Why Verifying a Provider’s Credentials is Critical

Provider credentialing is critically important for healthcare organizations. Not only does it protect your organization from lawsuits and fines it also protects your patients from incompetent or unscrupulous providers. Although credentials verification can be a complex process, following best practices in provider credentialing ensures a high standard of care.

Medical credentialing is the process of verifying that a provider’s qualifications are current and in good standing. Credentialing is usually performed upon hiring a new candidate and as a routine practice while the provider is employed by a healthcare organization. Credentials verification consists of confirming that the applicant’s education, work history, license and specialty certifications, and other unique identifiers such as NPI and DEA numbers are validated by consulting primary sources and then verifying that the candidate is not excluded from practice by checking state and federal exclusion databases.

Top 5 Provider Credentialing Errors

If credentialing is not done properly, the consequences can be severe. Even if you catch your mistakes in time and re-do the process, credentialing errors waste time and money. It can disrupt your revenue and billing cycles by causing delays in hiring and reimbursements. If credentialing errors go unchecked, you also risk the health and safety of your patients and expose yourself to potential liability, fines, and negative publicity. By avoiding the errors that follow, you can avoid credentialing pitfalls.

  1. Having outdated information on the provider’s background: Providers are expected to stay current with their licenses and certifications in the states where they practice. If they allow any qualifications to expire, they could be practicing medicine without a license, which exposes their organizations to potential lawsuits. Your organization is responsible for verifying that licenses are current and in good standing on a regular basis. In addition, state and federal databases regularly update their exclusion lists, so they should be checked at least monthly for any new information about your providers.
  2. Internal conduct investigations left unreported upon resignation: Any time an allegation of improper conduct, non‐compliant activity, or a legal violation is reported against a healthcare entity, that organization must conduct an internal investigation. Launching your investigation in a timely manner will demonstrate your commitment to keep patients safe and follow laws and regulations.
  3. Failure to authenticate critical data: This credentialing error can happen if the candidate fails to provide accurate or complete contact information for the institutions which conferred the credentials. Healthcare entities are required to provide primary source verification of credentials. Usually, this means contacting the institution directly. Without current contact information, credentialing staff using less reliable secondary sources for verification risk obtaining inaccurate or incomplete information.
  4. Credentialing specialist is under pressure to complete the credentialing and approves the application: When credentialing staff has insufficient time or resources to complete a thorough credentialing, they can become stressed and overwhelmed. This creates an environment where mistakes are more likely, especially if they are expected to perform the process quickly. Healthcare organizations should invest adequate time and resources for credentialing, and accurate data should be prioritized over speed.
  5. Data entry errors due to lack of attention to detail: Credentialing requires a large amount of data verification and data entry. If credentialing specialists neglect to fill out parts of the application or submit incorrect information, they can cause reimbursement delays, denied claims, or even the hiring of unqualified individuals. The government holds entities responsible for employing excluded providers, even if the error was unintentional. Healthcare entities should adopt best practices for credentialing and provide compliance training for staff, so they clearly understand credentialing procedures and procedures.

Best Practice Provider Credentialing

Provider credentialing is essential for the health and safety of both patients and organizations. Without proper credentialing processes in place, healthcare entities risk committing errors that leave them vulnerable to lawsuits, fines, and penalties. Human errors are inevitable; however, organizations can take steps to reduce the likelihood of error and mitigate risks.

Provider credentialing can be a time-consuming and complex process. Best practice includes the continual monitoring of your providers and staff after the initial credentials validation. Verisys can simplify your credentialing process and reduce human errors by automating your credentials verification and monitoring your staff. Verisys provides nationwide primary source verification and continuous monitoring of your providers and staff, notifying you of any changes in status. Verisys’ comprehensive provider exclusion database and in-depth screening process can help you stay compliant with state and federal laws and regulations, improve your reimbursement rates, avoid costly fines and litigation, and increase patient safety.

Verisys Written by Verisys
Verisys transforms provider data, workforce data, and relationship management. Healthcare, life science, and background screening organizations rely on our comprehensive solutions to discover their true potential. Visit verisys.com to learn how we turn problems into power.

  • Secure, configurable, and proven solutions
  • Accurate, compliant, and complete information
  • NCQA, URAC, and ISO accreditations/certifications

Follow us on LinkedIn