Guide to Insourcing Credentialing

The Cost-Saving Opportunity You May be Overlooking

Care delivery and optimization were key priorities for healthcare organizations last year as they navigated their way through a post-Covid landscape. And although care outcomes remain an area of focus, today’s leaders have made a turn toward digital optimization—and more specifically, automation and cost savings—as they eyeball strategic initiatives for 2024, according to a market research report curated by Huron.

In fact, the top trends impacting today’s organizations all come down to financial management and stability in the years ahead, which is no surprise considering today’s tight labor market and rising costs. A second Healthcare Life Sciences report by Salesforce reinforced this notion, claiming 79 percent of healthcare organizations cite creating efficiencies and lowering costs as their prime areas of focus. Employee retention, streamlining, and automation are all top of mind, as leaders continue to combat turnover, data silos, financial constraints and more. 

Although automation in particular has become a buzz term of sorts, the ability to streamline the most tedious parts of healthcare operations can have business-wide impacts for both payer and provider organizations. Most organizations have some combination of in-house and outsourced credentialing, which can cause efficiency and reliability issues. With new technology that increases credentialing productivity, today’s organizations have begun to reduce the load they are outsourcing to Credentialing Verification Organizations (CVOs) and are instead bringing these important processes in-house to improve quality, and reduce costs.

What should operations leaders and credentialing professionals know about insourcing their processes in today’s market? Can the promise of speed and cost savings from automation carry over into credentialing, while still meeting regulatory requirements? 

We explore those questions and more in this guide, detailing all that today’s professionals need to know about bringing your credentialing process in-house.

This guide will cover:

Part 1: The Issues with Outsourcing 
Part 2: How to Bring Your Credentialing In-house
Part 3: How In-House Verification is Possible with Verifiable

The issues with outsourcing

Today’s healthcare operations teams are no strangers to outsourcing their credentialing process to CVOs. In fact, these companies have long built their business approach on their credentialing expertise, leveraging timely completion of primary source verifications (PSVs) as their key selling point. Faster turnaround times are often touted as a perk, along with the removal of tedious paper processes and spreadsheets. 

CVOs with large volumes are also able to scale quickly—something that’s often tricky for internal teams. Not to mention, networks needing verifications done quickly bank on the peace of mind that comes with the regulatory expertise CVOs offer.

So, with that said, what could go wrong with outsourcing as a solution to credentialing needs?

Headaches that can come with outsourcing 

A lack of visibility

Since many teams rely on provider data and credentialing status updates, it’s common for other processes—like provider contracting, scheduling, and payments—to inherently become “stuck.”

Data silos

When provider data management is outsourced, it can live in multiple disparate systems and is often returned from the CVO as a flat data file or a PDF packet that needs to be manually keyed into the system of record. When multiple teams rely on this credentialing event data, inaccuracies, confusion, and misinformed decisions can occur.

Data accuracy pains

Since many CVOs still rely on manual PSVs and data entry, human errors still occur. Even small errors made during the process can result in delays and regulatory or accreditation risk.

Turnaround times that aren’t so fast

Since manual work is still included in today’s verification process, turnaround times are limited. For example, it’s not uncommon to see turnarounds stretch into 60 days or more. In turn, this impacts operational efficiency and the ability for an organization to scale, and slow the timeliness in which a provider can begin seeing patients.

Long term inefficiency

CVOs usually offer a short term gain due to their contract flexibility and expertise. However, organizations' have outgrown their flat service model and now require more functionality than they can provide. Forward-thinking financial leaders are more often thinking about long-term investments they can make for savings over time.

Poor provider experience

Credentialing is oftentimes the first touchpoint a provider has with an organization and getting off on the right foot is essential. Today's organizations are putting critical provider touchpoints in the hands of someone else—which can lead to a less than stellar encounter. With burnout among providers at an all-time high, today’s organizations need to partner with companies that ensure a seamless provider experience, guaranteeing the ease and speed at which a provider can join a network.

Why should today’s healthcare organizations consider insourcing?

Today’s healthcare environment is calling for leaders to employ technology that delivers on a lot of things—namely, cost savings and efficiency. When it comes to credentialing, automation has been proven to speed up processes, while drastically improving accuracy and reliability of a once manual process prone to error. 

By insourcing your credentialing process (using internal team resources along with technology), data centralization is made easier, resulting in new-found reporting capabilities, cross-team efficiencies, and transparency into provider pipelines—all of which contribute to a data-driven strategy that drives scalable network growth.

Even though the slow speed of digital transformation in the industry has made reliable automation difficult in the past, more databases are becoming digital, spurring along regulatory changes and digital verifications.

Modern Health did away with an error-prone, manual verification process in exchange for a tech-first solution

With Verifiable, Modern Health directly improved workflows and provider experience so much so that their NPS ratings related to a clinician’s onboarding experience increased. Verifiable successfully streamlined operations from initial onboarding to application, and as a result, Modern Health leadership saw a significant reduction in internal questions related to credentialing, freeing up valuable time. However, it’s the state of their overall compliance program that speaks most to the success of Modern Health’s partnership with Verifiable. 

“We started with license verifications and monitoring for a limited set of providers, but after just one year, Verifiable has become core to our overall provider network infrastructure.” —Hannah Clauson, Chief of Staff, Operations at Modern Health

How to bring your credentialing in-house

Bringing credentialing in-house with the right partner empowers today’s healthcare organizations to accomplish objectives like reducing the time to onboard providers, trimming credentialing costs and continuously improving the provider experience through technical operations and optimization. By automating the most time-consuming aspect of provider credentialing—PSVs—organizations experience speed and accuracy that manual processes can’t match. 

However, bringing credentialing in-house can feel daunting. In-house credentialing requires expertise on regulatory requirements and process adherence, which is why choosing the right technology partner is imperative to the success of an insourcing initiative. 

So just how exactly, can an organization bring their credentialing in-house with Verifiable? In simplest terms, you need the right people, process, and technology.

Insourcing myth:  “I need a huge team of full-time employees (FTEs) to bring credentialing in-house!”

Insourcing truth: Although it’s true that staff is needed to bring credentialing in-house, it’s often fewer than anticipated. Verifiable automates all primary source verifications, packet-assembly, and parts of data entry to speed up process times. Using Verifiable, credentialing specialists can manage the entire process for a provider and complete, on average, 250 credentialing packets per month. 

People to power your in-house endeavors

When bringing credentialing in-house, the number of full-time staff members needed will depend on provider count currently in your network, as well as any anticipated growth. When using Verifiable, ongoing monitoring runs on autopilot, allowing credentialing specialists to accomplish approximately 250 credentialing packets per month (compared to about 80 without automation). FTE requirements are also drastically less than those required in the traditional credentialing process, thanks to fully automated PSVs (including ongoing monitoring), auto-generated packets according to NCQA standards, and streamlined data entry through CAQH integration.

For an organization to anticipate their needs, it’s suggested they consider how many credentialing events take place in their network on a monthly basis. For example, as “back-of-the-napkin” math: 

  • If a current provider network is 15,000 providers, an organization needs to re-credential approximately 5,000 per year (with recredentialing occuring for most every 2-3 years), totaling about 416 credentialing events per month.
  • Anticipating some member growth, let’s say the organization plans to add 500 providers to their network each year, which equals about 41 credentialing events per month.
  • 416 + 41 = 457 credentialing events per month
  • If one FTE can accomplish 250 credentialing events per month, this means two staff credentialing specialists are needed to run and oversee the credentialing process.

For organizations determining how in-house credentialing could work for them, it’s critical to review credentialing needs on an annual basis while anticipating growth goals and more. By scoping out potential credentialing events throughout the year, organizations can easily determine how many staff members are needed to verify credentialing in-house with Verifiable.

Easy to understand policies and procedures 

To ensure compliance with the requirements behind healthcare credentialing, defined processes need to be in place. Thankfully, organizations like the National Committee for Quality Assurance (NCQA) have developed accreditation and certification programs to ensure minimum standards are met. When following their standard, organizational policies and procedures should include the following requirements: 

  • Any practitioner who is licensed to practice independently should be credentialed
  • Credentials are verified using a primary source, i.e., an original governing body or issuing agency of that information
  • Providers are recredentialed every two to three years
  • There is clearly defined rejection criteria in place
  • A credentialing committee is established to review and approve providers for practice
  • Non-discrimination policies are created to ensure a non-biased approval and rejection process.
  • Communication processes exist for notifying providers about discrepancies in their application, as well as notification of final decision
  • Confidentiality and protection of provider information is ensured
  • The provider network is kept up to date

How to uphold compliance standards and realize cost savings at scale

By choosing the right technology to support insourcing initiatives, organizations can successfully adhere to compliance standards, keep costs low, and provide an experience that providers and staff will appreciate. 

The following capabilities should be on a “must-have” list when evaluating the right solution:

  • PSVs that not only verify information automatically from the source, but also get through captchas, behind MFA protocols, and capture required screenshots
  • Credentialing packets are assembled automatically, not through copy, paste, or manual manipulation
  • Integration with CAQH for streamlining information intake, alleviating administrative burden on providers
  • Provider network management that centralizes and unifies data, leading to visibility across teams
  • Robust task management that’s connected to the provider data system of record
  • Automated alerts and communications to ensure no deadline is missed
  • Reporting that is configurable to an organization’s unique needs
  • Custom fields available for tailoring provider data

CHA Nevada offers medical, dental, pharmacy, behavioral health care, and food pantry services across 7 different locations—and managing all of those service lines is something most vendors couldn’t do. But since Verifiable manages all lines of service, provider types, and locations, we were able to truly centralize our data. Now, we can view workflow status, manage provider records, and customize reporting all in one spot.” — Holly Long, Director of Population Health Management, Community Health Alliance of Nevada.

Return on investment through automation

With Verifiable, organizations see return on investment in a number of ways, starting with how the software is budgeted. Often, CFOs manage an outsourced services budget differently than the budget for software platforms and technology. Since these budgets are often separate, there may be more dollar availability for technology that helps achieve operational efficiency, since this is top of mind for so many executives. 

Verifiable customers often see how return on investment comes with the replacement or reduction of a costly CVO. One such leading customer is Humana, who came to Verifiable searching for technology solutions to help insource away from their previous CVO vendor. Humana aimed to reduce costs, increase data quality and accelerate credentialing turnarounds to improve the provider experience. Humana chose Verifiable to insource, automate and centralize credentialing operations on the Salesforce platform. Through this work, Humana is currently projecting a 15 percent cost reduction, while improving quality and control over its previous CVO. 

But ultimately, beyond the hard metrics of cost-savings comes softer advantages, like the peace of mind that comes with reliable data and cost transparency.

How Verifiable is powering the trend of insourced credentialing

As credentialing professionals know, insourcing the process hasn’t been the best option for organizations—until now. As the current state of healthcare continues to require a stringent look at processes and dollars spent, leaders are quickly seeing how ripe credentialing is for an overhaul. In fact, by bringing credentialing in-house with Verifiable, systems and networks are seeing proven cost savings, quality control, visibility and faster clinician onboarding.

What makes Verifiable different from the rest?

Verifiable is the leading solution for automated primary source verifications and provider network management. Rather than offloading these tasks to people outside an organization, our goal is for leaders to have complete ownership over the process to ensure network compliance. 

Verifiable does this by providing a complete platform with self-service tools to do the work efficiently, effectively, and accurately. Our unique direct-to-source verifications are programmed to get through captchas, paywalls, and capture screenshots, while the unique technology integrates more than 3,000 sources to complete PSVs, all according to NCQA standards. In addition, the Verifiable coverage of automated verification sources spans way beyond just physicians—including dentists, pharmacists, nurse practitioners, mental health providers and many more.

Organizations like Humana, Zelis, Cityblock, Modern Health, and Wheel have brought their credentialing and monitoring in-house with Verifiable—and as a result, they’re credentialing four times faster, all while taking control of their provider data and creating an experience providers respect and appreciate.

Book a meeting with our team to find out how you can bring credentialing in-house.


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