Why is Credentialing Important? Protecting Patients from Bad Actors

Statistics of why credentialing is important in healthcare


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

$ Billions Lost to Healthcare Fraud Annually

Intentionally causing patient harm is less of a motivation than 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 lost to fraud, waste, and abuse. The National Health Care Anti-Fraud Association (NHCAA) estimates that 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 incident of healthcare fraud and negligence seriously threatens 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 governing bodies’ laws and requirements. 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 in addition to government regulation is 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, and best-practice-based internal bylaws, rules, and regulations demonstrate the intent to deliver quality healthcare.

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

Implement a Best-Practices Approach to Provider Credentialing (Verisys Plug)

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 of the best-practices approach are:

  1. Thorough license screening
  2. Continuous sanction monitoring

Verisys helps health systems with best practices credentialing and ongoing compliance to 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. FACIS database contains historical records dating back to 1992 for a longitudinal view, current records, and everything in between in a secure, aggregated search engine.

Using FACIS when screening and continuous monitoring is the core of provider credentialing and transparency. Next is accessing other critical primary sources for a complete 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. 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.