Credentialing Market Map: Tech solutions remain services-focused
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There is an essential component to being paid adjacent to—but not directly a part of—the traditional revenue cycle: credentialing.
Without being properly credentialed for a given payer, any claims sent in on behalf of a clinician may be denied, passed to patient responsibility, or paid at a lower out-of-network rate, making this process critical for provider organizations. While most vendors in this space do some combination of credentialing, licensing, and enrollment to enable providers to become in-network with a payer, this piece dives deep into the credentialing portion of the workflow.
Setting Standards
When a provider organization contracts with a payer, they agree to a set of rates and standards for care provided by the payer, while also agreeing to credentialing standards for all of the clinicians in their organization that might be billing to the payer.
These standards are overseen by the National Committee for Quality Assurance (NCQA) or the Joint Commission, and include verifying the educational background and residency, state and federal licensure, board certification, as well as work and malpractice history for each clinician.
Details such as personal information, licensure, training certifications, and liability insurance are managed in a data warehouse called CAQH Provider Data Portal, used by both providers and credentialing organizations for sharing information. In actual practice, most bodies responsible for credentialing rely on credentialing verification organizations (CVOs) hired to pull data from CAQH and perform primary source verification.
While in many cases payers act as the credentialing organization, often larger provider organizations will assume the responsibility of the core credentialing workflow in what is known as delegated credentialing. In this case, the provider organization performs the primary source verification and committee review themselves, allowing a new provider to see patients in a matter of weeks instead of months. In exchange, the provider orgs agree to regular audits and processes for monitoring credentialing by the payer.
Credentialing Workflow
The credentialing process works as follows:
Provider updates CAQH Provider Data Portal: Periodically, a clinician updates their profile with current information and documents on education, licensure, certifications, and work history and regularly attests to the accuracy of provided information (typically only when prompted or when joining a new organization).
Primary Source Verification (PSV): CVOs retrieve data from CAQH and perform verification of education, licensure, board certifications, work history, and malpractice history.
Committee Review: Each payer or (in the case of delegated credentialing) provider’s credentialing committee evaluates the clinician’s qualifications and conducts interviews if necessary, then makes a recommendation on the credentialing case, typically approved by an executive body.
Ongoing Monitoring and Recredentialing: Provider organizations are responsible for continuously monitoring clinician credentials and re-credentialing every 2-3 years to maintain standards.
Credentialing Platforms
Given all of the manual steps and data consolidation in this process, it’s easy to see why a number of tech-enabled CVOs have emerged. Their platforms connect to CAQH and primary source databases, and help automate tasks like validating educational backgrounds, professional training, certifications, and legal authorization to practice. Much of the work, however, requires emails, faxes, and phone calls to verify details, so these products also provide workflow tooling to manage tasks, requirements, and timelines.
Because the barriers to entry and switching costs are relatively low, there are a number of companies in this space competing both on product and on the quality of their services. This is a category in which we’ve done a number of product reviews on Andros, CertifyOS, Medallion, Modio OneView, Symplr, and Verifiable, if you’re curious to dig deeper. Other products in this space include Axuall, Baton Health, Credsy, CredentialStream, Madaket, MDStaff, MedTrainer, Medversant, RLDatix, and SteadyMD.
Although credentialing has already been shaped in large part by automation and data integration, there is also talk of blockchain and tamper-proof records enabling instantaneous verification. We’re skeptical, since these records include background checks, work history, and in some cases, reference calls, which we would hesitate to put on a blockchain. As a result, we believe it will continue to be a services-heavy industry, with a healthy dose of competition between all of these players.