Industry Voices—Hospital credentialing systems are no longer enough for payers

It’s time for payers to seek the right fit. (Getty/wildpixel)

Built on the theory that some things just don’t fit, the square-peg-in-a-round-hole analogy can easily be used to describe the process in which insurance payers manage provider credentialing.

Most insurance payers rely on hospital credentialing platforms to do payer-specific credentialing. And while there is a lot of overlap between hospital and payer credentialing activities, particularly with regard to primary source verification, hospital credentialing systems are the square peg.

The payer problem

Some payer-specific credentialing systems are available, but they are typically homegrown and therefore not adaptable, or they lack true enterprisewide capabilities. As a result, most insurance companies use hospital credentialing systems that come with their own set of problems. Because hospital credentialing systems are built for the specific needs of a hospital, they lack the data tracking and automation capabilities payers need to be successful and compliant.

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In the highly competitive insurance industry, payers are constantly tasked with finding new ways to differentiate themselves from their competition. Enhancing the physician on-boarding process through electronic automated processes as well as providing physician-specific data are two ways that payers can improve physician satisfaction and ease that process.

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Consider, for example, the layout of a building.

Knowledge of which doorway patients must go through or whether a clinic is on the first or second floor may seem like insignificant details to some, but for a patient with mobility issues, a doorway or floor can represent ease of access. Collecting this information and providing it to the physician, who in turn can provide it to their patients, improves patient satisfaction—and therefore physician satisfaction. Payers that are able to track this level of detail for patients are much more appealing for a provider to work with.

And while this information is important to payers, physicians, and patients, it is often less relevant to the hospital for compliance purposes and therefore, is not tracked in hospital credentialing systems.  

Another example of ill-fitting hospital credentialing systems is the inability to perform roster maintenance. Payers sell different types of insurance. They need a place to store customized rosters for their specific products and a process for managing this information. Because this information is irrelevant to the hospital, hospital credentialing systems don’t offer data fields or an easy method to track, store and easily report this data. As a result, payers must use yet another system to manage their roster maintenance.  

Despite limitations, hospital credentialing systems are force-fit by payers. To offset the shortcomings of these systems, payers use multiple systems to address their unique credentialing needs. This siloed approach, however, is inefficient. Because data is housed in disparate systems, it is less accessible, which diminishes its value.

 A brighter future for payers

Insurance payers no longer need to play second fiddle to hospitals when it comes to their credentialing technology platform needs. While it’s been a long time coming, payer-specific enterprise credentialing platforms are slowly entering the market. Vendors have taken what they’ve learned from hospital credentialing systems and incorporated best practices to create highly customizable credentialing platforms that meet the specific needs of the payer market.

These systems are flexible and nimble; enterprise-based and in the cloud, so they can be used by multiple groups in multiple states across the country. Further, improvements in business intelligence, analytics and advanced reporting ensures that payers can easily report on their data as well as use that data in actionable ways to improve physician and patient satisfaction. Customized payer platforms also improve efficiency and reduces costs for payers.

While this is considerable progress, additional development must take place on the payer side. Integrating payer credentialing software with contract life cycle management will further streamline processes.  

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This integrated platform is available to hospitals today and the benefits are significant. Using an integrated credentialing and contract life cycle management system, hospitals can save significant time by eliminating duplicate data entry.

Integrated platforms also offer hospitals cross-team access to provider data, which allows everyone involved in getting a payer ready to bill to track where a contract is each step of the way while greatly speeding processes. Similar benefits can be experienced by payers when payer credentialing systems are integrated with contract lifecycle data.

It’s time for payers to seek the right fit. Settling for a hospital credentialing system that can’t be customized to a payer’s specific data needs is no longer enough to be successful in today’s competitive insurance landscape.

Scott Friesen is the CEO of Newport Credentialing Solutions and has over 19 years of healthcare and leadership experience. Mr. Friesen's expertise is in the hospital, academic medical center, and multispecialty group practice setting. Mr. Friesen has deep expertise in operational, financial, revenue cycle, provider enrollment/credentialing, cloud-based software development and business process outsourcing solutions.

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