When the parent company of a US nursing home mandated that the home become accredited by the Joint Commission Accreditation on Healthcare Organization (JCAHO), the nursing home decided to reduce the cost by outsourcing its physician credentialing function to Cambron Credentials, Inc., headquartered in Florida.
As Sarah Emery, CEO of Cambron, relates, "In the course of our verifying the credentials for a dermatologist who had gone through three nursing homes in the region, we discovered that he'd been reprimanded by the state license board; his license had been suspended, then reinstated - but only under the condition that he could not work with women or with the elderly (about 75% of the population in nursing homes)."
Credentials verification has always affected hospitals, clinics, and preferred provider organizations, but there is a new foray into skilled nursing facilities and ambulatory surgery centers. The verification is required by those seeking accreditation by JCAHO or by the National Council of Quality Assurance (NCQA). It can become a stumbling block to accreditation. With JCAHO, 11 key elements must be verified for each physician every three years, but JCAHO has reserved the right to do spot checking starting in 2004.
"Organizations are coming up with some real surprises about doctors, nurse practitioners, and physician assistants who for years have been doing procedures they were not qualified to do," states Emery.
In-house = High Cost
Although the benefits of avoiding lawsuits are obvious, performing the credentials verification function in-house is both paper-intensive and costly. Standards dictate that each facility needs a dedicated verification person.
"It becomes a gigantic cost center," says Emery. "The resource materials alone to start this program cost $3,000 - $4,000, and the average compensation is $30,000 per person, plus benefits, and the cost of computer equipment, etc." Moreover, with just 10 facilities in a geographical area, for example, there are 10 people doing duplicate work and each checking on many of the same physicians.
Headquartered in Cleveland, Tennessee, Life Care Centers of America, one of Cambron's new clients, has more than 260 facilities in several states and reports it was completely overwhelmed by the verification process before outsourcing it.
Part of a larger, Florida-based, not-for profit healthcare provider organization, Health First Occupational Medicine and Health First Corporate Partners provide comprehensive occupational medicine and workers' compensation managed care services. According to Sonja Apfelthaler, provider relations representative, they refer their patients to a network of more than 100 physicians. "It's too costly to do the credentials verification on them in-house," states Apfelthaler.
They, too, chose to outsource to Cambron Credentials. Based on the data Cambron provides, Health First (and other Cambron clients) then decide whether a particular physician should be allowed medical privileges in its facilities or belong to the physician network referred to patients; alternatively, the organization may decide to ask the physician to explain why he/she did not disclose something or why there have been so many fatalities among his/her patients.
Better, Faster, Cheaper = Outsource
Outsourcing facilitates efficiencies in the verification function. "It's not only more efficient for the provider organization's staff," Emery explains, "but it's also more efficient for the physicians whose credentials are being verified." If a physician is involved with more than one of Cambron's clients, the physician only has to complete the paperwork once, and the results are presented to multiple Cambron clients. These same economies of scale, together with expertise in knowing where and what information to search, enable Cambron to charge a lower price than an in-house healthcare operation.
The average hospital takes about five months to verify a physician's credentials, according to Emery. Cambron completes the work, on average, in 32 days. A hospital's in-house employee gets roped into doing a lot of other things besides credentials verification, whereas the outsourcing service provider focuses only on this function.
Cambron also provides re-credentialing and value-add services such as
- pursuing and researching expired certificates;
- pursuing and researching licenses and insurance;
- advising of monthly Medicare and Medicaid sanctions;
- advising of quarterly adverse state licensing sanctions;
- financial checks;
- state sexual offender checks;
- criminal background checks;
- other relevant searches.
Emery says that provider organizations often do not know who all their in-house physicians are. Cambron developed a value-add streamlined reporting solution that allows clients to have an instant snapshot of in-house physicians, which can be used for multiple purposes such as medical records, billing, and state and federal programs.
Risk mitigation is an enormous benefit in outsourcing the verification process. Cambron's due diligence includes performing multiple accuracy tests and insuring checks and balances are in place before guaranteeing the verifications as accurate and current as of the date of verification.
Non-Core But Crucial = Outsource
Unfortunately, as organizations realize the high cost of performing this work in-house, they sometimes choose to squeeze it into the already-too-tasked medical records department, add it to the duties of a medical director's secretary or an office manager, or even hand it off to whomever is not busy and can type, rather than hiring a person dedicated to this function. This method of operation, however, does not allow for keeping up with evolving standards and regulations of the various states, federal and regional regulations, the agency for healthcare administration standards, JCAHO and NCQA, etc.
This crucial function can also facilitate increased market share of patients, as Emery points out that credentials verification is the "first line of defense for patients. Anybody can hang out a shingle and say she/he is a physician, and anybody can doctor up a license to look like it's genuine and belongs to him/her." When a provider organization is accredited by JCAHO or NCQA, patients know that all the affiliated physicians' credentials have been verified.
Being accredited is an elective process. Hospitals and skilled nursing facilities are not prevented from doing business if they choose not to be accredited by JCAHO or NCQA. However, as Emery says, "It does separate the wheat from the chaff." Outsourcing makes it affordable and faster. "It's the intelligent way to go," adds Emery.
Lessons from the Outsourcing Journal:
- Providers achieve economies of scale from verification of physicians for multiple clients thus lowering the cost for the healthcare client and providing efficiencies for the physicians.
- Outsourcing the credentials verification reaps the benefit of risk mitigation through the outsourcer's guaranteed accuracy and completeness of results.
- Services such as pursuing expired certificates, licenses and insurance; monthly Medicare and Medicaid sanctions; and quarterly adverse state licensing sanctions are too time-consuming for an in-house operation but are value-add benefits of outsourcing.