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Mitigate risk and elevate your quality of care. Improving both clinical and business outcomes starts with a smarter, more integrated approach to regulatory training, continuing education and quality management.

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Online store for Clinical Learners. Individual CE Credit and industry products for Clinical Learners are now available through NurseGrid Learn (Beta). Explore our robust collection of courses that provides an unparalleled level of flexibility and choice.

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Enhancing Health Plan Management

Enhancing Health Plan Management: How CredentialStream Transforms the Process

January 23rd, 2024
January 23rd, 2024

CredentialStream: Refining Health Plan Management

The current healthcare landscape is an ever-evolving terrain, marked by technological advancements, increased demand for quality care, and a slew of challenges. As healthcare spending continues to rise, individuals and health plans recognize that the need for innovative solutions has never been more apparent. The relationship between payers and providers continues to evolve with shifts in 2023 that focus on enhancing the digital experience and streamlining processes. CredentialStream® by HealthStream®, a cutting-edge provider data management solution, is poised to transform the way health plans operate by offering a complete solution for requesting, collecting, and verifying provider information, and ensuring excellence in healthcare services.


The 4 Challenges Facing Health Plans

The competition among health plans in today's market has never been greater. Health plans utilizing outdated technology lack the ability to keep up with the evolving market conditions and fall short of contending with their tech-savvy competitors. Competition is fierce, and health plans face many challenges that include:


  1. Rising Healthcare Costs:

    According to projections made by the Centers for Medicare and Medicaid Services, national health expenditures will surpass $7 trillion and consume close to one-fifth of the U.S. economy in 2031. Today, approximately 25% of healthcare spending is considered wasteful, with the largest source stemming from administrative costs at roughly $266 billion. As healthcare expenditure continues to increase, managing and controlling costs is a paramount concern.

  2. Data Security:

    Health plans handle sensitive patient data, making data security a top priority. Cyber-attacks on hospitals and doctors’ offices are increasing and becoming more disruptive. According to Health IT Security, more than 39 million patients’ information was exposed in the first half of 2023, and breaches have doubled in the past 3 years.

  3. Regulatory Compliance:

    Frequent regulatory changes, including privacy and reimbursement policies, require agility and adaptability. Health plans must navigate a web of regulation and accreditation standards such as The National Committee for Quality Assurance (NCQA), the Utilization Review Accreditation Commission (URAQ), the Centers for Medicare and Medicaid Services (CMS), and the No Surprises Act.

  4. Member Expectations:

    Today, healthcare consumers expect transparency, good customer service, personalized care, and digital tools to manage their health. Meeting these expectations is difficult and requires innovative tools to improve member satisfaction and retention.


CredentialStream: A Solution to Health Plan Challenges

CredentialStream is at the forefront of addressing these challenges, offering health plans the technology needed to thrive. Here's how CredentialStream can help:


  1. Excellence in Care:

    CredentialStream continuously assesses medical provider competency, ensuring patients receive care from esteemed organizations and skilled professionals. It expedites the credentialing process, improving operational efficiency and revenue generation. Smart logic functionality automates tasks, minimizes errors, and simplifies the entire credentialing and provider data management process.

  2. Compliance:

    Staying compliant with evolving regulatory requirements, including those from organizations like NCQA, CMS, and URAC, is crucial, and CredentialStream simplifies the process.

    Health plans handle sensitive patient data, making data security a top priority. In 2020, the healthcare industry suffered 642 data breaches, exposing over 28 million records.

  3. Integration and Interoperability:

    CredentialStream reduces manual data entry by offering best practice workflows and the ability to import data from various sources, including CAQH, delegated entities, and CVOs. API integration and interoperability sets the foundation for a more adaptive and efficient system capable of meeting future demands in the ever-evolving healthcare landscape.

  4. Data Accuracy:

    Consumers expect transparency, personalized care, and digital tools to manage their health. Meeting these expectations is a challenge. In compliance with the No Surprises Act (NSA), CredentialStream helps health plans maintain current and accurate provider directories.

  5. Network Adequacy:

    Accurate tracking of provider location, specialty, network status, and other details ensures health plans can meet regulatory and market standards.

  6. Contract Management:

    CredentialStream enables health plans to ensure high-quality care, appropriate provider compensation, and adherence to regulatory requirements.


Today's health plans must continuously innovate in a healthcare landscape rife with challenges. By automating and streamlining the credentialing process, ensuring compliance, and enhancing data accuracy and interoperability, CredentialStream empowers health plans to deliver excellence in care and navigate ongoing challenges with confidence. To learn more about managing health plan business demands with CredentialStream, request a demo here!

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