John Bou is co-founder and president of Modio Health, a CHG healthcare company.
As a major wave of change in federal administration is formed, scrutiny about how our healthcare system works is growing. One of the sustainable and costly challenges is managed waste. This is a problem that has long plagued the sector. The US healthcare system is highly well-known, with inefficiency contributing billions of dollars at unnecessary costs.
Of the many ways to reduce managed waste, one important feature has been mentioned. Provider credentials. Credentials (testing physician license and status at the state and national level) are fundamental to health care today. This prevents providers from seeing patients or receiving payments. It also requires that healthcare providers be properly qualified to provide safe and effective care to their patients. However, certification remains upset by inefficiency. Healthcare continues to lag behind as it continues to advance in clinical care, technology innovation and policy reform, but is probably not considered an attractive space to innovate.
What are the barriers to improving provider certification, where are the opportunities, and as a leader in healthcare and technology, why do you need to care for them?
Cost and avoidable waste waste
The US spent $4.3 trillion on healthcare in 2021, nearly 25% of which is considered waste. Cost of credentials We know that hospitals and medical institutions delays can lose millions of revenue, disrupt operations, and burden healthcare workers.
For example, a simple error in a provider's document can cause delays of up to six months or more, resulting in a lack of hospitals and medical practices, making patients unseen. This limits our ability to care for patients and serve our communities, resulting in substantial financial losses as healthcare providers cannot bill services that are not provided. Beyond the economic impact, inefficient credentials add to the administrative burden that contributes to provider burnout and labor shortage. Downstream effects affect patient care, increase wait times and limit access to essential services.
Prioritizing certifications
Despite the clear benefits, qualification reforms are not always in line with hospital budget realities, so there is no prioritization. Naturally, it focuses on frontline care and revenue-generating initiatives rather than back-office modernization. However, it is all part of the same system, and ultimately, these administrative adjustments can affect these priorities.
The current credentials process requires providers to submit the same data (e.g. education and training, work history, board certification) to each other in various organizations. The lack of a standardized certification repository leads to overlapping work and delays. This is where technology-dependent automated processes can work.
Technology and policy reform
Processes and innovation are important, but they are not just the factors needed to improve the sector's credential providers. Legal and policy considerations are highly relevant. The state-by-state credentials process may be ineffective. The time it takes to obtain a license varies in each state. Each state has its own licensing process and licensing requirements are very similar across the country, but most states require that doctors obtain individual licenses in all states where they are practiced. This can cause significant delays for the doctor.
It's also worth looking at the licensing reforms. In Tennessee, legislatures responding to the medical shortage crisis have been shot down by the Licensing Commission by streamlining the licensing process for applicants from foreign medical schools. Tennessee ranked 44th in the nation in overall health in 2024, with many of its counties being designated federal government as a shortage area for primary care health professionals.
The need for measures to ensure patient safety and the provision of high-quality, safe doctors and nurses is realistic. But at what point does Red Tape hamper the progression and solution of growing healthcare access problems?
I'm looking for the future
Without modernization, hospitals continue to lose revenue, providers continue to face unnecessary burnout, and patients experience delays in care. There are several clear steps to make the process more efficient and less burdensome.
•Start an internal conversation. A review of current policies and practices within your organization is the first step in determining whether it's time to upgrade your process and redirect focus.
• Optimize your processes. Develop interoperable, automated systems to minimize redundancy and slow manual verification processes. Consider leveraging AI-driven certification solutions to streamline validation and reduce long processing times.
• Prioritize compliance. Work with regulatory bodies such as CMS and state licensing boards to ensure that technology aligns with evolving compliance standards. By promoting standardization and increased participation in data, it can help create a national certification database, reducing repetitive management tasks and increasing efficiency.
•Continue to provide information. There is constant change within the healthcare sector. Staying up to date with state and regulatory changes reduces the likelihood of barriers and challenges.
Qualified reforms must be a priority as the healthcare industry works to curb waste and improve efficiency. We are a crucial moment. Over the next few years, there will be a real opportunity to transform your credentials and in doing so, creating a more sustainable and efficient healthcare system.
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