Hospitals and health systems face relentless financial pressure, yet many continue to forfeit revenue due to outdated and inefficient credentialing and payer enrollment processes. Forward-thinking organizations are breaking this pattern by modernizing these critical functions — shortening credentialing timelines and capturing revenue more quickly.
To explore why this shift is essential and how leading systems are driving transformation, Becker’s Healthcare spoke with two experts from Modio Health: John Bou, president and co-founder, and Claire Forgan, director of the project management office.
Leaving revenue on the table
Healthcare organizations cannot bill for a provider’s services until credentialing and payer enrollment are complete, linking the provider to insurance networks. Without credentialing, providers are unable to care for patients, and without payer enrollment, health systems cannot bill for those services or generate revenue.
With staffing shortages persisting at many healthcare organizations, there is tremendous urgency to hire physicians, onboard them and have them start seeing patients as quickly as possible. From a revenue cycle perspective, the goal is for these new providers to be able to bill payers to generate revenue.
Despite the urgent need for revenue, many provider organizations still rely on slow, manual and outdated credentialing processes — delaying access to the revenue potential of new clinicians.
“Credentialing is a big hurdle today,” John said, noting how many organizations still use paper folders and Excel spreadsheets to manage credentialing and payer enrollment, which takes 90 to 120 days on average industrywide.
“If doctors are sitting on the sidelines, unable to provide care and perform procedures, a lot of revenue is being left on the table,” John added.
Enhancing credentialing and payer enrolment to accelerate the revenue cycle
By streamlining credentialing and payer enrolment processes, it is possible to decrease the turnaround time for new providers by 30% to 50%, which means these providers can start caring for patients and billing 35 days sooner. “That’s additional billables for the hospital or healthcare organization,” Claire said. The result, she said, is “revenue they can recognize earlier.”
For large hospitals and health systems with hundreds of providers, speeding up credentialing and payer enrollment processes at scale can translate into millions of dollars.
Key steps to streamlining these processes include optimizing organizational workflows, adopting best practices and centralizing data from multiple sources to reduce manual searching and improve accuracy. Equally important is implementing a modern technology platform designed specifically for credentialing and payer enrollment, such as Modio OneView.
This modern platform tracks everything from credential expirations to renewals to payer contracts. It streamlines workflows, automates repetitive tasks, issues real-time alerts when credentialing is about to expire and needs to be renewed, and generates actionable reports.
Not only does streamlining processes and implementing technology accelerate the revenue cycle, it also cuts down on the amount of manual work — making it easier for the revenue cycle team to stay organized, minimize errors, adhere to compliance standards and improve overall process efficiency.
“You’re saving time and resources,” Claire said.
Automation and human expertise working together
Improving credentialing and payer enrollment is not simply a technology project; it requires the right blend of modern tools, redesigned workflows and human expertise. Some organizations choose to develop this expertise internally with support from Modio, while others fully outsource credentialing and enrollment to the company.
When Modio partners with a client, it tailors the approach to the organization’s unique needs. Each engagement begins with a workflow review and can include a dedicated project manager, implementation support, specialized teams and access to Modio’s highly experienced credentialing professionals. “It looks a little different for every client based on what their unique needs are,” Claire explained.
John added that experience is a critical differentiator. “We have decades and decades of experience with credentialing,” he said, noting that Modio helps each organization identify the best combination of people, processes and technology.
The results speak for themselves. For clients that modernize with Modio, looking back after just one year often reveals shorter turnaround times, faster onboarding of clinicians and millions of dollars in accelerated revenue. More importantly, it means providers can begin caring for patients sooner — helping hospitals and health systems deliver on both their financial and clinical missions.
