Tips for Measuring Effectiveness of the Credentialing Process

By Jana Altieri RN MS CPHQHealthcare ConsultantManaged Care Consulting ProJuly 31, 2023
Having accumulated nearly two decades of combined experience in healthcare Quality Improvement, both within a health plan and as a consultant, I have acquired invaluable insights that can be immensely beneficial for the NCQA accreditation process. By implementing these suggestions, you can effectively improve quality outcomes and make substantial strides towards achieving NCQA accreditation. While the following information offers valuable initial guidance, rest assured that more valuable insights will be shared in the future.

Performance Measurement in Credentialing

The first of the National Committee for Quality Assurance (NCQA) standards for Credentialing Accreditation pertains to the Internal Quality Improvement Process. NCQA emphasizes the importance of implementing performance metrics within the organization to assess progress towards goals and to make necessary adjustments for a seamless, effective, and timely credentialing process. One common issue I have observed in organizations is becoming excessively engrossed in day-to-day credentialing activities, leading to a lack of focus on monitoring the overall program. It is vital to strike a balance between day-to-day tasks and maintaining a vigilant focus on the broader program. To address this, it is crucial to establish an evaluation plan before commencing the credentialing processes. This plan should outline desired outcomes and the methods to measure progress effectively. Below are some examples of measures that can be utilized in the credentialing process:
  • Length of time to complete the Primary Source Verification (PSV) process.
  • Length of time for internal approval (compiling the complete application along with information from PSV to the committee meeting and any additional follow-up before final approval).
  • Length of time to complete the entire credentialing process (from provider application submission to eligibility for network participation).
  • Percentage of files returned for additional credentialing verification needed.
  • Accuracy of completed credentialing files.
In addition to establishing the metrics, be sure to set specific and measurable goals then track your progress against meeting them. Obtain input from practicing providers when analyzing them such as during regular committee meetings - and keep detailed minutes as you will need them for evidence of compliance during your NCQA survey!
It is a requirement of NCQA to have a Credentialing Committee to allow participating practitioners to provide advice and expertise for credentialing decisions. The committee is necessary to review credentials for practitioners who do not meet established thresholds and provide decision-making authority as to whether they should be credentialed (or re-credentialed).
In addition to assessing metrics related to the credentialing process, it is crucial to establish indicators that evaluate the outcomes of credentialing. The ultimate goal of credentialing is to identify and invite high-quality practitioners into your organization, ensuring the delivery of exceptional patient care and maintaining overall healthcare quality. To achieve these goals, consider implementing the following tips:
  • Collect and Analyze Complaints:
  • Consistently gather and analyze complaints regarding providers' performance and services. Categorize these complaints to identify specific patterns and emerging trends. Regularly monitoring complaints allows you to address potential issues proactively and enhance the overall quality of providers in your network.

  • Measure Patient Satisfaction:
  • Utilize patient satisfaction surveys to gauge their experiences with the providers in your network. Patient satisfaction is a critical indicator of the effectiveness of your credentialing process. Use survey results to identify areas for improvement and strive to enhance patient experiences. Individual provider satisfaction scores can also be taken into account when it is time for re-credentialing.

  • Seek Provider Feedback:
  • Encourage practitioners to provide feedback on the credentialing process and their experience of participating in your network. Understanding their perspective can shed light on potential pain points or areas of improvement in the credentialing process. Regularly engaging with providers and considering their input can lead to continuous process refinement.
ConclusionBy implementing indicators that assess the outcomes of credentialing, organizations can ensure that the ultimate goal of providing high-quality care and positive patient outcomes is consistently met. Collecting and analyzing complaints, measuring member satisfaction, and seeking provider feedback are essential steps to ensure ongoing improvement and the delivery of top-notch healthcare services. By setting specific and measurable goals and involving practicing providers in the analysis, organizations can continuously enhance their credentialing process and foster a network of exceptional providers.
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Disclaimer: Jana Altieri, an independent consultant with Managed Care Consulting Pro, provides opinions based on experience and is not affiliated with NCQA. For specific information, please refer to the official NCQA Standards and Guidelines.
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