Despite several emerging challenges—including labor shortages and financial volatility—nearly all health plan decision-makers said they will look for improved efficiencies in healthcare provider credentialing in the next 18 to 24 months. Although credentialing is typically required every two or three years, many plans also expect to voluntarily increase their credentialing frequency.
These findings stem from a recent ProviderTrust and Healthcare Dive survey, which asked 150 health insurer respondents about their perspectives on current trends, challenges and opportunities in provider credentialing. These insights, now available as a downloadable report, come amid new regulatory and market forces that could transform how credentialing is managed in the years ahead.
Key Factors Contributing to the Upsurge of Verification Focus
Survey results suggest an active fraud and regulatory landscape is driving the expanding urgency and frequency for provider verification.
More than half of respondents (51%) said increased pressure to reduce fraudulent claims would have the most effect on their organization’s future approach to credentialing. Another 40% cited increased prevalence or threat as the biggest influence on their credentialing strategy. Approximately the same number of respondents (39%) said virtual care regulations would have the biggest impact on their verification activities.
Additionally, many payers see credentialing as an enabler of better, more accessible care. One hundred percent of respondents said that ensuring accurate and real-time provider network credentialing supports healthcare equity and care quality.
Addressing Credentialing Barriers with Technology
Despite payers’ intentions to double down on credentialing, several challenges may prevent them—from difficulties scaling and lack of time to fear of inaccurate or outdated data. Without sufficient budget or staff, many health plans have embraced advanced tools that automate verification workflows to address these barriers directly.
“Everyone in the health plan agrees that they want a provider network that is top-notch with the right credentials who are best able to serve the market’s unique needs,” said Tony Threatt, Ph.D., Product Manager at ProviderTrust, in the report summarizing the survey results. “If those are the requirements of a more sophisticated and equitable verification process that improves care quality, how do we do that with limited resources? Technology is absolutely an enabler.”
Respondents considered automation highly valuable for various provider verification functions, including certification and license verifications, as well as state and board exclusion monitoring. Those use cases reflect the types of provider details subject to the most change—a sign that users are making the best use of modern tools, added Donna Thiel, Chief Compliance Officer at ProviderTrust.
“It’s only those high-risk areas that you need to be monitoring in real-time between credentialing applications,” Thiel said in the survey report. “You don’t need to constantly validate static information like education or work history. But when you start talking about something like a disciplinary action, for example, that’s something you do want to know immediately. Technology can check those areas that are prone to change, and that could expose the health plan to more risk.”
When, How and By Whom Verification is Completed
A slight majority of respondents (53%) said they outsource credentialing to a vendor such as a credentialing verification organization (CVO), while 47% said they do it themselves. However, experts said no matter who takes on the credentialing packet, the rising interest in provider verification plus the perceived value of technology could be the start of a so-called “hybrid” model that payers will adopt.
In this model, continuous monitoring activities take place to check high-risk areas like disciplinary actions between each re-verification. Given the costs and labor involved in credentialing, these interim activities may represent the most potential for tech’s ongoing promise.
“It’s certainly an efficient model that reduces cost for the health plans,” Thiel said. “All of a sudden, you’re not wasting money on unnecessary human-powered credentialing because so much of the data is readily accessible and actionable on a real-time basis.”
For full insights from the 2023 ProviderTrust and Healthcare Dive survey, download the report at providertrust.com.
ProviderTrust is a healthcare data and technology company based in Nashville, Tennessee that empowers a safer healthcare for patients, providers, and payers by leveraging always-accurate compliance intelligence. Learn more at providertrust.com.