Although the credentialing process can be complex, verifying and assessing the qualifications of a healthcare professional is crucial. And the proof is usually in the pudding. After a provider’s background is thoroughly vetted, only then are they granted clinical privileges.
So if credentialing ensures that a provider is certified to deliver safe, high-quality healthcare, why do providers have to be recredentialed—not just once, but again and again? And why is recredentialing important for providers and healthcare organizations?
What Is Recredentialing?
Recredentialing, often referred to as renewing insurance panels, closely mirrors the initial credentialing process. Recredentialing is a payer activity that entails reviewing and potentially requesting renewal of professional credentials to maintain status with a health network. If a provider does not complete the recredentialing process (typically done every two to three years, depending on the state and the health plan), they may not be eligible to continue participating in payers’ networks. But recredentialing isn’t done just for fun or just because payers want to be a pain. The main reason for recredentialing is for payers to meet National Committee for Quality Assurance (NCQA) standards to ensure that they are doing their due diligence.
On the provider side, recredentialing serves a key purpose: it allows providers to receive payment for delivering care. In this regard, recredentialing is important not only because it serves to verify the continued competence of a provider, but because it supports the maintenance of accurate and up-to-date information about a provider. If provider information is outdated, claims made to the payer may be denied or severely delayed, which can result in a significant financial loss.
The Recredentialing Process
As a part of the recredentialing process, a provider should be notified at least 60 days prior to the recredentialing review to submit their application. After the application is submitted, payers confirm that the application has been completed in full and that all required supporting documents are present. As part of this process, payers verify the status of the provider’s medical license and malpractice insurance coverage, review regulatory requirements, and conduct other administrative and financial checks.
We know this sounds tedious. And it can be, for both providers and payers. But fortunately, solutions are available that simplify and streamline the recredentialing process by allowing providers and payers to update and retrieve information within one universal database, saving both parties the hassle of repeating the same steps for different organizations. With some of these solutions, providers don’t even have to do anything at all.
Automating the Recredentialing Process
The most advanced and seamless recredentialing solutions apply sophisticated automation across a variety of organizations to the point that recredentialing becomes an afterthought for humans and handled by smart technology. In fact, some people using solutions like this may even be wondering why this blog is even necessary because they’ve forgotten the headache that comes with archaic recredentialing processes.
The CAQH online data repository is one example of how the recredentialing process can be smoother serving as a database for member payers and providers to use. The key feature here is that CAQH aims to ensure that data is updated more frequently as opposed to allowing good provider data management to linger until the point of credentialing expiration.
Taking this a step further, additional solutions that are already used regularly for provider transactions, such as provider enrollment and primary source verification, among others, can serve as an even more comprehensive single source of truth. These solutions focus on building a structured data store that makes it easy for provider data coming in from one task (like provider enrollment) to be applied to another task (like recredentialing).
In short, the next generation of recredentialing and provider data management solutions work smarter, not harder, on behalf of providers, payers, and the clearinghouses that often facilitate transactions between them.
Automation applied to recredentialing can help improve workflows, expedite processes, enable greater access to shared data, and keep providers and payers in good standing with each other. Though it may seem trivial, recredentialing is more than a background check. It is essential to supporting the quality of a provider network and is a path toward improving the business operations of healthcare. Through automation, recredentialing can be one less action item on the to-do list of those providing, paying for, and enabling high-quality healthcare.
Learn more about Madaket’s Provider Data Exchange (PDX) Platform that enables frictionless, faster, automated provider data management.