Council Post: The Provider Credentialing Maze: Are We Protecting Patients Or Slowing Care?
John Bou is co-founder and president at Modio Health, a CHG Healthcare company.gettyProvider credentialing was built to protect patient safety by ensuring that every clinician is properly trained, licensed and...
John Bou is co-founder and president at Modio Health, a CHG Healthcare company.
getty
Provider credentialing was built to protect patient safety by ensuring that every clinician is properly trained, licensed and qualified to deliver care. While that mission still stands as one of the most important processes in healthcare, over time, the system designed to safeguard patients has grown into an increasingly complex group of governing bodies, state-by-state requirements and redundant verification processes, hindering care rather than supporting it.
For example, dozens of healthcare and accrediting bodies with a specific role in provider credentialing have been established in the U.S. (with the first one dating back over 100 years ago), but that does not include individual state medical boards, specialty boards and payer-specific credentialing programs that have also sprung up over the years.
Furthermore, based on industry credentialing standards and the average physician’s career trajectory, a physician's credentials will need to be verified and reverified hundreds of times over the course of a provider's career. This is a Modio Health internal estimate derived from CAQH ProView application data, NCQA re-credentialing standards and industry research indicating the average physician maintains active contracts with 19.2 payers at a given time.
I've found that a single credentialing application can require upward of 140 core data elements, with physicians enrolling in as many as 25 payer networks on average. Add to that the 70 state medical and licensing boards with their own criteria, and it’s no surprise that credentialing timelines I've observed routinely stretch to three or four months. The result is a process riddled with duplication, fragmentation and preventable delays. And unfortunately, it’s a bottleneck to care, as providers can’t see patients.
At some point, we need to address the elephant in the room: Have the very governing bodies tasked with protecting patients become a barrier to delivering care?
Creating More Work Versus Creating Value
It’s important to understand the role governing bodies play in shaping credentialing requirements. Organizations such as the National Committee for Quality Assurance (NCQA), the Joint Commission, the Federation of State Medical Boards, the American Board of Medical Specialties and individual state medical boards each set standards intended to ensure quality and patient safety.
The challenge is how they operate in relation to one another and how they impact provider credentialing. These entities were created independently to help with regulation; however, no single authority validates their requirements. As a result, their standards often overlap, creating layers of verification that are duplicative rather than valuable or helpful.
For providers, this translates into an ongoing cycle of submitting the same information in slightly different formats repeatedly. For hospitals and health systems, the burden is operational and financial, meaning that teams must track and comply with multiple frameworks at once, often without alignment between them. What was designed as a system of checks and balances has, in practice, become a fragmented process that requires providers to repeatedly prove what has already been verified elsewhere. It’s exhausting and also a waste of time and resources in a sector where those elements are already sparse.
Improving Safety Or Creating More Problems?
The burden of provider credentialing raises an important question: At what point does this redundancy stop enhancing safety and start delaying care? Either way, patients are put in a vulnerable position, as are providers and healthcare organizations.
No one is arguing against the necessity of provider credentialing, and multiple layers of verification can serve a purpose. Additional checkpoints may help identify gaps or inconsistencies, ruling out the bad actors. However, when those same checks are repeated across disconnected organizations, their value diminishes while their cost increases. Additionally, a majority of red flags identified in the credentialing process, usually caused by incorrect or missing data, more often than not punish qualified physicians rather than weeding out bad actors as intended.
What emerges is not a more rigorous system, but a slower one. In a system that is already struggling with its workforce, it may be introducing a different kind of harm in the form of delayed access to care.
From Silos To Centralized Systems
So, the big question remains: Where is the opportunity to improve? Having a centralized source of truth could help speed up the credentialing process exponentially, as people would no longer have to rely on separate, siloed data sources. There is also a ton of room here for AI and automation to better support credentialing teams in repetitive tasks and eradicate redundancy.
A central governing body, such as the Interstate Medical License Compact (IMLC), is another route to unify the process. The IMLC already exists and is making headway in improving provider credentialing across the country, but a more unified approach with a regulated body at the helm could greatly move the needle.
A highly qualified doctor in one state should be a highly qualified doctor in another state. While every effort should be made to ensure qualified providers are the ones seeing patients, a crowded landscape of governing bodies at the helm doesn’t necessarily improve that. More oversight doesn’t always mean better outcomes. Sometimes it just means reduced patient access and more paperwork standing between a provider and the patients who need them.
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