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The Merits and Importance of Provider Credentialing

December 7, 2020

A stringent credentialing process that meets compliance requirements is designed to keep bad actors out of the healthcare delivery systems where they have an opportunity to harm patients and defraud payers.

As Hugh Greeley describes in his blog, bad actors have taken advantage of the sick, vulnerable, and helpless for personal greed and power for at least as long as history is recorded. Unfortunately, these types of individuals may exploit those seeking medical help when a loved one’s well-being or survival is at stake.

Medical Error is the Third Cause of Death in the U.S.

There is some controversy around this estimate because of an unconcise definition of “medical error” and the methodology of measurement. The figure published in 2016 by the British Medical Journal (BMJ) is some 250,000 deaths per annum were attributable to medical error, making medical error the third leading cause of death in the U.S. Granted, not all medical errors are caused by bad actors, but preventing entry as well as quick discovery and extraction of bad actors is certainly a valid place to start.

$ Billions Lost to Healthcare Fraud Annually

Intentionally causing patient harm is less of a motivation than is fraud that results in personal gain, but patients are often the collateral damage of fraud schemes. Estimates range from 3% – 10% of the entire federal healthcare funding is lost to fraud, waste, and abuse. The National Health Care Anti-Fraud Association, (NHCAA) estimates about 3% or $68 billion annually of the $2.26 trillion in healthcare spending is squandered through fraudulent activity while some government and enforcement task force calculations up the percentage to 10 for more than $300 billion wasted annually.

The ubiquitous incidence of healthcare fraud and negligence is a serious threat to the sustainability of the healthcare system and the citizens it serves.

Government Measures in Place to Protect Patients and Prevent Fraud

The Federal and individual state entitlement programs have put measures in place designed to protect patients while mitigating fraud, waste, and abuse through a regulatory framework. Reimbursement from entitlement programs for healthcare services provided to beneficiaries is contingent on compliance with, and adherence to the laws and requirements set forth by the governing bodies. Those who are found to abuse this system face fines, civil monetary penalties, and possible imprisonment.

Standards Organizations Help Guide an Organization’s Quality Measures and Development of Sound Processes

Another layer of guidance additional to that of government regulation are the quality standards-setting organizations that issue certification and accreditation to healthcare delivery systems. These standards-setting and enforcement organizations regularly monitor and audit for compliance. Examples of these organizations are The Joint Commission (TJC), Det Norske Veritas (DNV), Healthcare Facilities Accreditation Program (HFAP), Utilization Review Accreditation Commission (URAC), and the National Committee for Quality Assurance (NCQA).

Transparency is the Answer to Quality Healthcare

Adherence to government requirements, quality standards, as well as best-practice based internal bylaws, rules, and regulations demonstrate the intent to deliver quality healthcare.

Enforcing compliance is the only path to full transparency, and transparency is the single path to risk mitigation: risk to patients, risk to staff, threats to financial solvency, legal exposure, and reputational demise.

The following is contributed by Hugh Greeley, author of Hugh’s Credentialing Digest

The rationale for rigorous credentialing has deep historical roots!

Jan Sanders Van Hemessen (1504-1566), a Flemish artist, painted a piece known as "The Surgeon".

Jan Sanders Van Hemessen (1504-1566), a Flemish artist, painted a piece known as “The Surgeon”. The masterpiece hangs in the Prado Museum in Madrid, Spain. The following description of this gruesomely compelling piece was found in the  Annenberg Center for Health Science on the campus of Eisenhower Medical Center in Rancho Mirage, California:

“The sixteenth century was a period of great turmoil and civil war in the Netherlands. At the end of the century, the northern provinces-now Holland-emerged Protestant and independent, while the south-primarily Belgium-remained under the control of Catholic Spain.

“During this time, common folk who had neither money nor access to legitimate, trained doctors were usually treated by medical quacks. Some of these swindlers were itinerants who traveled through towns and villages providing entertainment along with their miracle cures and potions. Others were residents who dispensed a combination of herbs, charms, and illusion.

“During the Renaissance, stones in the brain were believed to cause epilepsy and needed to be removed surgically. One common procedure began with the ‘surgeon’ making an incision in the hapless patient. Using sleight-of-hand, the charlatan would palm a stone, slipping it unseen into the cut. With much fanfare, he would then remove the stone, claiming to have discovered the cause of the ailment.

“In this painting, we see a young man supposedly insane. To the right, his father wrings his hands in desperation. The mother holds her son’s head while the surgeon extracts the ‘stone of madness’. Behind an array of instruments, a woman assistant prepares an ointment. In the background hang several stones which have been successfully cut out of the head of other patients as a sign of the surgeon’s skill.

“The caricature, flamboyant color, and dramatic subject matter are typical of Van Hemessen’s art.”

The Surgeon: Had this imposter been required to produce a license, certificate of competence, evidence of proper education and training, and freedom from any apparent sign of past problems, he would not have been able to grievously injure this unknowing, gullible patient.

Credentialing has merit and importance. When compliance feels laborious and pointless, remember the real reason for oversight through regulations and standards.

Implement a Best-Practices Approach to Provider Credentialing

Integrating a best-practices approach with the credentialing process builds a culture of excellence while creating a structure that systematically adheres to multiple layers of external requirements and standards in addition to internal bylaws, rules, and regulations.

The two fundamental components to the best-practices approach are:

  1. Thorough screening
  2. Continuous monitoring

Verisys helps health systems with best-practices credentialing, and ongoing compliance to the gamut of regulatory requirements and quality standards—assuring a quality healthcare experience for all patients.

FACIS® is Verisys’ proprietary database that provides primary source records on provider exclusions, sanctions, debarments, disciplinary actions, and indictments among other critical actionable data insights. The 8-million-record, aggregated FACIS database contains historical records dating back to 1992 for a longitudinal view as well as current records and everything in between in a secure, aggregated search engine.

Using FACIS when screening as well as for continuous monitoring is the core of provider credentialing and transparency. Next, is accessing other critical primary sources for a full picture of providers, volunteers, staff, board members, investors, and vendors. Important data points additional to FACIS include OFAC, DEA, nationwide license and certification boards, Sex Offender and Abuse registries, and the Social Security Death Master File.

A single search inquiry through Verisys’ powerful data platform delivers real-time results on multiple data sources.

Let Verisys streamline your credentialing process and ongoing compliance with the best data in the industry and the highest accuracy rate of matching data to identities.

Hugh Greeley Written by Hugh Greeley
Credentialing and Healthcare Industry Expert
HG Healthcare Consultant
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