Here’s how blockchain could accelerate credentialing

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Alexander Gaffney Senior Manager, Health Research Institute, PwC US October 04, 2018

A clinician who joins an office, physician network or hospital must first have his or her credentials—educational history, licensures, regulatory history and more—confirmed, which could require contacting more than a dozen entities and take months. Delays can lead to significant revenue losses.

The clinician also must be enrolled in a payer’s network to accept insurance payments, which also takes months. During these waiting periods, the clinician earns little or no money for their employer or practice. This is not an uncommon occurrence.

A blockchain-enabled system would permit data relevant to the provider and payer credentialing process to be shared and updated in real time. Processes that take weeks or months could be accomplished in days.

Quick facts about credentialing

  • The inefficient credentialing process is costly to providers and payers. The Council for Affordable Quality Healthcare estimates that payers spend more than $2 billion a year maintaining provider databases, 75 percent of which could be eliminated by establishing a single source of truth, such as a blockchain.
  • Each physician in a practice submits an average of 18 applications for credentialing each year. That requires 80 minutes—including 69 minutes of staff time and 11 of physician time—per physician. Payers then spend time and money verifying these claims.
  • The National Association of Medical Staff Services (NAMSS) estimates that most physician credentialing takes more than 120 days, while health plan enrollment takes 60 to 180 days.
  • Those costs don’t even take into account another system wide burden that blockchain could simplify: Credentialing and directory updates to list locations where a physician sees patients and whether a physician is enrolled with a certain insurer or is taking new patients. NAMSS estimates that 12 to 18 percent of provider directories are out of date or incorrectly list a provider as participating in a plan.
  • A recent CMS audit of Medicare Advantage online provider directories found that 52.2 percent contained inaccuracies. According to CMS’ 2019 call letter, it will begin taking enforcement actions against some Medicare Advantage organizations that don’t correct serious provider directory deficiencies.

Credentialing with blockchain

Blockchain could simplify this process by allowing one update to reach multiple entities.

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Provider credentialing

  1. Provider/health professional uploads background information (i.e. educational history, certifications, licenses, malpractice insurance, etc.) to the blockchain
  2. Primary sources authenticate provider background information in the blockchain
  3. Health facilities verify provider data on the blockchain using primary source verification, and accepts or rejects the provider, uploading the result to the blockchain

Payer credentialing

  1. If accepted, the enrollment application is submitted to the payers
  2. Payers verify data via the blockchain using primary source verification and either accepts or rejects the application, uploading the result to the blockchain
  3. Patient verifies that the provider is in-network and has necessary credentials using blockchain
  4. Government regulators periodically audit provider credentialing processes

 

Read more about how blockchain could transform healthcare processes in PwC’s report.

Contact us

Benjamin Isgur

Health Research Institute Leader, PwC US

Alexander Gaffney

Senior Manager, Health Research Institute, PwC US

Tel: +1 (202) 836 1604

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