medical credentialing

Best Ways to Address Top 5 Challenges in Medical Credentialing

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Medical credentialing is a complex process that requires verifying healthcare providers’ credentials. It is necessary to ensure that patients get quality care. However, it also comes with several hurdles that healthcare organizations must face. Let’s discuss some key challenges in credentialing and the best ways to overcome them. 

Need and Scope of Medical Credentialing

The credentialing process demands verifying information on a larger scale, including academic records. Healthcare providers can do it by submitting the credentials or outsourcing to third-party medical billing and credentialing services. However, outsourcing might be the right choice if you want a hassle-free process. 

1. Academic Records

Obtain medical school attendance, graduation, internships, residencies, fellowships, and other post-graduate training details. Primary source verification is required to validate diplomas, transcripts, certificates of completion, and training details directly from the issuing institutions.

2. Licenses

Collecting active medical license details for every state the provider will practice in. It includes license numbers, issue/expiration dates, and disciplinary status. Licensure must be re-verified on an ongoing basis.

3. Specialty Certifications

Board certification must be verified through the appropriate specialty boards, such as the American Board of Medical Specialties. Details like certification status, expiration dates, and disciplinary actions must be gathered. Recertification is required regularly.

4. Hospital Affiliations

Confirming full details on present and past hospital network privileges, including dates, departments, and any restrictions or disciplinary actions. It often requires coordination across multiple facilities.

5. Work History

Documentation of a minimum 5-year work history is typical, including location, responsibilities, and reasons for leaving. Employment details are verified through the Human Resources departments.

6. Malpractice Insurance

Evidence of current malpractice coverage with details on policy numbers, insurance carriers, coverage dates, policy limits, and claims history. Minimum coverage amounts are usually mandated.

7. Ongoing Education

Track CME credits, specialty training course completion, and other ongoing education credentials. Minimum annual CME requirements must be met.

8. Criminal Background Checks

Performing county/state/federal-level criminal record checks to identify any exclusions.

As you can see, the scope of credentialing data collection and verification is highly expansive. Managing this carries significant compliance risks and resource burdens. Automated credentialing systems are critical for healthcare organizations today.

Challenges in Medical Credentialing

Difficulties Ensuring Data Accuracy and Integrity

Maintaining precise and up-to-date credentialing information is crucial yet challenging. Many healthcare institutions rely on manual data entry and spreadsheet tracking, which are prone to errors such as:

Missing or updating documents leads to compliance gaps. A survey conducted in 2022 revealed that 9% of providers possessed expired licenses.

  • Personal and practice details need to be corrected to maintain directories. Research indicates that 18% of doctor directories contained inaccurate location or specialty data.
  • Redundant efforts across departments managing provider data. According to a recent analysis, credentialing teams spend 21% of their time re-verifying information from other sources.
  • Absence of audit trails demonstrating due diligence.

Ever-Changing Compliance Standards

Compliance presents one of the most formidable challenges in medical credentialing, as standards are constantly in flux. Key requirements include:

  • NCQA regulations stipulate complete and current credentials, with new 2022 standards necessitating tracking of 10 separate provider details.
  • Timely re-credentialing every 2-3 years. AMA data indicates that 60% of providers miss re-credentialing deadlines.
  • HIPAA mandates safeguarding personal data, escalating breaches by 30% from 2020 to 2021.

Significant Time Demands

The medical credentialing requires extensive time commitments involving gathering, verifying, auditing, and updating data. Staff members often chase documents from various sources while managing multiple provider files.

Despite the presence of sizable credentialing teams, backlogs are common due to ongoing hiring demands. A survey conducted in 2022 revealed that an average of 35% of credentialing departments need to be more staffed.

The sluggish pace of credentialing impedes provider onboarding and practice expansion. On average, it takes 102 days to credential a provider fully.

Specialized Skills Required

Recruiting and retaining qualified credentialing staff poses challenges due to the specialized nature of the work. Key requirements include:

A meticulous attention to detail and organizational skills, as credentialing involves up to 200 checkpoints per provider file.

Exceptional communication abilities for interactions with providers. A survey revealed that 72% of providers express dissatisfaction with communication during credentialing.

Proficiency in compliance protocols and standards. However, only 23% of credentialers possess relevant certifications or accreditations.

Many healthcare practices face obstacles due to limited relevant training and high turnover rates. With experienced teams, accuracy and compliance may be maintained. Allocating resources to recruit, educate, and retain specialist staff is essential.

Streamlining Solutions

Overcoming these challenges is vital, and potential solutions include:

  • Credentialing Software: This automates data tracking and monitoring for accuracy, potentially reducing errors by up to 57%.
  • Document Management: Streamlining attachment handling through online profiles can enhance record accessibility by 65%.
  • Instant Credential Verification: Real-time credential checks via digital networks can accelerate the verification process by weeks.
  • Alerts and Notifications: Prompt reminders for expirations and missing items can minimize re-credentialing deadline misses by 75%.
  • Reporting and Analytics: Providing insights into bottlenecks enables targeted workflow improvements.
  • Staff Training Programs: Investing in continuous learning opportunities has been linked to 38% better staff retention.
  • Outsourcing Assistance: Partnering with medical credentialing experts can supplement resources and improve throughput by over 50% during peak periods.


Medical credentialing requires robust processes as a fundamental aspect of healthcare, directly affecting patients. Yet, challenges such as limited resources, large data sets, compliance concerns, and frequent updates threaten effectiveness and quality.

Implementing automation, specialized personnel, and continuous training empowers healthcare entities to revolutionize credentialing. Prioritizing investments in productivity and optimization tools becomes essential for surmounting these hurdles.

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