How AI is Transforming Healthcare Credentialing:

• Automated Document Processing (IDP): AI, utilizing Optical Character Recognition (OCR) and Natural Language Processing (NLP), can automatically extract and interpret data from various credentialing documents (licenses, certifications, transcripts, work history), reducing manual data entry and errors.  
• AI-Powered Primary Source Verification (PSV): AI platforms can directly connect with primary sources (licensing boards, medical schools, NPDB) for real-time verification of provider credentials, drastically cutting down verification times.  
• Continuous Monitoring: AI systems can continuously track changes in a provider’s credentials (license status, sanctions) from various databases, providing timely alerts for potential issues.  
• Enhanced Accuracy and Compliance: Machine learning algorithms cross-reference data to identify inconsistencies and ensure consistent application of credentialing criteria, while also staying updated with evolving regulations.  
• Predictive Analytics and Risk Management: AI can analyze historical data to predict potential delays, identify fraudulent credentials, and assign risk scores to applications for focused review.  
• Streamlined Workflow and Task Management: AI can automate the routing of tasks, generate reminders, and provide AI-powered virtual assistants to guide providers through the process.  
• Integration with Other Systems: AI-driven platforms can integrate with HR, EHRs, and payer systems for seamless data sharing.
• Bias Detection and Mitigation: Emerging AI tools can analyze credentialing criteria to identify and mitigate potential biases.

The Importance of Telehealth Credentialing

Proper credentialing is critical for maintaining patient trust and ensuring high standards of care. It helps to:

• Verify the identity and qualifications of healthcare providers.
• Ensure that providers have the necessary training and experience for telehealth services.
• Maintain compliance with regulatory and legal requirements.
• Protect patient safety and privacy.
• Enhance the overall quality of telehealth services.

When Does Re-Credentialing Occur?

Re-credentialing is required every three to five years depending on the insurance panel. This process ensures that your credentials remain up-to-date and compliant with insurance panel requirements. Failing to complete re-credentialing can result in delays or loss of in-network status, so it’s important to stay on top of any associated deadlines.

Navigating the insurance credentialing process can be overwhelming, but you don’t have to do it alone. MedTrust specializes in handling all aspects of credentialing, from initial applications to re-credentialing and beyond. Our team is committed to making the process as seamless as possible, so you can focus on what matters most—providing quality care to your patients.

Let the team of experts at MedTrust help you navigate the credentialing process and set your practice up for success. If you have questions or need assistance with your credentialing, contact MedTrust today. We’d love to help you every step of the way!

What’s Included in Credentialing?

Credentialing involves verifying multiple aspects of a provider’s qualifications, including:

• Education and Training: Verifying degrees, residency, and relevant training
• Licensure: Ensuring the provider is licensed to practice
• Experience: Reviewing the provider’s clinical practice history
• Criminal Background: Conducting a background check
• Malpractice Claims: Checking past malpractice cases and other risk factors

Why Is Credentialing Important?

Credentialing is crucial because it ensures:

• Patients receive care from qualified professionals
• Maintaining Quality Standards by validating educational background and professional experience.
• Regulatory Compliance to avoid legal consequences and ensure proper reimbursement for services
• Healthcare providers can accept third-party reimbursements from insurance companies. 

Who’s Involved in Credentialing?

• Healthcare Providers: Responsible for submitting the required documentation
• Credentialing Organizations: Responsible for verifying submitted information
• National Agencies: Oversee credentialing standards to maintain quality care

Efficient healthcare credentialing is crucial for several reasons:

• Patient Safety: It ensures that healthcare providers are qualified and competent to deliver care, minimizing the risk of errors.
• Revenue Cycle: Reduces claim denials and speeds up reimbursements, improving the financial health of healthcare organizations.
• Compliance: Helps healthcare facilities adhere to regulatory standards and avoid legal issues.
• Provider Satisfaction: Streamlines the onboarding process for new providers, improving their experience and satisfaction.
• Reputation: Enhances the reputation of healthcare organizations by demonstrating their commitment to quality care.

Inefficient credentialing can lead to significant delays, increased costs, and potential risks to patient safety. It is therefore essential for healthcare organizations to prioritize and optimize their credentialing processes.

Medicare Physician Fee Schedule:

• The 2025 Medicare conversion factor will be $32.35, a 2.83% decrease from $33.29 in 2024
• This reduction is due to budget neutrality requirements and expiration of temporary relief enacted by Congress
• Overall reimbursement for cardiovascular services is projected to remain flat compared to 2024

UnitedHealthcare Changes:

For Medicare Advantage plans, UnitedHealthcare is implementing new prior authorization requirements effective January 1, 2025

Delayed care and preventive services

Deductibles also influence how patients use healthcare services. Patients tend to delay or forgo care, including preventive services, when facing high deductibles. This can lead to more severe health issues down the road, potentially impacting a provider’s ability to deliver timely and effective care.

Financial risks for providers

As patients become responsible for larger portions of their healthcare costs, providers face increased financial risks. They may struggle to collect payments from patients who cannot afford their deductibles, affecting the providers’ revenue stream. Given the potential financial burden of high deductibles, providers may need to offer payment plans to help patients manage their healthcare costs and receive the care they need.

Shift in service utilization patterns

Demand for services tends to slacken across the board during the deductible phase, including both preventive care and expensive tests. This shift can impact providers’ workflow and resource allocation.

Reduced patient visits and demand for services

High deductible health plans reduce overall employee health care spending by 12-14% annually, primarily due to patients reducing their demand for services. This decrease in utilization affects providers’ patient volume and revenue, especially early in the year when deductibles reset.  For example, if a patient has a $5,000 deductible, they will need to pay the first $5,000 of covered medical expenses before their insurance starts paying.

Delayed care and preventive services

Deductibles also influence how patients use healthcare services. Patients tend to delay or forgo care, including preventive services, when facing high deductibles. This can lead to more severe health issues down the road, potentially impacting a provider’s ability to deliver timely and effective care.

Get Paid and Send Reminders

Make sure you have no unpaid invoices waiting to be sent out. If you do, don’t wait any longer. If you have insurance companies or patients who haven’t paid their invoices yet, begin the follow-up process right away.

Record All Expenses

Close out your practice’s financial year by making sure you’ve properly recorded and updated all your income and expenses. Falling behind on recording or categorizing expenses can make the new year messier than it needs to be and can lead to undesirable surprises down the line. 

Properly recording all expenses in your accounting software will keep your numbers accurate. It’ll also help your CPA find all your tax-deductible expenses easily when they assist you.

Pay Any Outstanding Invoices

While making sure your practice is receiving payments, you should also confirm that all your unpaid vendor debts, bills and employee payments are squared away before the new year.

Consider Annual Bonuses

A bonus not only shows your appreciation for your hardworking employees but also boosts morale going into the new year. Additionally, if you pay out your annual bonuses before December 31, the IRS considers them a deductible expense which will lower your taxable income. 

Purchase Medical and Office Equipment

If you’ve been eyeing some new medical or office equipment for your healthcare practice, now might be the time to buy. Purchasing qualifying equipment and implementing it before the end of the year can allow you to expense the cost up to a certain amount. 

Plus, end-of-the-year sales make it easy to find just the right price for your clinic.

Current Challenges

Inadequate Coverage – Many Americans still lack comprehensive health insurance coverage, leading to increased medical debt and poorer health outcomes. The uninsured and underinsured often delay seeking care until their conditions worsen, resulting in higher costs and negative health outcomes.