How to Measure the Success of Your Credentialing Processes

Credentialing is the process by which a provider becomes in-network with an insurance plan. It's a critical first step that allows providers to accept third-party payments and get paid for their services. But how do you know that your efforts in credentialing are successful, and serving your business needs? Or, if you know that there is a problem, how do you identify what the problem is and how to fix it?

That’s where Key Performance Indicators (KPIs) come in. A KPI, or Key Performance Indicator, is a metric that helps businesses track and measure the success of their efforts. Tracking the right metrics transforms credentialing from a one-off task into an ongoing, data-driven process that can truly strengthen your practice’s revenue cycle. It’s about building a KPI dashboard to help you make smarter business decisions, whether you're evaluating a new hire, assessing your payer relationships, or optimizing your credentialing process. It’s about taking that subjective frustration and turning it into objective data that tells a clear story. 

Credentialing KPIs

Here are five essential credentialing KPIs, as explored by Jeremy and Kathryn Zug in the final installment of our credentialing series on the Claim Game Podcast:

1. Insurance Revenue Target Analysis

The goal here is to ensure your payer mix supports your profitability goals. This KPI helps you evaluate the profitability of each insurance company you accept, and compare the average revenue you receive per claim to your target minimum threshold. This is crucial because it can help you identify underperforming payers and make sure your business strategy is in alignment with your financial goals.

2. Time to Contract

This metric measures the time it takes from submitting a credentialing application to getting an in-network result for a provider. The data can provide insights into the time it takes to get revenue and help you optimize your hiring timelines. You can also drill down to see the time it takes to get a welcome letter, which can help you understand the administrative cost of following up on applications.

3. Application Completion Accuracy

Accuracy of application completion should be investigated if you’re seeing frequent application denials or a long "Time to Contract" for a specific payer or from an employee who is completing and submitting credentialing applications. Tracking this KPI helps you identify potential training needs or process gaps that are slowing down your credentialing efforts. By reviewing the number of follow-ups or if additional documentation was requested after the initial submission, you can see if changes need to be made to your process. This can help you avoid problems later on, like claims denials.

4. Credentialing Efficacy

This KPI measures the percentage of in-network contracts you get out of the total number of applications submitted. Efficacy data can be evaluated by insurance company to help you assess your insurance partners. By keeping an eye on your success rates by payer, you can make smarter decisions about which partners are working for your practice.

5. Application Denial Reasons

If you have a high volume of application denials, it’s useful to evaluate the reasons in association with each payer or employee. This metric allows you to drill down and see whether denials are due to a closed panel, an application error, or a provider not meeting the qualifications. This data can help you determine whether you should retrain staff or refine your payer list.

Making the Most of Credentialing KPIs

These KPIs can help a practice avoid costly mistakes, like firing an employee who just needed training to become a high-performing credentialer. You don’t have to overcomplicate it to get started; you can use the data you’re already collecting in your credentialing logs and EHR reports. Turning subjective frustration into objective data can transform your practice’s revenue cycle and set you on the path to financial growth.

The journey to a healthier, more profitable practice doesn't have to be a mystery. By leveraging these key metrics, you can transform the way you approach credentialing and make decisions with confidence. To help you get started, we've created a downloadable Credentialing KPI Dashboard, available to subscribers in the Hourglass Learning Hub. It’s a tool designed to help you input and analyze your credentialing data, so you can track your time to contract, measure application accuracy, and more. You can dive deeper into RCM best practices and find other tools and templates to help in the credentialing process by visiting the Hourglass Learning Hub. It’s time to stop guessing and start measuring—your practice will thank you for it.