Question

Is there a connection between credentialing and quality outcomes? Why or why not? Which ones? As the healthcare manager, how do you ensure the monitoring of physician credentialing? Please detail the process. How can an institution ensure high standards and consistency in the credentialing process from physician to physician and from time to time?

Answer 1

There has been no solid proof of a connection between quality outcomes and credentialing. But there are plenty of positive pieces of evidence that suggest a direct lineage between the two. As a healthcare manager, it is important to ensure physician credentialing. There can be two methods-
1. One to many- Traditionally, physician credentialing departments have not experienced high rates of growth and as such, have managed their providers in a one to many management structure. In the one to many management structure (as depicted below), a single physician credentialing specialist manages every component of a large number of providers and their physician credentialing life cycle. This management structure has worked in the past because the volume and complexity of physician credentialing did not necessitate an alternative. Providers practiced at one or two locations, would only participate with 20-­25 health plans, and would have successful, long-­term careers. One issue with the one to many management structure is the operational risk. By having one physician credentialing specialist manage every aspect of a large number of provider’s enrollment, there exists a centralization of domain expertise. A second issue with the one to many management structure is scalability. Understanding that physician credentialing specialists are falling further and further behind due to the increasing number of providers coming on-­board, it is very difficult to scale physician credentialing staff to meet growing operational demands.

2. Many-to-many-

The response to concerns regarding the one to many management structure is a team-based management structure. Taken from the successful team based management techniques used in revenue cycle management, the team based management structure creates specialized teams to manage each of the specific tasks of the credentialing life cycle. These teams are created based on each task of the credentialing life cycle. For example, one team might be a data entry team, a par/non-­par team, an initial CAQH and CAQH re-attestation team, an applications processing team, a credentialing follow-up team, or a re-credentialing team. Each team should be managed by a team lead and in turn, the team lead should be managed by a manager or director. The benefits of a team-based management structure is specialization and increased efficiency. Further, by managing your credentialing life cycle in a team-based management structure, you create a scalable foundation upon which to grow your credentialing enterprise. Finally, a team-based management structure provides stability and increased morale in your department. In the team-based model, if a data entry specialist leaves your department, you only have to find a new data entry specialist, not a highly skilled credentialing specialist.