Automation can solve the provider credentialing crisis, exec says

Workers and companies in some sectors want artificial intelligence systems to stay away.

One sector where the AIs are welcome is health care provider credentialing.

The organizations that help employer-sponsored health plans and other payers verify that doctors, physicians and chiropractors are who and what they say they are hope the AIs will speed that up.

Related: Q&A: How can automated credentialing reform health care administration?

Health plans have been promising providers that they understand the desperate need to improve credentialing for more than 25 years, but provider data sources continue to be highly fragmented, Rehan Mirza, chief growth specialist at Verifiable, said in an email interview.

“This has resulted in the verifications and monitoring process being highly manual,” Mirza said.

The impact

Credentialing delays increase costs, frustrate the providers and increase the amount of time workers with rich health benefits have to spend hunting for primary care providers, ob/gyns and dermatologists who really, truly are willing to see new patients sometime in the next decade.

Getting qualified providers into a plan network often takes about three to four months. Credentialing typically accounts for about 20 to 60 days of the provider network enrollment, according to the Colorado Association of Health Plans.

The friction

The idea of checking up on doctors and other providers may sound as if it should be simple. But Verifiable has had to form connections for taking in data from about 3,200 data sources, including medical boards, state licensing agencies, agencies that track state and federal sanctions, and Medicare and Medicaid provider exclusion lists.

The sites to check for medical doctors are often different from the sites for dentists and psychologists, and the sites for social workers are different from the sites for doctors and nurses, Mirza said.

Verifiable started up in 2019. The founders have raised about $47 million in investor capital for their efforts to maximize credentialing automation.

The firm aims to compete with the many other players already in the market by taking the time to set up ongoing data feeds, rather than using telephone calls, emails and manual website searches to tap what seem like minor information sources.

Verifiable has found that creating the data connections has already reduced the amount of manual verification work it does by about 76% and made each credentialing check about four times faster.

The company has also started using AI systems to comb through the records it’s taking in.

The gameboard

Organizations that shape the data requirements and some of the data streams include health plan and health care provider accreditation organizations such as the National Committee of Quality Assurance, the Joint Commission and the Utilization Review Accreditation Commission.

Some states are trying to help by joining multistate provider licensing and credentialing compacts.

“However, this doesn’t address the core challenge of the manual credentialing work that needs to happen,” Mirza said.

NCQA guidelines may force the issue, by shortening provider network enrollment times and requiring all players to think harder about their data, Mirza said. Fear of NCQA deadlines could make life easier for data users like Verifiable, by pushing the data providers to adopt popular standards for formatting and sharing data.