The Current State of Payer Enrollment and Credentialing

Payer enrollment and credentialing is a chaotic space, filled with complexities and inefficiencies. Many organizations are still struggling with onboarding payers and providers in a speedy, error-free manner.

Perhaps your organization is one of them.

To analyze the above, Medallion surveyed nearly 350 healthcare specialists, managers, directors and C-suite executives. Their findings are quite eye opening…

In this article, I’ll discuss key findings from Medallion’s report and highlight their toolkit to improve payer enrollment and credentialing.

The State of Payer Enrollment and Credentialing

Medallion surveyed nearly 350 key decision makers in healthcare to elucidate the complexities of payer enrollment and credentialing.

Payer Enrollment

Surprisingly (or perhaps not so surprisingly), nearly 40% of healthcare professionals reported moderate reliance on manual processes in their payer enrollment workflows. Almost 70% of respondents reported using two or more software tools, adding fuel to the fire. Such manual processes coupled with multiple systems that don’t talk to each other are recipes for complexity and inefficiency.

Unfortunately, the enrollment process is quite nuanced: organizations must gather info from providers, all while staying privy to rapidly changing requirements from different payers. Failing to keep up means delayed reimbursement or none at all. 46% of those surveyed reported revenue impacts from these slow turnaround times and poorly designed workflows. Notably, a study from Merritt Hawkins showed that a single internal medicine provider may generate around $7,300 on average per day, meaning any delays in this enrollment process are costly.

The most irking part of the payer enrollment process is the reliance on physically submitting/mailing applications for enrollment and manually tracking down a provider’s enrollment status with the payer. In fact, 30% of those surveyed say they spend over eight business days just gathering provider info for enrollment. A delay of eight days for an internal medicine physician could be $58,000 of missed revenue.

The manual nature of these workflows not only hinders operational efficiency but also magnifies compliance risks and data inconsistencies. A concerning 131 survey participants pinpointed errors, compliance issues, and inaccuracies as primary culprits for enrollment denials. This manual entanglement significantly contributes to the challenges faced, particularly in ensuring the accuracy of applications from the outset.

Credentialing

Credentialing echoes a similar sentiment as payer enrollment, with 84% of those surveyed reporting turnaround times exceeding 15 days and a stark 52% still entrenched in entirely manual workflows. This critical function for verifying provider credentials and maintaining compliance is plagued by administrative inefficiencies, leading to revenue leakage and potential compliance violations.

The survey also highlighted that about 60% of respondents allocate more than half a business day to primary source verifications per provider, pointing to the prolonged and intricate nature of the credentialing process.

Based on all the above info, the biggest challenge is balancing speed and accuracy.

Speed is critical to avoid losing revenue, but accuracy is perhaps the most important aspect of credentialing, since missing a step or two can lead to financial repercussions. Unfortunately, this means 30% of respondents manually verify each provider’s credentials by visiting individual sites. But, on the positive side, around 60% of those surveyed report blending manual and automated verification tools.

Staff Turnover

Here’s what surprised me the most: 57% of healthcare organizations reported issues with staff turnover and staffing challenges, underscoring the urgent need for streamlined processes and automation. This turnover rate is higher than that of PAs and NPs!

The survey data illuminates an apparent demand within the healthcare community to shift towards more efficient, automated, and accurate payer enrollment and credentialing processes. 

The Medallion Touch

Medallion is a technology platform that streamlines the payer enrollment and provider credentialing processes. As you learned above, the enrollment and credentialing space is in dire need of efficiency, and this is what people want…

By automating and integrating the complex and traditionally manual processes involved in verifying healthcare providers' qualifications, managing their state licenses, and navigating the intricate payer enrollment landscape, Medallion addresses inefficiencies in these critical areas.

Key benefits of Medallion's approach include:

• Automated Credentialing: With intelligent automation that lets you onboard providers using just five data points, confirm a physician’s credentials directly from original sources, such as universities and licensing boards, and generate a credentialing file for committee review, Medallion reduces the time and potential for error, ensuring a faster, more accurate, and reliable credentialing process.

• Streamlined Payer Enrollment: Medallion accelerates the payer enrollment process, traditionally bogged down by administrative hurdles. Automation of provider onboarding, enrollment applications, submissions to payers, and continuous tracking and visibility reduces the administrative load, facilitating quicker provider integration into insurance networks.

• Quality Assurance: As I said above, accuracy is perhaps the most important part of credentialing. Medallion leverages AI and automated quality assurance technology to review applications for errors, ensure primary source documentation matches the provider, and flag any deviations from set guidelines. 

By tackling the inefficiencies head-on, Medallion expedites the process of integrating healthcare providers into the system (and generating revenue for the healthcare organization) and ensures the accuracy and compliance of the credentialing and enrollment processes. The result is a significant improvement in operational efficiency, a reduced administrative costs, and smoother integration of providers into healthcare networks, ultimately leading to quicker patient access to care.

Dashevsky’s Dissection

Insurers and providers spend over $800 billion annually on administrative costs, showing the dire need to improve operational efficiency. The lack of operational efficiency in healthcare is costly. As I mentioned previously, the average revenue leak of $7,300 per day due to delays in payer enrollment or credentialing, and consequently patient care, underscores the economic and clinical impact of inefficiencies in these processes.

Medallion, with their emphasis on automation, stands out as a pivotal tool in this landscape. By integrating accuracy into every step, Medallion ensures that the processes are not just faster but are also dependable and compliant. This dual focus on speed and accuracy aligns with the broader mission of healthcare: to provide timely, effective care.

To gain a deeper understanding of these issues and the transformative solutions Medallion offers, I encourage you to dive into the full report. It truly opened my eyes to the struggles (and potential) in the payer enrollment and credentialing space.