Credentialing is burdening small hospitals—and underserved communities pay the price
When a healthcare provider applies for work in a patient services environment, a behind-the-scenes credentialing process triggers to ensure the provider has the relevant education and degrees, necessary licenses, training, and professional experience they claim to have. Only after this credential check—along with a look into any past criminal activity or malpractice claims—will a provider be permitted to work.
The process sounds like a standard employment background check, but in healthcare, the lack of a centralized data repository and disparate regulations from state-to-state means credentialing is a time consuming, manual process—one that puts small, independent hospitals and practices at a major disadvantage.
“If you're in a big health system and you're a physician, you may not actually know that much about credentialing because there are huge teams working on this, ‘buried’ in the basement, and they're just taking care of this for you,” said Fawad Butt, a data analytics expert, with past experience in executive roles at UnitedHealth Group and Kaiser Permanente.
Despite his expertise in making use of huge troves of data, Butt said there is no way to automate this process. Credential checking involves linking data from hundreds of disparate primary sources, has many moving parts, and is only growing in complexity. While artificial intelligence can help, no algorithm can handle the full job. Ultimately, providers need to maintain their own records to speed things up.
“When you're an allied provider [who works with a health system], maybe a physical therapist, occupational therapist, behavioral health, those kinds of folks, increasingly you are taking [credentialing] into your own hands because you have to make sure that you're licensed in all of the places that you're seeing patients,” Butt said. "And, with virtual care and telehealth being on the rise, you have folks that have 50+ state licenses they have to manage. So, most of the work is in helping the organizations verify all of those.”
Butt is an adviser for Baton Health, a startup that is centralizing primary source data for all healthcare providers to aid recruiting and credentialing teams. Baton’s CEO and Founder, Robert Coombs, admitted that the process for credentialing is “boring stuff” and can only be solved by manual box checking, but he lamented that it doesn't get enough media attention. Challenges associated with credentialing are serious problems that healthcare organizations need to solve if they want to get paid—and timely reimbursement remains crucial for the survival of small, independent hospitals and practices.
Payer-provider contracts create snags
Reimbursement challenges arise when a payer refuses to cover care a patient received, and that commonly happens when a tending physician is 'out of network.' Managing the complex web of payer-provider relationships strains healthcare organizations and leaves patients with surprise bills. It's a situation no one on the patient care side of the equation wants to encounter. If a hospital brings in a doctor, they need to be sure that provider is eligible for reimbursement with all contracted payers before they care for patients. Otherwise, someone is going to be left holding the bag.
“I think a lot of organizations face a ‘Sophie's Choice.’ They have a practitioner who's gone through their process to get hired but has not yet been enrolled with the payers. Do they allow that practitioner to see patients knowing that they're probably not going to get paid for it, or do they allow those patients to go unserved, or served by other practitioners who are already overwhelmed?,” Coombs said.
The problem is, the credentialing process can take months, and cutting that time down is essential to reduce the strain on community providers and hospitals.
“I'm not going to say that [solving this problem] is going to fix healthcare, but there has to be a major impact when every nurse in a hospital, every physician in a hospital—all of the allied providers—are blocked from delivering care,” Coombs noted. “That's going to have a pretty big impact, particularly in small communities.”
Blockchain to the rescue?
Where do credentialing services get the data they need to check all of the educational, regulatory and reimbursement boxes necessary to approve a provider? Turns out that’s very complicated. While payers operate some of the most complete databases in healthcare, building an API into their warehouses isn’t the answer. Butt said relying on payer data actually creates new issues with reliability, especially because payers have struggled to devise a way to keep their internal provider databases current.
A solution payers have explored is the use of blockchain, an example being the Synaptic Care Alliance, a coalition of payer groups working together to solve their mutual data quality concerns, in this case the need for continued maintenance of provider databases. The Alliance has run successful pilot studies, but real-world uses for blockchain in healthcare are still largely hypothetical.
When asked how they felt about blockchain to solve the problems surrounding credentialing, both Butt and Coombs were skeptical. Without an objective arbiter to ensure data is up-to-date and accurate, a shared blockchain ledger isn’t a solution, they said.
“My take on blockchain is it’s a solution that was looking for a problem,” Coombs said. “I think it would be a little naive for anyone to step forward and say that health system ‘A’ is going to verify information and health system ‘B’ is just going to take it on face value that it's true. Instead, what happens is another health system looks at it and says, ‘well, sorry, we can't trust it. Even though you did your trusted workflow on it, that's not ours.’ So nobody's actually ready to cede that level of trust to anybody else.”
“And that's why I think a lot of the digital wallet solutions make sense for self-reported information, but I just don't see them being viable for primary source information verified in a credentialing workflow,” he added.
Butt concurred. While he thinks a decentralized shared ledger has its use cases, the current technical limitations of blockchain hinder real-world implementation, particularly for something this data-intensive.
“I think the limitations that exist are as follows: One, the transaction speeds that we need are quite high, and I don't think any blockchain can them handle today. And then the second thing is, the contracts that would have to exist between all these entities to be able to trust each other's information—I just don't think it's going to happen anytime soon,” he said. "I think the technology idea and the architecture might be good, but [blockchain's] development—and the complications on contracting across these systems—are bigger challenges.”
Butt added that a lot of the necessary data for credential checks is stored in state and federal government databases—and governments are not particularly good at keeping their databases up-to-date, especially when it comes to records of where their data comes from. Without being able to confirm with an initial source that data is correct, healthcare organizations can’t rely on its accuracy. That alone has been one of the biggest hurdles to developing a centralized repository for credentialing services.
For now, information remains siloed and credentialing providers is completed only with a lot of manual cross-checking. Unfortunately, that means rural communities are more likely to feel the impact from associated time and labor costs.
“One physician not being available in an area for a month where there are only two physicians has a major impact on that area, versus being in a market where there are a hundred and one is out of commission,” Butt said. “So, I think there's just a disproportionate amount of impact on underserved communities, smaller markets and smaller players."
Chad is an award-winning writer and editor with over 15 years of experience working in media. He has a decade-long professional background in healthcare, working as a writer and in public relations.