Credentialing is a multi-step process to assess and verify the qualifications of a licensed or certified healthcare provider. The credentialing process must occur before a payer or healthcare institution begins a relationship with an individual clinician. The Centers for Medicare & Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations both require provider credentialing.

• At least 15 data points from each provider
• Manual, paper-based data exchange between providers and payers
• Approximately 90 to 180 days for the approval process
• Occurs for all new relationships, and then at regular intervals (every 1 to 3 years)

1. Primary Source Verification (PSV) is a healthcare organization’s process of sourcing information to confirm the legitimacy of an individual clinician. This includes proof of residency and internship completion, undergraduate and graduate transcripts, practice and board certifications, state licensures, practice history, and additional background documentation. There are various methods for conducting PSV, including direct correspondence, documented telephone verification, secure electronic verification from the original source, or reports from CVOs that meet the Joint Commission requirements.
2. Privileging is a healthcare institution’s approval and authorization of a new clinician to perform specified medical services. This is akin to making the clinician a new user in the system and granting them the privileges to offer services within specific facilities. Privileging must be completed prior to a provider performing medical services.
3. Payer Enrollment corresponds to the direct payer-provider relationship. For a clinician to participate in-network with third-party payers, those payers must perform a verification of the clinician’s identity and experience.

The payer enrollment process must be completed with accurate information before a clinician can bill a payer. While filling out forms may seem like a simple, administrative task, the dissimilar processes used by payers, clearinghouses, and other third parties involved creates many opportunities for error and delayed approvals.

1. 1. Provider onboards and starts the credentialing process as a new clinician. There are at least 15 data elements required per provider including contact information, national provider identifications (NPIs), and primary practice locations.
   2. Provider informs the payer that they are interested in credentialing. Before paperwork begins, providers typically contact the payer to determine whether credentialing is possible. In some cases, payer panels may be closed to new providers, but if the payer is accepting new clinicians, the provider receives notice of the information required to enroll.
   3. Provider manually completes a variety of forms. A single provider will enroll with an average of 25 payers, which means they need to complete and submit 25 separate forms via separate pathways. Each payer requires the same information but in their unique format.
   4. Payer receives a provider’s application. The provider often fills each form by hand, prints it, signs it, and faxes or mails it to the payer.
   5. The 90-to-180-day review process begins. Throughout this process, provider staff may spend valuable time following up via phone multiple times; in many cases, there is no portal or email system to provide alerts and updates. In the meantime, the clinician is barred from performing or billing for services.
   6. Payer performs a separate and different verification. In the spirit of due diligence, payers perform their own verification of the clinician’s background. This is collected, logged, and tracked primarily using paper forms or spreadsheets. While more reliable than paper recordkeeping, spreadsheets still present a host of security, privacy, and efficiency concerns. Additionally, this piece is often outsourced to other companies that also utilize manual, paper-based processes, adding layers of complexity and increasing the potential for mishandling of information. In general, the information that is being verified by the payer has already been verified by the provider, and if any information is found to be missing or incorrect, the process begins again with the provider.
   7. Payer accepts provider application. Once the forms are compliant, the payer accepts the provider’s application, and the clinician is deemed “in-network.”
   8. The process repeats in 1 to 3 years. The National Committee for Quality Assurance (NCQA) credentialing standards require payers to re-credential every three years, and the NCQA recommends that providers re-credential every two years.6 Although those intervals keep both groups accountable, they can lead to a fragmented process that is only practiced when those standards require them, creating more room for error.

1. Fragmented Data: During payer enrollment, the provider data gathered are constantly pulled from and verified by a variety of sources, including providers, national board records, or third parties. In other words, many “sources of truth.”
2. Lack of Ownership: Lack of clarity in roles compounds the problems created by fragmented data in the payer enrollment process. On the provider side, larger organizations have in-house medical staff offices (MSO) or centralized verification offices (CVO) to handle provider data management. Other organizations may have dedicated credentialing staff. The smallest of groups will utilize administrative staff. On the payer side, collection, verification, compiling, and data cleansing are all separate functions, often handled by separate departments. As a result, provider data is often split and duplicated between human resources, recruiting, billing, and others. With the variety of hands working within the process, there is no single, centralized owner of the data, and compartmentalization leads to inevitable error.
3. Manual Tasks: The sheer amount of data that must be managed by the involved parties is enough to create problems. When the majority of work is done by hand, human error heightens the risk of failure, added cost, and delays in the process. Many payers still require “wet signatures” from providers. Even in cases when processes are done digitally or by third parties, providers are required to print and physically sign forms, then re-upload. This step creates many potential issues, from poor transmission fidelity to accidental document duplication.
4. Inconsistent Data: Whenever a provider’s data needs to be altered (i.e., address changes), the updated information has to reach payers before the clinician can perform any further services. Otherwise, the provider is at risk of prior authorizations, claims, and reimbursements getting denied. An estimated 2% to 2.5% of provider demographic data changes each month, triggering added iterations of the data management processes, which create more opportunities for error.

While it may not be obvious, provider data drives the most fundamental processes in the healthcare system. Provider data management, which includes the tasks and processes involved in controlling, managing, and updating information on healthcare providers, is critical, but plagued by inefficiencies. The ability for providers and payers to manage provider data – demographic, professional, and financial – effectively and efficiently is the foundation of a successful provider-payer partnership.

Sound data management processes help to ensure swift credentialing, enrollment, network participation, and payment of providers. When these processes fail, costs escalate. Mismanagement of provider data – often the result of repetitive, manual, error-prone processes – contributes heavily to claims processing errors, adding nearly $17 billion annually in unnecessary healthcare costs.

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