Provider data management: Why hospital execs should make it a priority | Viewpoint

Provider data management and the credentialing process are the engine drivers of healthcare. Without them, providers cannot care for patients, the hospital engine stops running, and revenue growth stalls.

Provider data management and credentialing should be a high priority for hospital spending, Bill Christy writes.

Provider credentialing and privileging involve the verification of a provider's identity and qualifications to deliver medical services. Despite being a time-consuming and detailed process, credentialing is a non-negotiable requirement and plays a pivotal role in enabling healthcare organizations to fulfill their commitment to delivering high-quality patient care. The credentialing process takes anywhere from 30-90 days with traditional PDM methods, but by adopting technology that conducts PDM for a hospital, the lead time to get a provider into practice is significantly reduced.

Many hospitals still maintain outdated PDM processes that delay the credentialing and privileging of providers because information on each individual is manually compiled from disjointed sources. This inefficient operation creates a chain reaction of delays in the hospital with a slow administrative flow keeping providers from practicing medicine and causing delays in patient care due to the shortage of credentialed providers available to see them.

PDM and credentialing should be a high priority for hospital spending in 2024. Without these essential processes, hospitals and their providers are unable to deliver top-quality care.

Identifying areas for improvement

In the traditional PDM process, medical staff professionals dedicate extensive time to managing and verifying provider data to ensure they meet accreditation standards. In any given health system, the number of providers ranges from hundreds to thousands.

The manual collection and documentation of provider data can be a daunting task for professionals, so automating data collection eases the strain on the credentialing teams and speeds up the process by eliminating manual work. The work professionals do is the gateway to quality, so equipping them with the right tools enables the delivery of quality care from providers that have been verified by a standard and trusted source. By ensuring quality on the front end of the care process, more efficient and quality care delivery is enabled on the back end.

The process of credentialing and re-credentialing also poses a challenging and time-consuming administrative burden for healthcare providers.

The completion of forms, scanning of source documents, and collection of accreditation materials requires extensive time, which could be spent working with patients if the process were simplified. This diversion of attention from patient care results in a financial setback for the healthcare organization and raises the risk of provider burnout.

Not only does the credentialing process allow providers to practice medicine and provide care, but it also prevents costly errors from surfacing across the organization. An inefficient or inaccurate credentialing process contributes to errors for medical staff professionals and providers, potentially causing harm to patients because processes adhering to the highest quality standards were not put in place. Effective credentialing necessitates a thorough process, and when this process encounters issues, expenses accumulate.

According to a study by Merritt Hawkins, the average physician earns a facility about $2.3 million per year, so when a provider is bogged down in the credentialing process, this can cost an organization an estimated $9,000 per provider per day in delayed or lost revenue.

Furthermore, mismanaged credentialing has the potential to result in patient leakage, harm, or even death if treatment is not promptly scheduled or is delayed. This, in turn, may result in costly lawsuits related to negligent medical credentialing, with lasting implications for a health system's financial standing and reputation.

Holding processes accountable

PDM is one of the rare areas that touches all of healthcare. Quality of care, value-based reimbursement models, and regulatory factors are all areas directly impacted by the throughput of provider data management.

More specifically, the No Surprises Act, which protects patients from surprise out-of-network bills for emergency and certain non-emergency services, mandates accurate and up-to-date provider directories to ensure patients have access to reliable information about the network status of healthcare providers. Health plans are required to maintain current and accurate provider directories, enabling patients to make informed decisions about their care and avoid unexpected charges.

This necessitates a more rigorous and efficient approach to PDM, emphasizing the need for real-time updates and improved data accuracy. Healthcare organizations must enhance their PDM to be interoperable, remain compliant, and deliver the quality care that patients expect.

The many factors that play into credentialing and PDM have a direct impact on reimbursement rates for providers and their organizations. If providers are not accurately credentialed and the quality of care delivered is insufficient, reimbursement from Medicare and Medicaid payers is at risk. The most important benefit of an end-to-end PDM solution is improved quality of care, making it an essential component of operations to ensure the best outcomes for patients and reimbursement for providers.

Looking at the year ahead, PDM should remain top of mind for healthcare leaders as they determine how to prioritize budget spending. Given the severity of consequences for insufficient PDM and credentialing, hospitals can eliminate the risk of high-cost repercussions and even increase revenue by choosing to invest in a PDM system that streamlines processes and makes the work of providers and MSPs more efficient.

Through the utilization of integration and credentialing technology that seamlessly connects health system processes and provider data, providers are properly vetted with the skillsets they need so that harm and risks to both the patients and the health system are minimized.

Bill Christy is executive vice president and managing director of provider data management at symplr