Why Provider Credentialing Can Save You Money and Improve Patient Care

In order to prevent bad actors from harming patients and defrauding payers, strict credentialing processes that meet compliance requirements are necessary.

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

The figure published in 2016 by the British Medical Journal (BMJ) is some 250,000 deaths per annum were attributable to medical error. 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.

Healthcare fraud and abuse costs billions
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 conservatively that 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. 

Government Measures in Place to Protect Patients and Prevent Fraud
Measures have been put in place by the Federal and individual state entitlement programs to safeguard patients while reducing fraud, waste, and abuse through a regulatory framework. Payment from entitlement programs for medical treatment given to beneficiaries is subject to their observance of the rules and regulations established by the regulatory bodies. If it is shown that someone has abused this system, they could be subject to fines, civil penalties, and even jail time.
The establishment of sound procedures and the use of quality measures are guided by standards organizations.
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).

What can you do?

Implement a best practices approach to provider credentialing

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

• Thorough screening
• Continuous monitoring

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 10-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. 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.