Provider credentialing is a critical yet often overlooked element to successful revenue cycle management (RCM). Across the healthcare industry, there is a lack of awareness about how an efficient, accurate credentialing system can streamline medical practices’ RCM workflows and assist in capturing revenue that may otherwise be lost or delayed. This is because the connection between the benefits of a credentialing platform and the RCM function is not always intuitive nor immediately clear, causing departments to be siloed. However, bridging the gap between credentialing and RCM functions is essential for preventing revenue loss, reimbursement delays, and other challenges — and ultimately aids in bolstering practice efficiency and financial stability.
In most healthcare organizations, the credentialing and RCM functions — with their respective teams, tools, and processes — are often seen as separate entities. As a result, teams frequently duplicate efforts in pursuit of the same shared goal: enabling their clients to provide high-quality care that also gets properly reimbursed by payers.
“It’s really important to have a single process and to see the full cycle of RCM and credentialing as one piece because if you don’t, payments could be delayed, or worst case, not realized at all,” said John Bou, COO and co-founder of Modio Health.
“At my company, our two teams, billing and credentialing, work hand in hand,” says Cheryl Lee, Director of Credentialing at Claimocity. “We’re having meetings set up with just these two teams to find out what issues they’re seeing and where we are in the process. We do need to talk to each other just for the success of the customer.”
In addition to having a siloed approach, many organizations still use outdated credentialing processes, such as Word documents, Excel spreadsheets, and calendar entries to track provider and payer information. Relying on such manual tools can result in timesensitive verifications to fall through the cracks, said Ms. Lee.
“Without getting contracting and credentialing right, practices may or may not get paid,” she said. “Then there’s additional work to appeal denied claims if providers haven’t been adequately credentialed.”
A modern credentialing system addressing a myriad of challenges
Achieving credentialing and billing/RCM teams’ shared goal requires a modern credentialing system. An updated, state-of-theart system ensures an organization’s providers are not only qualified and privileged to see patients, but are also in-network, meaning their services are reimbursable by the payers the organization works with.
Such a credentialing system must be able to monitor providers’ licensures, payer enrollments, and facility privileging, as well as send reminders regarding licensure revalidation, enrollment expiration dates, and other upcoming changes that require action steps.
“With Modio, once we add a provider or a payer, all of their licensure information, contract expiration dates, and other history are online,” Ms. Lee said. “We don’t have to do manual completion of forms.”
Claimocity, a practice management and billing software solution for medical practices, uses Modio to optimize its solution. Ms. Lee recalled that when the partnership started, Claimocity was providing services to about 30 providers, whose information was maintained manually across managed spreadsheets. With Modio, it has grown its client base to around 1,500 providers.
“Moving from 30 to 1,500 clients is massive growth,” Mr. Bou said. “If you don’t have a platform, that would be really hard to achieve using Excel documents and calendar and Post-it Notes. With Modio, the ability to scale is made possible.”
Beyond growth, a modern credentialing platform improves transparency plus trust
The real-time tracking and notification capabilities of a streamlined credentialing platform like Modio enable organizations to be transparent about the processes they follow. This helps to solidify their credibility in the eyes of payers, providers, and other partners.
“It has been beneficial to be able to share with our customers where we are in the process with their credentialing in a report, rather than an Excel spreadsheet,” Ms. Lee said. “We track and provide the number of applications we’re submitting for them, the number of touches we have for the payers throughout the month — we’re very transparent about what we do for them.”
Medical practices must take deliberate steps to integrate credentialing into broader processes
Though there are no formal guidelines for how organizations should approach improving their credentialing processes, a good place to start is by assessing strategic needs.
For Claimocity, the highest-priority need was growth. “Modio has been the biggest asset to us because of the growth it has helped us achieve,” Ms. Lee said. Regardless of specific needs, integrating credentialing is critical because of the central role it plays in supporting organizations’ reviewing, training, and auditing needs.
“Credentialing can make or break your business if it isn’t done correctly,” Ms. Lee said. “I don’t know how we would do what we do without utilizing Modio’s software. I’ve used other credentialing software in my lifetime, and Modio is by far the easiest; I don’t have to reinvent the wheel.”