up-to-date with the latest regulations, requirements and industry best practices.
Efficiency and streamlined processes: They have the knowledge and experience to navigate through various licensing boards, educational institutions and other credentialing entities, reducing delays and ensuring timely completion.
Compliance and risk mitigation: Licensing and credentialing teams are well-versed in regulatory requirements, including state and federal laws, accreditation standards and industry guidelines—mitigating potential risks.
Thorough clinician background checks: A dedicated team can conduct comprehensive background checks on clinicians, verifying their education, training, licenses, work history and other credentials.
Consistency and standardization: They can establish clear guidelines, checklists and documentation templates to ensure uniformity in evaluating and verifying clinician qualifications. This consistency enhances the quality and reliability of the credentialing process.
Enhanced communication and collaboration: The licensing and credentialing team serves as a central point of contact for clinicians, internal staff and external credentialing organizations—minimizing delays.
Ongoing monitoring and re-credentialing: They can proactively track expiration dates, facilitate re-credentialing processes and ensure clinicians maintain their credentials. This helps maintain a high standard of care and keeps the organization in compliance with regulatory and accreditation standards.
4. Outdated credentialing workflows and technology
Often, especially for smaller healthcare companies, credentialing is done by hand—leading to inefficiencies, errors or delays. Outdated credentialing workflows can also create inconsistent information due to decentralized databases, reduced data security and privacy and increased compliance risks. Regulatory requirements change, if your workflow isn’t changing with them then it could lead to non-compliance.
The solution:
Build or outsource a dedicated team of licensing and credentialing experts to stay up-to-date and regulatory standards and requirements. Some companies have also found success using credentialing tools or technology that easily stores clinician documents and forms to organize and access later.
5. Permitting patient treatment before credentialing is complete
This is a big no no and can get your organization into trouble. For example, say a provider starts treating patients before credentialing is complete only to reveal they don’t have the required certification.
You are now liable, as the organization, for any negligent practice or damages. In this negligent credentialing case, a similar situation occurred. An Illinois jury awarded the plaintiff nearly $8 million due to foot amputation caused by damage from a physician with an incomplete residency and no board certification.
Also, it’s important to remember that credentialing is one of three processes that need to happen before a provider should begin practicing. The other two include privileging and payer enrollment.
Privileging: Often confused or roped into credentialing, privileging is the process of ensuring the provider has the required training and certifications that meet the minimum requirements.
Payer enrollment: This is the process by which the provider is enrolled into insurance plans, networks and Medicare/Medicaid in order to be reimbursable. Enrollment can be a whole beast by itself. Our guide to payer enrollment runs through everything you need to know from types of payer contracts, coverage, timelines and potential bottlenecks.
The solution:
Wait for all official credentialing, privileging and payer enrollment documentation and approvals to return before allowing any clinicians to see and treat patients.
6. Failure to find unreported adverse actions
Clinicians can fail to report negative sanctions, so the healthcare entities hiring them must ensure a thorough background check and PSV. These background checks protect patients from incompetent practitioners and failure to identify these is likely to result in negative consequences for the patient and organization. There are three frequently used data banks for clinician background checks. They include:
National Practitioner Data Bank (NPDB)
The Board Action Data Bank of the Federation of State Medical Records (FSMB)
American Medical Association Physician Masterfile (AMA)
7. Lack of follow-up credentialing
Neglecting to conduct regular re-credentialing or ongoing monitoring of clinicians can result in outdated or incomplete information about their qualifications, licenses or disciplinary actions. This poses a risk to patient safety if a clinician's circumstances have changed since the initial credentialing.
The solution:
Aim to re-credential your healthcare providers at least every three years if not more. This will keep you compliant and keep your patients safe.
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