Rethinking Credentialing for Next-era Payer Performance

Credentialing remains one of the most fragmented operational functions across the healthcare payer landscape, with providers repeatedly submitting the same information and payers independently verifying identical data. This duplication increases administrative costs, delays provider onboarding, and contributes to inaccurate provider records, making credentialing a growing operational and strategic challenge. This Viewpoint explores how changing regulatory expectations, greater interoperability, and advances in automation are creating momentum for a more coordinated approach to credentialing.

This report examines how credentialing can evolve from periodic, payer-specific verification toward a shared model built on standardized provider data, API-driven integration, continuous monitoring, and reusable verification. It highlights the foundational capabilities needed to support this transition, including interoperable data exchange, centralized provider records, workflow integration, and governance frameworks that enable trusted data sharing across participating payers.

It also presents a phased roadmap for enterprises seeking to modernize credentialing while maintaining payer-specific decision-making. By reducing duplicate verification efforts, improving provider data quality, and accelerating provider activation, healthcare enterprises can strengthen operational performance, enhance provider and member experiences, and unlock greater value through ecosystem-wide collaboration.