Go From Credentialing Chaos to Compliance Confidence

In this episode, we're joined by Kandi O'Brien, the Founder of Delegated Credentialing Pro’s and an expert with extensive experience in credentialing and compliance. 

Kandi shares her fascinating journey in healthcare, from clinical roles to owning urgent cares, and ultimately specializing in compliance and credentialing. We discuss the importance of credentialing, its various aspects, and why it's crucial for patient safety, regulatory compliance, and maintaining organizational reputation. 

Tune in to our conversation to learn more about: 

• The significance of credentialing as the first step for providers entering healthcare facilities. 
• The distinction between facility credentialing and professional (provider) credentialing. 
• The complexities of enrollment and why it's not synonymous with credentialing. 
• The concept of delegated credentialing and its benefits for organizations, including improved efficiency and revenue generation. 
• The primary source verification process and ongoing monitoring for compliance. 
• The potential challenges and considerations associated with delegated credentialing. 

Episode Transcript

CJ: Welcome everybody to another episode of Compliance Conversations. My name is CJ Wolf with Healthicity, I am the host today. As usual, we are excited to have Kandi O'Brien with us. Welcome Kandi! 

Kandi: Thank you! Thank you so much for having me today.  

CJ: We are so excited to have you here and to talk about a really, really important topic. We're going to be talking about credentialing, but before we get there handy, we love to our listeners love to kind of hear, you know, how'd you end up where you're? What are you doing now? You know, we all come to kind of compliance and regulations in healthcare from different directions and from different pathways and so love to have you share what you're comfortable sharing about that.  

Kandi: Awesome! So, I've been in healthcare my entire life. I started out clinical and then started running small offices and so forth. And that just grew and grew and grew. And I owned some urgent cares in Boston and then ended up in Key West. And so, ending up in the bigger hospital systems, I realized, you know, having JCAHO audits and things like that, I knew that there were compliance elements that some of the offices weren't hitting and so forth. And so, I found myself doing a lot of trainings around it with a variety in my offices. And so that one thing kind of led to another and that brought me to a facility that was called eQHealth Solutions and they're still around, but they had the Florida contract for OCA. And so, it was case management, utilization management and call center. And so, I quickly had to become familiar with URAC accreditations because that was part of my role. And so, moving from that, I got into the compliance area with credentialing and so I worked on the payer side for five years. In the last five years, I've been on the practice sides helping companies, open startups and so forth with setting them up from day one to do delegated credentialing, rather than having to go back. So, it's been an interesting and fun journey, but I'm definitely a little bit of a compliance nerd, so it's a good fit for me. 

CJ: Yeah! Well, we all are here, we're all a little bit compliance nerds. And they're like, whoever grows up thinking they want to do this right, like, I always trying to explain to my younger children; "But Dad, what do you do? Yeah, I try to. Help people follow rules well, that doesn't sound fun. that's a terrible job." But you know, there are some cool things about we all know what those are. But today we want to talk about credentialing. Such an important topic and with your expertise and experience, let's just kind of level set because you know we have a lot of a lot of our listeners, you know compliance professionals and they are aware of credentialing, but some of them might not be, you know, super involved in the weeds and the details over the credentials.  

Kandi: Sure!  

CJ: Why don't you kind of level-set for us and just why is credentialing important? Why are we even talking about?  

Kandi: Well, the way I look at it is credentialing is the first path of a provider walking in the door, right? And So, what that means is you need to ensure first and foremost that you have patient safety. So, by doing credentialing, you know you're evaluating that providers credentials and history and so forth. Ensuring that you know there's nothing going on with them. There's a cost associated with, you know, providers who have extensive malpractice and you accept them in, you know, you're opening yourself up to some risk. There are also government monies, so most payers accept government monies. So, in turn, they have to follow rules such as you can't be on Medicare Opt Out and for that reason that trickles down to the actual organization or provider level to ensure that government funds are not going somewhere that they're not supposed to. And then I think the most important thing for an organization is really their reputation. You know, I am a big fan of watching Doctor Death, and there's been a few episodes now. And when people say, like, what do you do when I say have you watched Doctor Death? That's why I do what I do so it's really important to evaluate each provider.  

CJ: Yeah, absolutely. And you mentioned, you know, telling us a little bit about your professional path kind of on the payer side and this and that. So, there's credentialing pieces on multiple sides, right?  

Kandi: Right, yes.  

CJ: Yeah. So, it sounds like you have that experience knowing what it's like, you know, from a payer perspective. But and now it sounds like you're focusing on, you know, the provider side of making sure they get credentialed in a, you know, in a timely manner and to your point of just, you know, it's to make sure that the person has the right credentials experience training right to take care of patients in a certain space and the kind of element if you will.  

Kandi: Correct!  

CJ: Yeah. So, then tell us what it is and what it is because, you know, as a compliance officer, you know you hear credentialing and there may be like a credentialing committee or it might be, you know, but what is it and what is it not so that we kind of have it clear in our mind what kind of falls in under that category of credentials?  

Kandi: So that's a great question. Credentialing in and of itself is a word that's used that encompasses an umbrella of other things. So, for example, if I were to say: "Oh, CJ, you got a new car, what did you get? And you say, oh, I got an F-150." Immediately my mind says that's not a car. And so, you know, I look at the word credentialing similar to the word vehicle, you know, you could have an e-bike, you could have a bus, a van, you know Mack truck, who knows? But they all fall under that vehicle category. And so, credentialing is very similar to that. So, in essence, there's different ways to credential.  

So, there's facility credentialing, which is done usually at like the hospital level, so any of those inpatient types and they fall under a different set of standards and there's plenty of them that they can fall under. But you know, mostly your Joint Commission and other accreditations like ASC's and so forth. These are all areas where you can't physically pick a provider from a directory. So, it's that service line of business. And so, the facility itself goes through and does their own credentialing, which is a little more stringent than outpatient credentialing in the sense that they have bylaws and their committees are set up differently and so they have peer reviews to ensure, you know, doctor Wolf is not going to perform some sort of surgery that he may or may not be trained in, but he says he can do it. So, there's peer references, there's, you know, all sorts of sign offs for different types of procedures that they might do and so forth. And so that falls under what's considered facility credentialing. And so that and that also can be delegated at the payer level, but just falls under a different category.  

Then you've got enrollment, which is the actual process and this is what gets most confused about the word credentialing. Everyone assumes enrollment and credentialing are the same thing, and they really aren't. When you when you do enrollment, you're submitting an application to six different payers let's say and now all six of those payers go and perform the same credentialing.  

CJ: That's right!  

Kandi: So, it's a long and tedious process and can take up to 180 days and so that amounts to lost revenue because let's say, you know, you were coming on board in three months and we don't have your credentials yet, even if we sent your application the day, we knew you were coming on board, we're probably still waiting. So now you're going to show up as a provider and only be able to see. Cash pay patients or out of network patients. So, it's just not, it's the system is not very conducive to being efficient.  

CJ: Yeah! 

Kandi: And so, for me, where I kind of specialize is the provider services side, the professional services. So that's anyone you can go and pick from a directory. And so, I like to work with groups on setting their credentialing up because credentialing is actually verifying their credentials that they're not on Medicare Opt Out and any other malpractice. That's the process of actually doing it.  

And so, the difference is when you do professional services and you have over 100 providers it's a huge benefit to your organization to do delegated credentialing and what that means is the payers will give you your organization the authority to do the work on their behalf. So that means you still have to follow all their policies, regulations, everything that they're subject to now comes down to you. However, you control that timeline.  

CJ: Ah! 

Kandi: So, you let's say now I know you're coming in in three months. Well, guess what? If my team gets your credentialing done in five days and gets you approved through credit com at the end of the week. You're going to be listed in payer directories probably before you show up.  

CJ: Yes! 

Kandi: So, it's totally different. Like you send a roster with your information on a monthly basis, that sort of thing. So, for me, that's what I like to set up because I want to see organizations be fiscally sound, and every time you get a new provider, there's usually a gap of loss in finance. And so, to avoid that and to have a better process, you know, in my opinion, it's far better to become delegated when you have a larger volume of providers.  

CJ: That you know that's really great background information and you know, so I'm not a credentialing an expert by any means, but I know that where the world's overlap a little bit you kind of told us the story of you know could take up to 180 days and there's pressure to financially get that provider working and getting reimbursement. And so, if you don't get all this stuff done, and I've seen this and unfortunately it happens, I know it's probably not as common, you know, too common, but where the organization is just under pressure, they're like, “Well, let's just bill and this other doctor's name, who's already credentialed, already cleared,” you know, we know that this other doctor that we've hired, we know they have a license. So, it's not like they're going to provide that care or it's illegal, necessary, but that might not be the same thing as a payer allowing you to, reimbursing you for something and when you get into the government payers, that's a huge no, no a huge no, no for any payer. But you know there's all sorts of settlements and risks in that regard. And so, to your point about you know because money kind of drives a lot of this and you want people to be able to generate revenue, right? 

Kandi: Right, right! And to your point, yes, they do that all the time. And you know, I can't tell you how many times I was on calls with like office managers or you know, the doctor who owns the practice, and they're like; "Oh, well, we'll just fill it under me!" And I'm like, "That doesn't work! That's not legal!" 

CJ: Exactly! And that, you know, there's settlements. You know, I'm you talking about kind of compliance nerd, I'm a compliance nerd in that I read a lot of these settlements and headlines enforcements just to see what's going on. People make that mistake all the time.  

Kandi: Oh, all the time. Yep! 

CJ: Yeah. Well, this is awesome.  

Kandi: But they've....  

CJ: Sorry, go ahead, Kandi  

Kandi: Oh, I was just going to say they figured they can get away with it, you know?  

CJ: I know, right? And some probably do, but the ones that get caught are the ones we read about. Let's talk some more about this in a moment. We're going to take a really quick break and we'll be right back with Kandi OBrien.  

Welcome back everybody from the break. We are speaking with Kandi OBrien, an expert in credentialing and also this concept of delegated credentialing and you described very well what that is and why an organization want to pursue it. Any other thoughts on just the concept of what delegated credentialing is and why an organization will want to pursue?  

Kandi: Yeah. So, if you've got a credentialing program set up and so my recommendation to my clients is always to have one credentialing committee that reviews files that have issues. So, let's say a malpractice claim, but most providers who come through the door don't have any issues. And so, what I set up for them is called a clean file process and so that gets signed off on once a week. So, they're actually approved on a weekly basis. So as long as the credentialing aspect, you know all their data has been pulled and verified that providers credit date can be that Friday. And so, then they immediately go on the next roster out to payers and sometimes payers take a little longer than they're supposed to. So, the provider it let's say if they start next month, you still may not see them in the directory, but they can still see the patients and that's huge. They know that they can eventually bill once they're loaded into the system. And so, they just hold that billing off until they've been officially loaded, and then they can send all those bills and they know they're going to get paid versus, you know, a regular provider that's going through the enrollment process you don't know how long it's going to take and you know again now you're trying to pigeonhole and say, "Okay, they can only take cash, pay patients, which are rare, you know, or you know, Medicare or whatever."  

CJ: Yes!  

Kandi: So, it ends up just making a far more efficient process and definitely more efficient in revenue and so the providers want to be part faster. They really want to see the patients from day one and you know, credentialing everyone considers an administrative burden, right? Everyone hates the word credentialing, just like they usually hate the word compliance and you really have to think from the top level of the management system and help them understand that by doing what you're doing, if you're not ditching so much money and your providers are probably not that happy when they come on board because they can't do this and they can't do that. In my mind, it's a win-win all the way around. Setting up the program. I love to set up program, so it's kind of easy for me. But you know it really if you can get a provider credentialed in five days versus waiting 180, that's huge!  

CJ: That is huge, like I've never even heard of that before. So, obviously you're doing something right there. You mentioned talking about this clean file process, just maybe just take a step back. Tell me what kind of databases are being kind of checked, right? So, you're checking, you know, there's schooling, you're checking state licensure. You're checking what malpractice records like tell me a little bit more about the things that are getting checked.  

Kandi: Yep! So, in our world it's called PSV, which stands for primary source verification. So, you're going to the primary source to get your verification information. And so, like for education, for example, if they're board certified, all of their educations it within that and so board certification is the only thing we have to verify. If they're not, then we go to the school itself and get that information. We also do any license that they have, any training that they have, malpractice. Malpractice comes from a database called NPDB, which I'm sure you've heard of. And actually because of Doctor Death, that's why that was created, which I love. And so NPDB gives you any license sanctions, any malpractice claims, any of that. So, it's kind of a one stop shop which is nice. And then you do all your federal queries, which are OIG, SAMs, Medicare Opt Out and then you also look at other elements like, there's Death Master File, so there's certain little elements here and there, but it all really goes back to your going to that primary source for that provider. So typically speaking a clean file would be, you know, there's no license sanctions, there's no Opt Out. There's no malpractice, you know, it's just a here's a provider who's been practicing doing a great job moving along. And which is the majority, thankfully!  

CJ: Exactly! It's good that you mentioned you're if a part of this process is, you're checking like the OIG and SAMs, so you're checking for exclusion lists because I know a lot of compliance programs that will do that as well, so it's probably good to meet with your credentialing folks say; "Okay, do we only need to do this once?" The answer I'm assuming is yes, why pay for it twice? And you're going to do it, right? and then you know, where is the verification going to be that we did it if we're called on these five years from now is there a piece of paper or document that shows? Yep, we checked... ?  

Kandi: Yes, correct there is. And you know there's also called what's called ongoing monitoring. And so, what that means is on a monthly basis, you're still checking all those sanction sites. So, your state sanctions, OIG, SAM, all of it. So, it goes in the background and does a constant check.  

CJ: Yep! 

Kandi: And so that way you're never missing something.  

CJ: Exactly! And that's the best practice in the compliance sense and so it's good I think that compliance officers are aware of what credentialing professionals are doing just so that you're all on the same page. You know who's doing what and what's getting done. Not, you know, you're not spending extra money, and you're also not saying' "Oh! I thought you were doing that." And they say I thought you.  

Kandi: Exactly! Yes, exactly. And you know most people who do this type of credentialing have a software system that all of that stuff's built in, but compliance doesn't necessarily have that. And so, it's like it. And even if they do, they might hire an outside company to run it or whatever. However, they want to work. But to your point, let's not pay for all the doctors or nurses, nurse practitioners, etc. that credentialing deals with, let's just do the employees, right? So yeah, there's a cost benefit for that for sure.  

CJ: Exactly, right! So, any other pros and cons of delegation that you have come across.  

Kandi: Yeah! So, you know, a lot of people when they go into it, they think, "Oh my God, there's so many things I have to be compliant with," and they're not wrong. But at the end of the day, you know we've talked about how it puts you in the driver seat so you can actually boost your revenue, but the cons and I don't really look at these as cons, I just look at them as best practice. But you know the biggest con is that you're under the same obligation as the payer, which means when there's a state audit, you're going to be a part of that when there's an accreditation on it, you're going to be a part of that. Anything that has to do with any standards and laws that change, you have to ensure that your practice is following that.  

So, for example, there's, I want to say a handful of states that require a certain application for a provider and you have to ensure that you're using that application. And then they have turnaround times that they require like 60-day turnarounds times for some of them, I love those states. And so, and then you've also got you know any sort of pay or audits that happen outside of that. And so, what will happen is let's say and NCQA or someone is doing an audit for the payer, they'll give you a couple days to say, "Hey, I need you to send me your roster," and then they'll pick out, you know, which providers that they want. So you have to really kind of have a quick turnaround time for that rather than, you know, just holding it off, I'll get to it next week. You know, so that's kind of the important piece.  

But then I think the one con that everyone struggles with is the roster submissions every month. Since every payer does their own thing and has their own little tweaks and so forth for credentialing, they if there would be a universal spreadsheet that each payer would just take, it would make this process so much easier, but they don't. So, you have, let's say you've got 20 payers you're delegated with. Now you've got to pull twenty sets of rosters.  

CJ: Okay! 

Kandi: And so, let's say there was an error on one of them, chances are pretty good there's going to be an error on all 20.  

CJ: Got you! 

Kandi: So now you submit the roster. Now you've got 20 payers coming back saying; "You got to fix this. You got to fix that. You got to fix this." So, it kind of becomes a little bit cumbersome if you don't have a good way to generate a roster. So, I would say that's probably the most annoying thing in my opinion, and again I actually had started talking with a company who does rostering within payers to help them decipher if rosters are clean or not? And so, I'm hoping to work with them this year and do a pilot with one of my clients on doing it on the provider side of the house. So, hoping to find a fix.  

CJ: So, this question may show how ignorant I am on the topic, do some payers not allow delegation like is that the ultimate authority they, it's the payer who says yes you can or no you can't or...  

Kandi: Correct! Yep! So, you enter into, it's called the delegation agreement. And so that says all the responsibilities that you hold on behalf of them. And so most payers like I know years ago, Aetna would accept, you know, 50 would be the size of the group and now they bump that up to 100 because people are catching on that delegation is far more effective.  

CJ: Gotcha!  

Kandi: Because it saves the payers money at the end of the day, they don't have staff doing the work you do.  

CJ: Yeah! So are there payers who say no or I mean, do you run across that?  

Kandi: I do and I think a lot of it is when it's market saturation.  

CJ: I think.  

Kandi: So, like during COVID, mental health went crazy.  

CJ: Ah yeah!  

Kandi: And so now there's so many mental health providers within, you know, the payer realm. But they're kind of like, "Okay, we're going to take a step back for the state of New York for, you know, mental health," and that would actually apply even if that provider or providers tried to submit an application, right? It would get kicked back saying, "Sorry, we're not accepting anyone right now." So similar type of instance, but it doesn't happen very often.  

CJ: And you mentioned states, I'm assuming this process also has to be done for like US territories like the Virgin Islands, Puerto Rico, Guam, American Samoa...  

Kandi: Yeah, there's not a big business in the delegation world for that, but it just depends on where the payers are at. So, if they do happen to have, you know, a group of providers out there, I just feel like those are so small that you're probably never going to get a provider group out in those areas that would even qualify.  

CJ: Well, I can tell that you like you like setting up professional services for delegated purposes. What do you like about it? You sound passionate, excited about it. What do you like?  

Kandi: Yeah! I mean, I like working with individual client like working at their pace and their speed and what they're allowed like what they have for resources, not just human resources, but technology and just saying; "Okay, what is the best way to set this up?" And so, I do have a lot of clients that use the CVO so that they don't physically have to do the primary source verification themselves, so they sub delegate to that entity. And then they do the other pieces of it. But it's really, you know, I've got another client who's been they thought they were doing credentialing for the past several years, and it turns out that they were about 75% there. So, you know, it's really just seeing where they're at, what they need. I've had other clients that are like, can we get this done in a month? And it's like, yes, we can. But you also have to be open and performing the services right, a credentialing service for six months before you can even get audited, right? Because how are you going to audit something that doesn't exist.  

CJ: Exactly!  

Kandi: So, I love working with them on that stuff, helping them understand what ABC means. They're like I said, they're a lot of standards, accreditations, laws, rules. And so, I really like working with them and helping them understand. And then also, you know, I talked to them about other operational things, because again, I come from the operations world. So, it’s really easy for me to help them set up what they want their department to look like from a staff perspective. So, it's been great for me to do what I love with them, but also help them in other ways. So that's what I really enjoy. 

CJ: Well, and that was going to be one of my questions is. So, you're doing a lot of the heavy lifting for clients, but what do you see clients have to do internally like do they have to have a full-time person assigned to credentialing? Is this something that somebody does is third, you know, maybe third job on the client side?  

Kandi: Yeah. Yeah, so typically they have like one person who will start it up and then the ones who use the CDO obviously, their staffing is much less because they don't have staff that are actually doing the primary source verification, which is the bulk of the work. But they might have a manager like so for example, my very first client, I think they have 17,000 providers now. So, I think they've got like three or four people working in the department now just because it's so much data coming every day. So, they're kind of managing it that way. But you know, setting up credit comes like, that's huge when you've got a huge volume.  

CJ: Yeah! 

Kandi: So, it really depends and that's why you know, I do have a lot of clients who sway to the CDO side because they don't want to have to hire credentialing person and have them figure it out. So, but there does need to be oversight on their part for sure.  

CJ: Yeah, absolutely. Because I mean, you still are ultimately accountable for what's not coming down.  

Kandi: Exactly!  

CJ: We see a lot of that in compliance too, right? Where somebody like want to hire me or someone else to kind of be their compliance expert. But yeah, I can provide content expertise and help in a lot of the heavy lifting, but the ownership still has to rest with the organization.  

Kandi: Exactly!  

CJ: Do those individuals like do they typically work for HR; do they typically work for operations? Like, where are they usually placed in the organization?  

Kandi: They usually work on the revenue cycle. So yeah, they fall under revenue cycle, which in essence makes some sense, but I always feel like it should be kind of on an island of its own because it is on an island of its own and nobody fully understands it in other departments.  

CJ: Right!  

Kandi: So, it does technically fall under revenue cycle.  

CJ: That makes sense to me.  

Kandi: Yeah, but they're, you know, I've got other clients who started their businesses and theirs doesn't fall under revenue cycle. There's this on an island of its own, and they work with operations. So.  

CJ: Got you! Well, Kandi, we're getting kind of close to the end of our time. I'd love to give guests kind of a moment if they have any last-minute thoughts where the words of wisdom. I think if you're willing to share your contact information, we can include that in the show notes so people can reach out to you if they're interested in learning more. But any last-minute thoughts or comments?  

Kandi: Yeah! I mean, I think you know, again I'm very partial to delegated credentialing. I think any organization who's got over 100 providers really needs to take the time to look into it. It's not that hard to set up, it's process change, but at the end of the day, I just think of the lost dollars that are there. So, I think that that is really the driver of having a healthy financial organization.  

CJ: Yeah, fascinating! And Kandi, thank you so much for taking some time to share these insights. Your expertise is apparent. Your passion is palpable. And so, I love it. And so really appreciate your willingness to be on the podcast today.  

Kandi: Yeah! Thank you so much for having me!  

CJ: Thank you! And thank you to all our listeners! We love your support and if you think this particular episode could be of use to somebody, send it along to them. And as always if you know somebody who would make a great guest or a topic that you'd like to hear more about, please feel free to reach out to us because we want to bring you the most pertinent information for you. So, thanks again for listening everybody until next time, take care!