Credentialing 101
The Complete Playbook on Credentialing

Meri BrickJuly 01, 20219 minute read

Credentialing can be a long and grueling process, but a very critical one in the medical field. It is the first step in clinician hiring for healthcare providers operating hospitals or clinics, as well as, telehealth companies launching virtual services nationally. Any time you are bringing on a clinician to support your patients and represent your brand, thorough credentialing must be performed.

It is such a critical step in delivering quality medical care that you absolutely can’t risk any shortcuts being taken. Have you heard those horror stories where the doctor caring for a patient isn’t actually a licensed physician? Credentialing exists to avoid nightmare scenarios like that for both the patients and the healthcare organizations.

All About Credentialing…. And More

The official definition of credentialing as set by the American Nurses Credentialing Center (ANCC), is “a term applied to processes used to designate that an individual, programme, institution or product have met established standards set by an agent (governmental or non-governmental) recognized as qualified to carry out this task”.

Wow, that’s a mouthful! Let’s simplify it a bit for the purpose of this blog and dig in on how it relates to the medical field specifically. Credentialing is the act of researching a clinician's background to make sure they are exactly who they say they are.

This requires investigation by a licensed expert into all:

  • Board certifications

  • Locations of medical licenses

  • Education and training

  • Work history

  • Residency

  • Red flags

All medical professionals must pass the credentialing process before they are allowed to begin work at any healthcare facility in the United States. That means they are not permitted to support patients until credentialing is complete and they are approved as a certified provider. This process typically spans an entire three months, but can take even longer should the smallest error be detected in the application or the proper supporting documentation not be submitted. For this reason, it’s pivotal to entrust your credentialing to someone who knows what they’re doing.

On average, it’s about $100-$200 to credential an individual healthcare professional, although this price does vary a bit depending on the credentialing service provider used. That estimate does not include the initial software cost or the labor to manage it. Usually, the employer pays all fees associated with credentialing. So, if you’re expanding your business across new geographies or adding more patients to serve, those clinician credentialing costs can stack up quickly.

It’s also important to note that the process and timeline may vary slightly based on which accrediting organization you’re working with. Here are the top ones you’ll likely come across with their primary focus areas highlighted:

  1. The National Committee for Quality Assurance (NCQA): The NCQA accredits organizations and individuals ranging from health plans, like Health Maintenance Organizations (HMO) and Preferred Provider Organizations (PPO), to physician networks, medical groups, and individual physicians.

  2. The Joint Commission (TJC): The TJC accredits a wide range of organizations including general psychiatric, children's hospitals, nursing homes, and ambulatory care providers.

  3. The Utilization Review Accreditation Commission (URAC): The URAC also accredits many different types of healthcare providers. In some cases, they do so across the entire organization. In other instances, only within the functional areas.

These healthcare accreditation organizations are dedicated to ensuring ethical and safe care for all patients. Because of this, the credentialing process is repeated multiple times throughout a healthcare provider's career to ensure all information is up-to-date and no events happen that revoke their license or strip them of their credentialed status.

Importance of Credentialing

Credentialing is the most crucial step in the hiring process to ensure that the healthcare provider is legally allowed to practice medicine. Let’s walk through why.

  • Patient safety - There are people out there, believe it or not, that impersonate healthcare professionals. They have no education or training in the field and no business treating patients. In fact, it’s estimated that 98,000 patients die every year from medical errors in the United States. This is a terrifying statistic that all medical practices should be working to lower. Credentialing every physician that enters a medical facility can help improve that statistic and increase patient safety. Without credentialing, you run the risk of letting these scammers slip through the cracks, cause serious harm, and increase the number of medical errors in the US.

  • Patient trust - As you know, building relationships and establishing trust between the clinician and the patient is essential to delivering quality care. Giving patients the confidence that their provider has the knowledge and experience to understand and treat their specific health concern is vital. Not only does it allow the patient to trust their provider, but it allows them to trust the medical practice as a whole. That relationship the provider builds with the patient will, more than likely, keep them coming back and seeing that provider on a regular basis. Recurring patients is a win-win for the clinician and the business and a huge piece of that puzzle lies in credentialing.

  • Brand protection - The credentialing process also keeps the healthcare organization safe from reputational damage, potential lawsuits, and patient harm. You should have someone on-staff or partner with an outside firm that specializes in credentialing to make sure you do not miss anything required by state or federal laws.

In summary, thorough credentialing ensures that the horror story mentioned earlier does not happen to your organization or your patients. I think we can all agree that we’d rather not make headlines tied to lack of due diligence or patient endangerment.

The Risk of Cutting Corners

Now that we understand the importance of credentialing, let’s discuss some of the risks that could come from cutting corners.

Obviously, the greatest danger of all would be unknowingly putting your patients in harm's way. Patient safety should remain your top priority at all times, and verifying the clinicians who will be interacting with them is a must. They will be viewed as an extension of your brand and a direct representation of your expertise.

Here are a few other concerns to be aware of should you fall out of compliance:

  • Lawsuits and settlements - If a physician has not been fully vetted and they’re lacking appropriate training, medical malpractice can occur. The legal ramifications would not only fall on the physician, but also be the hospital, clinic, or telehealth company. This could result in a serious lawsuit.

  • Loss of finances - Lawsuits lead to settlements and settlements lead to large amounts of money being paid out. The average settlement for a medical malpractice lawsuit in the United States is around $242,000. That’s a LOT of cash your organization would be losing.

  • Damaged reputation - Falling out of compliance is a big deal and you bet the media is going to be all over it. Bad press leads to a damaged reputation throughout the community and also nationwide across clinicians, patients, payers, and partners.

  • Cancelled reimbursement - If a provider that works for your healthcare organization is not credentialed, the insurance companies have the right to cancel reimbursement for the healthcare services that provider performed. This includes cancelled reimbursement from Medicare and Medicaid. This will result in losing thousands of dollars and that all falls on the medical office to pay.

  • Loss of business - Depending on how bad the legal case, settlement, and reputational harm is, you could risk losing patients AND your entire company as a result. It’s hard to bounce back from negligence when it comes to people’s health and safety.

Credentialing In-House vs. Outsourcing

Credentialing is a very tedious, time consuming process that leaves you two options. You can either hire certified, internal staff to manage this 24x7 or you can outsource it to a third party with a full credentialing team and proven experience under their belts.

Let’s start off with what it takes to maintain the credentialing process internally.

  • Credentialing software: In-depth research and comparison across credentialing software will need to be performed to ensure you are purchasing the right tool for your unique organization. You will need to map out the features required, the budget allocation, and the capabilities and bandwidth of your team to support it.

  • Staffing: To keep the credentialing process running smoothly internally, it’s important to have at least one experienced credentialist on-staff. Ideally, two to three. As you can probably tell, this process is complex with little room for error. Any mistakes in submission quickly rack up dollars and additional time waiting. An expert will be able help guide your organization through the credentialing steps and to make the implementation process run smoothly.

For the above reasons, many organizations find it’s easier, less stressful, and surprisingly cheaper to outsource clinician credentialing to an established firm. That’s less people you have to bring onto your staff and salary, less risk should the process be performed incorrectly, and more time your internal team can refocus on driving business growth and value.

If you’re leaning towards outsourcing your credentialing, doing your homework to find the right partner is super important before signing a contract. Always double-check the standards they are credentialing against and make sure they have a clear understanding of your organization and the patients you support. In many cases, whatever firm you choose can also take on many other daunting tasks from your to-do list, including licensing, payer contacts, and even clinician staffing.

Benefits of Outsourcing

In addition to all of the benefits we just touched on, there are several other perks that come with hiring a third party to carry out your credentialing.

  • The software is taken care of. Outsourcing means not having to find the right credentialing software for your organization, purchasing that software, and supporting it through ongoing refreshes. Your partner already has the software and knows the ins and outs of using it effectively.

  • The process gets streamlined. Outsourcing also means a more streamlined process for your internal team. Trust the credentialing to the professionals. They have the methods, timeline, requirements, and connections down. They’ve been there, done it, and bring proven expertise that’s extremely valuable.

  • The clinician application system is already set up. Oftentimes your credentialing partner will also have a system setup for processing, vetting, and contracting clinicians. Again, one less thing you have to worry about purchasing and running.

  • The connections have been made. The credentialing experts usually have relationships with healthcare payers including Preferred Provider Organizations (PPOs), Health Maintenance Organizations (HMOs), and insurance agencies. Having familiarity never hurts when trying to expedite this process.

  • The success rate is high. Leaning on experts in the space means less margin for error, resulting in the quickest possible turnaround time and a well-executed application the first time around. That peace of mind is invaluable.

While we’re on the topic of outsourcing credentialing, we have to touch on OpenLoop briefly. OpenLoop has a full team of dedicated licensing and credentialing experts who align to the National Committee for Quality Assurance (NCQA) standards. That means that any client who partners with us can offload the headaches of staffing, licensing, credentialing, and payer contracts to save time, money, and stress. We are a one stop shop for all your credentialing needs.

Given our long standing relationships with providers across the nation, we’re able to rapidly scale up clinicians to support your patient demand, while also ensuring they’re aligned to your company’s unique culture, knowledgeable about the patients you support, and tech-savvy enough to run your telehealth visit.

Our team of credentialing experts are the best in the business. To make sure we are fulfilling our mission of delivering healing anywhere, our credentialing team works 24/7 to expand our network of certified clinicians. And it’s paid off! OpenLoop services all 42,000 zip codes nationwide, accelerating the delivery of patient care by connecting that community of certified clinicians and insurance partners with telehealth companies across the United States.

That officially wraps up everything you need to know about healthcare credentialing! Feeling overwhelmed by all that goes into it? Offload your to-do list to us! Let’s grab some time to meet on the ways OpenLoop can help you confidently offload your clinician hiring, licensing, and credentialing.

Media Contact

Jess Greiner Director, Marketing
jess@openloophealth.com
641.780.1114