Does an EHR Handle Credentialing? Not Exactly.
Your electronic health record solution isn’t a credentialing system, it’s an integration hub. It moves data between systems but doesn’t perform verification, approvals, or payer enrollment.
An EHR plays an important role in the credentialing process, but its role is indirect. It focuses on integration and data flow, not on performing credentialing itself.
What an EHR Actually Does for Provider Credentialing and Privileging
An EHR provides interfaces that allow external credentialing systems to exchange provider and personnel data with the EHR.
Integration requires middleware or custom development, which many smaller organizations avoid due to cost and complexity. Manual setup continues to be common for large and mid-size EHRs and EHR solutions geared towards small practices rarely integrate deeply with credentialing systems.
- Incoming Provider Information
The EHR can receive data to create, update or inactive provider records. This data is fed from external credentialing databases using an API or via a pre-configured flat file of provider data. - Outgoing Provider Information
The EHR can send updates about provider data back to those systems to keep everything consistent. The credentialing system benefits from receiving volume reports to support quality metric reporting, if your solution has this functionality.
What an EHR does not do: verify medical degrees, licenses, board certifications, or conduct background checks. Those critical steps remain the responsibility of credentialing systems and teams.
Why Credentialing Is Outside an EHR’s Core Scope
Credentialing involves primary source verification, peer references, compliance checks, and payer enrollment, which are complex processes outside the EHR’s primary purpose.
Even large EHR vendors like Epic only enable integration through HL7, FHIR APIs, or vendor-specific interfaces. Actual credentialing still happens elsewhere.
How Epic Handles Privilege Lists
While Epic does not manage or approve privileges, it can import privilege data from an external system and enforces it within the EHR.
Integrating privilege lists is a complex process. It involves mapping CPT and ICD codes between the credentialing solution and the privilege lists in Epic. Successful implementation requires careful planning, coordination, and collaboration across multiple departments, with clearly defined milestones to ensure the medical staff’s ability to provide services is not disrupted.
Key factors to consider when planning this type of optimization project include:
- The number of delineation of privilege forms in use.
- How privileges are defined and detailed for providers during initial credentialing and recredentialing.
Here’s how it works:
1. Source of Privilege Lists
- Privileges are designed in a credentialing system that can be exported in a format consumed by the EHR.
- These systems determine which procedures or services a provider is allowed to perform.
2. How Epic Receives Privilege Data
- Integration through HL7 (using STAFF or PRV segments), flat files, or APIs.
- Stored in the Provider Master File (SER) or related tables.
3. How Epic Uses Privileges
- Blocks or warns if a provider attempts to schedule or document a procedure outside their privileges.
- Restricts certain workflows or OR schedules based on privileges.
- Generates reports for Joint Commission compliance.
4. What Epic Does Not Do
- Validate privileges or manage approval workflows-that stays in the credentialing system.
Example:
If Dr. Smith is privileged only for laparoscopic appendectomy, Epic will:
- Allow scheduling/documentation for that procedure.
- Block scheduling a laparoscopic cholecystectomy if privileges do not include it.
Why Epic’s Move Matters (But Isn’t the Silver Bullet)
Epic stepping into credentialing signals something important:
Credentialing is no longer just a back-office function-it’s strategic.
Errors here cascade into delayed revenue, compliance risks, and operational inefficiencies.
But here’s the reality:
No single software, automation, or AI solution can eliminate the systemic challenges in credentialing and enrollment, such as:
- Payer policy shifts (e.g., underpayment issues, prior auth changes, CMS Method II updates)
- Constant legislative updates
- State-by-state telemedicine rules
- Medicare, Medicaid, and commercial payer complexities
Each change requires:
- System updates
- Workflow redesign
- Staff retraining
- Budget for implementation and support
And while Epic brings powerful integration, payer enrollment bottlenecks remain policy-driven, not technology-driven.
Where an EHR Adds Value to Credentialing
- Better access to OPPE and quality data
- Smoother onboarding workflows after board approvals using automation to build or inactivate provider profiles
- API-driven integrations to support Medical Staff Professionals (MSPs)
An EHR will complete platforms like MD-Staff, CredentialStream, Medallion, MODIO, QGenda, but it won’t replace the need for strategy and expertise.
The Bottom Line
Technology is part of the solution, not the whole solution.
Healthcare organizations need more than integration-they need a partner who understands payer requirements, compliance risks, and operational realities.
At Cred2Bill, that’s where we come in:
Helping you build credentialing and enrollment strategies that keep pace with regulation, reduce revenue risk, and work seamlessly with technology-Epic included.
Ready to rethink credentialing beyond software?
Contact Cred2Bill for a strategy that works in the real world.
