The Changing Landscape of Credential Verification

Alright. That sounds good to me. Welcome, everyone. I’m Regan Drales. I’m an account development leader at ProviderTrust. Thank you for taking time out of your day to join our webinar, trends, challenges, and opportunities across provider credentialing. Couple of, housekeeping items before we get started. Phone lines are muted to eliminate any background noise. If you do have a question during the presentation, feel free to type it in the chat, and we will address those questions, along the way or either save them for a q and a at the end. We are recording today’s presentation, and we will send out the recording in an email following the webinar. These are our presenters today. I introduced myself. Donna, would you like to introduce yourself? You bet. Thanks, Reagan, and welcome, everyone. I’m Donna Thiel. I’m the chief compliance officer here at ProviderTrust. I get to say often say I have kind of the best job here at ProviderTrust. I get to manage all of the traditional compliance sorts of things and our audits, but I also get to spend a lot of time with our clients and our prospects, really understanding the industry and understanding what’s going on. And I spent, thirty years in, the compliance world in a in a large health system. So I love being able to stay connected to that and excited to, to talk with you all today. Tony? Thanks, Donna. Tony Threep. I’ve been, working within the provider trust, and our payer space, for about four years now, helping to build out, technology and strategies, to assist, the payers, specifically focused recently on our credentialing point of view and and how we can use data to best, meet the credentialing workflow and and meet our payers where they are today. Thanks, Reagan. Thanks, Tony. Alright. Quick agenda for today. So overall topic is we are discussing a survey completed or that was distributed by a provider trust. So we’ll give some background on that, review and discuss findings from that survey, and then discuss some additional industry insights. And like I said, we’ll save time for a q and a session. And we’re running for about thirty minutes. So just to provide a bit of context into this survey, it’s been very clear become very clear to provider trust over the past several years that, provider credentialing is becoming a strategic imperative for health plans. So, while credentialing used to be just a requirement, it’s, no longer something that payers are doing just as a requirement. It’s becoming an essential part of a larger provider data management strategy. So in the survey, we surveyed fifty participants that all work at health companies, health and they’re involved in provider network data management or credentialing in some capacity. So thirty three respondents, are in credentialing roles. And really what survey is doing in a nutshell is asking why payers are elevating credentialing with more attention and strategy than they have in the past. So let’s just jump into some of these results. So, Donna, over half of our survey respondents, we had fifty one percent, they cited fraud as most impactful to their organization’s future approach to credentialing. What is your what is your take on how fraud is driving trans across provider credentialing, and how are governing bodies addressing that? I think we’re seeing it in a number of ways, and I certainly think when you talk about how our governing bodies bodies enforcing it and and I think about, like, what should we be doing. Right? We think about as we think about credentialing, credentialing is is more of a point in time. Right? We do credentialing every couple of years, and we’re we’re we’re missing things in between the credit and the recred process that could potentially create an avenue for for fraud. Right? We could be submitting claims on practitioners who are no longer licensed or they’re excluded. So, certainly, the kind of the traditional, the historical way of of doing credentialing just, I think, has a little bit of an an inherent risk of fraud. I think when we think about our, governing bodies or we think of regulators, one thing that really jumps to my mind is, last April at HCCA, the Healthcare Compliance Association at their annual meeting, the inspector general always, presents at that conference and, always has a nugget or two that we walk away from saying, oh, gosh, need to pay attention to that. And in this past year, she focused on managed care and and really spoke directly to the managed care, audience and and said, you’re all falling behind. Your compliance programs aren’t robust enough. You need to look at the, the people in this room at this conference, and you need to think about how to, enhance your compliance programs and think differently about how you’re managing fraud. So, I always look at that, and and I feel like, that’s that’s kind of a a call to action for us and, thinking about how can we do things differently, where should we be be looking and thinking. And I think credentialing is is a really good opportunity for us to, improve upon a process that really hasn’t changed for for quite a few years and has been relatively, a manual and and just point in time. And I think that’s where fraud, potentially, comes into that conversation. Yeah. The thank you, Donna. The, definitely, when we’re thinking about, the frequency at which providers are credentialed by payers, I think that that’s, the the most obvious opportunity for increasing compliance and credentialing. So instead of, thinking in the traditional, we do initial CRUD and then we recred every three years and then we have some ongoing monitoring in between. Our conversations with payers recently have really been around how can we do more primary source verifications in between CRED and recred and think of it more as a continuous process that we’re doing using a data partner strategically. Absolutely agree, Reagan. I think that’s gonna, immediately impact, your level of risk and, ultimately, right, result in less scrutiny by governing bodies related to to fraud or waste in that particular case. Okay. So moving on to the next findings of our survey. This is so this finding is basically that accurate credentialing enables better and more accessible care. So we’re saying, ensuring accurate and real time provider network credentialing supports health care equity, and it also supports care quality. And it was unanimous, among the survey respondents that, they agree with these statements to some extent. And so as health plans begin activating strategic directives with more frequent frequent provider verifications and trying to make health care more equitable and improve quality of care, they are encountering encountering challenges. Tony, what are some of the the key challenges encountered by health plans, and how can technology help address those challenges? So I I think it it just, follows a a quick story. Right? If if we think about large payers or or a payer of any kind, you’re, organized by a contract or or market or otherwise, and usually you’re covering, multiple multiple markets. So, the minute you the minute you add more, groups to the to the mix that you have to to manage or or make sure that you’re credentialing, is the minute that that the complexity of of how many, across market lines, making sure that you have the understanding of of the different requirements for those markets. It just that that’s a huge challenge. And, you know, you know, the the groups and and organizations that we’re talking with have, hundreds of thousands of providers that that they need to have credentialed during each credentialing cycle. Of course, we all know, and luckily, that doesn’t happen all at one time. You know? It’s not like this is a, well, it is an event every time that it happens. Luckily, it’s not you know, this is the thing we do every April fifteenth, for for our entirety of our network. But it does mean that, the way that we’ve we’ve understood it, to be managed in the past is with people. And and you have you may organize your organization, in a way that that each market has has its own team that that does, that does a lot of work. The the the problem that that has obviously, that’s it means if you’re doing lots of markets, you do across state lines, you’re doing all these things. Now you end up having teams of of by market or by region, and and you could potentially have some duplicated work. And, of course, you know, there’s only so many providers in the country. But if each team is doing the same activities or similar activities, you know, then then you begin to have a problem, and it adds time. Right? How you you then have to back up, when you start start doing those processes. So it just it just, is is a lengthy procedure, and and we had in fact heard that, specifically from one of the respondents in the survey. Right? It’s a it’s a lengthy procedure, and it’s hard to maintain. Right? So now, not only are you taking a long time to do it, but it’s a lot of different requirements to meet all of the credentialing needs, and and that provider is is across multiple lines. And so, I think the thing that we, you know, we’d wanna think about then if this is if this is a problem in in ensuring, you know, health of health care equity and and otherwise, how can we begin to look at the multiple sorts sources of data, in the verification process and and begin to simplify that and and, you know, use technology in that use case, to make the credentialing process better. And in fact, we heard that from one of our, respondents as well. Thanks, Tony. So, speaking of the different sources and different tools that can address the challenges that you just described. We so what what we’re looking at right now is our our survey responses to the question that asked, how valuable would you consider a tool designed to help payers automate the following categories of provider credentialing? So you can see the dark blue is the response is extremely valuable, and then we move into different levels of value until we get to gray and this kind of gold color that are, they don’t find them valuable, at all. So there’s nearly universal agreement that automation is a valuable tool for provider credentialing. Donna, from your perspective, where can plans find the most value in automation, and are there specific sources that you think they should be focusing on over others? Absolutely. And I think this slide really depicts, our opportunities. Right? When you think about the credentialing and the recredentialing process and the different components that we are required to credential, some of that data is static. Right? When you think about, the, work history or education, that’s not something that’s traditionally changing over the course of time. But then when you look at these components, like license verification or certifications, or if you’re looking at, a board cert or you’re looking at exclusions, all of those things could potentially change on any given day. Right? We know that, someone’s license status could could change at any point in time. There could be a board sanction that causes a licensure action that causes perhaps even an exclusion, right, if you follow the, the breadcrumb trail. So when I think about it and and we talk to folks, oftentimes we hear, oh my goodness. We we can’t automate everything. We can’t do all of that. It’s such a huge disruption to our process. I I think we have the opportunity to think differently. Right? We’re not trying to automate everything. I think there’s there’s a value proposition of where human beings continue to do credentialing work or recredentialing work. But when we can leverage automation, when we think at think about licenses and certs and board actions, those are those are sources that technology can go out and automate and grab that information and bring back in real time meaningful information, actionable information that then the human beings can can, interact with that information and take action with the practitioner or gather additional information. But the action of actually going to the board and manually keying something in, returning a license or returning a result is is really inefficient. And and like Tony was talking before about if your if your workforce is broken down into regions or states and you have cross functions, someone could be going to the same licensing board sixty two times when in reality, automation could do that for them and have one single response that’s coming back. So I think really looking at the the credentials that could change in real time and have meaning impact. Right? Meaningful impact to a change is where I absolutely would be spending my time and where I’d be looking for automation to try to help reduce that burden, on your your workforce and the, literally, the manual hours that are going into tracking that information. Thanks, Donna. So when we’re when we’re thinking about tools that can automate some of these sources for a credentialing process, We we wanted to get clear in the survey on what is most important in that tool aside from just the actual sources. So, Tony, will you walk us through where plans place the highest value, in an an automation tool and kind of how provider trust is equipped to address each of those areas. Yeah. So we heard in the survey that, the the main area we want that folks want to have automation as as Donna was saying as well is is the certificate and license. And we we also wanna be able to monitor, in automated fashion, the the state exclusion lists and and board actions. And, you know, I think the thing that to think about there is is just the the number of sources that you can go to, the number of specific license types that you may need to collect. When we’re going to to specific boards, there there there are things to think about, like, you know, the the the board you’re going to, the certificate type you’re looking for. Does it require a number or not to perform the verification? Right? All of these things, provider trust, you know, has has expertise in because this is where we live every day. But but if I were thinking about putting that burden back onto, you know, an individual, within my organization, I mean, you know, I don’t know how long. I’ve I’ve never done a time study about how long it would take to perform a a full credential package for someone. But if it if it takes, I don’t know, ten minutes or fifteen minutes and and you because you go to the board and and you searched by one thing that you thought that the license type was and only to find out it’s that’s not the license type, so then how many how much duplication or or rework are you having to do because because of that, potential problem? You know, I think that that’s, again, that’s why we would lean into automation here and and and have that happen. You know, I’ve seen, for an entire credential package come back, in in under an hour, with automation. And and if I was if if I were doing that, then then that would allow me to do other the other, aspects of of building out that credential package where I can automate those areas. I mean, I think that that a couple of things that I would add additionally. Right? And and I think this is something that that I that we that folks will have to contend with is that if if once you have the the accurate data, and you continuously monitor it. Right? I think we we’ve heard a lot in our conversations, in the market about, hey. I I do this at credit and recred only. But I think that that that potentially, as as Donna said, opens up opens us up for risk. Right? Because there are things that happen in between, the initial credit three years later, for a provider. This is why folks have, other things like the NPDB as a part of their, as a part of their cycle because, you know, things happen in in health care that we wanna be able to maintain and and have understanding. I think then that last piece I’d I would I would hold on to is is how are you going to get this data back into your source systems? And one one thing we know is that as we continue to add in automation, that this data has to go somewhere. And ideally, it goes back into your, sort your your system of truth, your source system, through an integration of some kind. And and I think that as as folks continue to think about how they’re going to, continue to rethink the the credentialing workflow, provider data management, thinking about a data partner who is able to integrate, back into your source system, and bring that data to you is gonna be the most, something that I would have is is something to think about, as you move forward. Thanks, Tony. So so looking at interdepartmental information exchange. It’s so nineteen percent of our respondents say data stays within a single department, and twenty five percent say that data is shared between departments only as needed. Tony, what can you tell us about data silos and how they’re contributing to data quality concerns and therefore acting as a barrier to these strategic credentialing initiatives? Yeah. I think it’s it it comes down to to this, Reagan. One, we know that that provider data lives across an organization. Right? There are there are many reasons that a an organization and different departments collect different pieces of data, to to to meet certain, workflow needs. Right? And I may need to collect, you know, a Social Security number in one area, but but I may need to collect an NPI in another. And what ends up happening and what we see is that, you end up with a multiple, multiple views of the same person, Right? And multiple, ways of of having that data. What you end up end up having is then is that there’s no single truth source of truth of of who a provider is in inside your organization. Names is another case. Right? You may have the full name in this system, but you may have the nickname in this other system, and you may have an abbreviation in another one. So, that happens across teams. And and the question, of course, is is who owns that data and how does that happen? A lot of folks we’re talking to these days are going under a process of trying to get to that singular provider. How do we get to one data provider that then that source information goes across our organization? It’s still a challenge. Right? We’re still we’re still in that, data reconciliation system reconciliation process, and that’s that’s probably gonna be many many, many years, in the making, but that’s one thing. And the other thing is is not just across teams. Right? I think one thing that that’s what we think about and go too often is that, you know, the credentialing team owns this piece of data, but the contracting team owns another, and the provider directory team owns yet another piece. But it’s also within, a singular team. There may be a singular team that is because of the way, technology was at the time that has the same product but a replication of the same product. Right? So you may have a provider system or a claim system that is that is segmented by your market. So even though you’re one team, you have to go to different logins of the same product and and have a different view of that provider. So, you know, that’s a challenge, and it and it’s a challenge of of getting to that singular provider with the singular set of data that’s truly verified. That that is going to be a challenge as we move forward. So, thinking about the different, the interdepartmental data exchange challenges, we asked our respondents what exactly is it that prevents them from exchanging information between departments. And so our two key takeaways were different departments have different access permissions and safety protocols, which makes it difficult for us to verify that data remains safe and secure. And then also compatibility issues occur between the departments while data is transferred. So, Tony, how can platforms like provider trust consolidate and then in integrate across the ecosystem of credentialing data sources? Yeah. I think that that someone like provider trust, but, is is at is, really apt to help out in this space. But but I think the thing that just to take it away from provider trust, I think that what I would ask, those who are who are listening in today is think about what you’re trying to accomplish. And and then I think you wanna work with a partner that can that can help you accomplish those goals. And what and what I mean by that, to be really explicit, is, again, if you have, twenty five source systems across your entire organization, each of them has a a piece of the provider information. You’re gonna want a partner, that can take all of that, help you design a solution that brings all the data together, to then not only when they bring the data together, we’re able to reconcile that data and then create ultimately what’s one provider across your entire organization. That then across all markets or contracts or however you’re organized, you can see that, you know, John Smith has MPI one two three, has, you know, a state license, a a DEA, and a and a board certification, And and that is builds out that one profile. And then you’re gonna want that profile, of course, if we’re talking about credentialing, to be verified and then sent back into the right, source system or systems, across your organization. And I think, you know, we we do that. We have experience in that. That’s what that that is what, provider trust has been able to to do in the market. And I think the one the one key thing that I’ll say again that was, you know, honestly, maybe a side benefit of of the work we do is our ability to to help create that one provider profile. You know, that was that is not a value proposition I’d say we’ve sold in the past, but our ability to to help folks see see across their organization and get insights allows not only for the just to know, right, to have the knowledge that this provider is is in par, nonpar across my my entirety of my organization, But that also helped to reduce work, because because you don’t have to then, at that point, do, the same verification, you know, sixty two times like Donna said. You can do it once. And and that clarity and understanding of a of a provider is is very helpful. And and, ultimately, it’s it’s that ability to get that back into your system that that helps drive your needs. Sorry. I was trying to find a way to unmute myself. So moving on to the next subject here, this is the benefits of a hybrid credentialing solution. And the question that was asked in the survey was, how does your organization monitor and verify the credentialing of providers in the health plan’s network directory? So forty seven percent say, that they work with a vendor, such as a CBO. No. I’m sorry. Forty seven percent say they do it internally and have a manual process, and fifty three percent say that they work with a vendor partner such as a CBO. So, traditionally, the approach to credentialing has been, that either a plan does credentialing manually or works with the CBO. Provider trust clients have found a great deal of success in a hybrid approach to credentialing. So, Tony, can you tell us more about what a hybrid approach to credentialing is and kind of what the value is in engaging with a data partner for credentialing versus a traditional CBO where we’re passing paper back and forth. Yeah. I think I think we’ve covered a lot of it already, Reagan. And and the thing that I would add here is, right, one, look at the, the extent of the data that you have that you need to verify to build out your credentialing packet. What of that data, do you need to have, or or what data what of that data, do you have trouble collecting? And that’s probably the the area that I would say might be the data that you would you would still have to have a manual process. Right? We know about certificates of insurance or or other, bits of information that you you do have to contact the provider. You do have to, get, get that that data sent to you, hopefully, in an email, but maybe we’re still using fax machines, right, to to bring it into the packet. But there are things, like education. I would hope that education over a period of a provider’s career doesn’t change. Right? That they have always gone to that, college or the that medical school, and we can verify that at one time. And then the last piece, of course, is the things that that Donna brought up earlier. Right? We know licenses change, that they change status throughout the throughout the three years. Right? Potentially, you have to renew a license every year. Hopefully, you renew it on time, but what if you don’t? And, also, what happens if something happens to your license in that period, whether it’s a a a board action that that we’re able to see or the status changes? It gets revoked or or otherwise. That’s the the the piece that we’re talking about that that could potentially change throughout that time that we you’d wanna have an automated solution. You wouldn’t just want it. We believe anyways, that you don’t just want that at the initial credit and the recurrent. You want to know about the, efficacy of your network, throughout the process. And and that’s why you would use an automated solution. You’d use a data partner to help bring in that, data, in your process throughout, throughout the life cycle of your provider. And so if we think about think about it in those buckets, that’s where you would, you would work with someone like provider trust to to push that ahead in your organization. So I’m just, outside of provider compliance and monitoring, the time in between initial and recrad to further our provider network stays in compliance, what other impact does a hybrid approach have on credentialing? I think from my perspective, just kinda pulling it altogether from the things that we’ve already talked about today. Right? It it’s really an efficiency model. It’s a risk reduction model and, ultimately, a cost saving model. Right? Because if we’re if we are identifying a bad actor, someone had that’s had a licensure change in instantly or or in a much more efficient time frame than once every three years, we’re gonna get that provider out of our network and, reduce our risk of of fraud or of billing and losing dollars. So I think there’s that side of it, and then certainly the efficiency side of not having redundant work and not having, folks having to do all of that manual effort. So I think it improves efficiency, reduces your risk, and hopefully, reduces any potential, you know, paybacks or, you know, reimbursement issues that that you might have on the health plan side. Thanks, Donna. So that wraps up our, summary of the survey results. Moving into, kind of a q and a section here. Donna, I’m gonna hand hand it over to you. Awesome. It’s it’s thirty minutes, so I think I’m gonna jump to our our final question, Reagan, if that’s okay with you. I think, what’s a a couple of things maybe you can answer, jointly. One is what are the things are you seeing in the industry that we haven’t talked about today that the survey didn’t specifically, highlight? But then, also, I would love for you to talk about how we’re really partnering with our clients and and prospects on building kind of that business case use case for for switching to a hybrid model, how we you know, how does that look and feel? Because we know change is really hard. Right? And I think, one of the things that that we’re we’re really proud of, right, is our partnership with our clients in trying to really improve processes, not just change for the sake of change. So if you don’t mind, Reagan, kind of addressing both of those, I think that’d be great. Sure. So one thing that wasn’t cited in the survey, which I found interesting, was the impact of COVID on credentialing teams. And I just in every conversation that I’ve had this year with large regional payers and national payers, they all said that they were impacted by COVID to some extent. So that’s, I’m getting behind because of the extension on recred timelines and then subsequent, staffing shortages, not being able to hire people that have this expertise, and, really, all of those things just kind of, cascading into huge backlog issues is something that everyone has brought up in our conversations. So I thought that was interesting that none of the survey respondents responded that way. But in terms of how provider trust works with our clients, I think, I mean, what we want to do first is just really have a thorough understanding of how you’re doing credentialing today, how are you doing the primary source verifications, where do you see opportunities for improvement. And then we would just line item out all of the requirements and those that we can automate for you. So you’ve got initial credit requirements, ongoing monitoring requirements, and recred requirements. So we would say, out of all of those, this is where we can add automation in. We help create business cases. So looking at the number of FTEs that you have doing that work, just the the manual resources that you’re putting on that work versus, how quickly can provider trust to give us this result? What’s the level of accuracy? What is, the total cost savings there. Awesome. Thanks, Reagan. Mhmm. Well, that wraps it up. It’s twelve thirty three in the central time zone, one thirty three for Tony in the eastern time zone. We really appreciate your time today. As always, we love, being able to share some insights with, with folks, and we hope that you found some value in this conversation. And And as Reagan said, I believe an email will come out with this recording. And if there’s anything that this team can do to support you, by all means, just reach out. We’re happy to, talk at any point in time. Thanks so much, everyone, and have a great day.