Ep. 115: Nyleen & Shannen – Smarter Credentialing Strategies
Here’s what to expect on this week’s episode. 🎙️
Credentialing isn’t just about checking a box – it’s about keeping your patients and center safe.
In this week’s episode of This Week in Surgery Centers, Nyleen Flores (CEO of MedElevate) and Shannen Reyes (President of Advanced Quality Compliance) unpack what really goes into credentialing at surgery centers.
Here are a few takeaways:
✅ Credentialing goes far beyond license verification—ongoing peer reviews, background checks, and privilege management are essential.
✅ Excel may still be common, but if you’re managing more than a handful of providers, it’s time for software + dedicated support.
✅ A common deficiency cited by surgery center accrediting bodies? Credentialing.
✅ An example of credentialing gone wrong: one missed hearing aid change led to a bowel perforation because no one tracked changes in provider status. This could have easily been avoided.
✅ Patients can and should Google their doctor, check their state’s medical board, and even set up a Google Alert for their provider’s name prior to having a procedure done.
✅ Nyleen and Shannen just launched Credentialing Chronicles to shed light on credentialing pitfalls, real-world cases, and how to protect your ASC and your patients.
Give the full episode a listen for even more insights!
Episode Transcript
[00:00:00] Welcome to this week in Surgery Centers. If you are in the ASC industry, then you are in the right place every week. We’ll start the episode off by sharing an interesting conversation we had with our featured guest, and then we’ll close the episode by recapping the latest news impacting surgery centers.
We’re excited to share with you what we have, so let’s get started and see what the industry’s been up to.
Erica (2): Hi everyone. Here’s what you can expect on today’s episode. Nyleen Flores, CEO of MedElevate Solutions, and Shannon Reyes, president of Advanced Quality Compliance are both on today to talk all about provider credentialing. Nile and Shannon both have decades of experience with credentialing and have helped countless surgery centers better organize their credentialing processes, ultimately helping them mitigate risk and keep patients safe.
Together we’ll go through common misconceptions and the best systems and tools to use for [00:01:00] credentialing. And if this isn’t enough credentialing info for you, we’ll also cover the new podcast they recently launched together called Credentialing Chronicles.
After my conversation with Nylene and Shannon, we will switch to our data and insights segment. You’re likely familiar by now with our full state of the industry report, but we’ve recently released 12 new benchmarking reports that are shorter, solely focused on the data and take a deeper dive into one single specialty at a time.
So today we’re spotlighting cardiovascular, ASCs. So I’ll walk through 10 key metrics from 108 CV centers that represent roughly 9,100 unique cardiovascular cases. I hope everyone enjoys the episode and hears what’s going on this week in surgery centers.
Erica (2): Nyleen Shannon, welcome to the podcast.
Nyleen: Hey. Hi. How are you?
Erica (2): Good, good. Can you please tell our listeners a little bit about yourselves, ? I. [00:02:00]
Nyleen: Yes. So, I’m Nyleen and I have been in the a SC space probably for the last six years or so, used to run a surgery center. I’ve been doing credentialing for about I.
17 years and met Shannon about a year ago. And so we became fast friends and decided to do a really fun endeavor together. Since we are in love with this thing called credentialing Shannon, what about you?
Shannen: I’ve been in credentialing same for about 22 years. Came out of corporate America and opened up my CVO this year. Our CVO celebrating 10 year anniversary. Women owned baby NCQA certified. All that good stuff.
Erica (2): Congratulations. That’s awesome. So given all of that expertise, can you please give us the 32nd overview of what credentialing is?[00:03:00]
Nyleen: So credentialing that’s a lot in 30 seconds. Only because the word credentialing is actually used for different kinds of credentialing. So there’s credentialing that a lot of people know. Yeah. With like insurance companies. So you have to credential with an insurance company to enroll. Right? So it’s like an enrollment, it’s called payer enrollment, and that has a credentialing process.
And then there’s credentialing where we are checking and verifying the credentials of the doctor that walks in to see you. Did I miss anything Shannon?
Shannen: Yeah, the latter is more done on the hospital surgery center approach, and it’s just ensuring that the doctor has good peer references, good education, that those things can be verified licensure and that, really looking for board actions, NPDB actions, things of that nature on the ladder, part of the credentialing that Nylene is talking about.
Erica (2): Perfect. Yeah. So what are some of the most [00:04:00] common misconceptions that surgery centers have about credentialing?
Shannen: It’s
Erica (2): easy.
Nyleen: Oh, miss. Yes. My software does it for me. I have a database. A one.
Shannen: Yeah. I got sold this expensive, awesome database.
Nyleen: Yeah the computer does it for me.
Shannen: Exactly. I think really too that it’s just that it needs care, it needs organization, it needs constant monitoring and that’s something that’s very important in credentialing.
And I think some, sometimes that’s lacking and it creates a little discourse.
Erica (2): Sure. So are there specific or just general kind of systems and tools that you would recommend for successfully tracking, credentialing, tasks, deadlines, all of that?
Nyleen: Well, obviously if you have a CVO they do it for you.
So yes, there’s that option. You can hire a third party service to do it for [00:05:00] you or an agency that can run it for you.
So that’s one option. The other option is having a database, of course, to monitor and alert you when things are. Firing, things like that. But most importantly, it’s really educating your administrator, especially in the surgery center world and or the business office, whoever is handling the task that we are calling, credentialing and verifying that a doctor is clinically competent to perform along with your clinical leadership to ensure that they’re reviewing.
Peer review and ongoing monitoring of these doctors, so having a good system, processes, and then any software that can help you with that is ob Obviously the best way to do it.
Shannen: And I’d say keeping up too, gotta keep up with it. Yeah. It’s not a one and done. You gotta, it’s ongoing every month, we’re looking, tracking.
Sure.
Erica (2): Do you find that is it possible, I wouldn’t, it doesn’t sound like it would be a best practice, but is it [00:06:00] possible for a surgery center to manage this in-house without any software or tools to support them or not really?
Shannen: Well, I, what we find is that a lot of people are doing that currently using an Excel spreadsheet document.
That’s what all of us used to use back in the day before all of the thousands of credentialing softwares came on board. And so, yeah, it’s possible people are doing that every day. And, software companies are beating down their doors saying, let me get you over to this software. But is it advisable, depending upon your provider staff, if you have five providers, then yeah, it’s completely possible.
If you have, let’s say you’re tracking 20, over 20 providers, you guys are anticipating growth, things of that nature, then at that point you’re gonna need to go ahead and transition over. To a software. And remembering that the software doesn’t come with the support of managing the software.
So you have to have a dedicated person either outsourced to on staff that knows your software, knows how it works, knows everything that’s coming in and outta that software.
Nyleen: Yeah, for sure. Definitely. [00:07:00]
Erica (2): Gotcha. So if a center currently is behind or disorganized with their credentialing or just has concerns, what is the best way for them to get back on track?
Where can they start?
Shannen: Even like a company like, Nyleen’s they look at messes like that, right. And they say, this is what you should do. And then they advise after the assessment of say, Hey, maybe this part you can outsource, Hey, maybe this part we can, look at a different biller.
Your biller’s not really doing the best. And they really organize all that. For you. That’s the greatest approach. The other thing is bringing in somebody that’s familiar with the credentialing world and being able to give you that assessment.
I think a lot of times people think they know what’s going on, but then when they call all the payers and they realize that the person never submitted applications, they’re getting denials, they’re, AAA HC is knocking down the door and they don’t have files. It, it becomes a red fire alarm at that point and you don’t want things to get to that.
My love you. You don’t want it, Erica.
Nyleen: Yeah. The last thing you want is that is a surveyor to come in and be like, [00:08:00] oh my goodness, where is the NPDB before privileges were granted? Where’s your privilege form? So the problem is if you look at the publications from the accreditors, so whether that’s Joint commission D-N-V-A-C-H-C, triple HC.
All these accreditors that are, monitoring our surgery centers and we pay so much money to be accredited by their number one deficiency is always credentialing when it comes to surgery centers. And that’s because it’s not given the level of attention. And again, I’m gonna tell you a hundred percent, that’s my opinion, even though it’s proven with documentation.
But let’s just say it’s number one most ignored and. If you ask me one of the most critical roles within a surgery center to ensure that we’re providing best practice and safest care to our patients. Sure.
Shannen: And I would listen to Nyleen because she literally has about 12 or 15 certifications behind her name.
You’re so, I’m [00:09:00] just saying. She is the certification directory of all certifications. So if you’re gonna listen to somebody, it would be Nylene Flores. Okay.
Erica (2): Yes. Every time I go to tag you on some in something Nile, on LinkedIn. Yeah. Yeah. I,
Shannen: I get all the,
Erica (2): The acronyms after, but. Well deserved.
Shannen: It’s three sentences long, right? Erica’s, that’s what I tell her all the time. But we love you and all your knowledge. Everybody else does that. Nobody else has that. Nyleen.
Erica (2): So what are some of the biggest risks or consequences of poor credentialing practices?
Nyleen: There is a lot of crazy stuff happening in surgery centers because it’s more of I’m your buddy. I am buying in, I have rights because I own part of the surgery center. I can do whatever I want. And so what happens is, while we understand that physicians do a lot of training, [00:10:00] that doesn’t necessarily mean that an orthopedic surgeon can take out a gallbladder, right? So surgery isn’t surgery. So there has to be processes in place. To not only check doctors initially, but check them ongoing. We can get into some juicy stories, but there’s things that change and that’s why Shannon was talking about like ongoing problems.
Give you an example. A doctor that’s aging, he’s a GI doctor, for example, he’s aging and he went from not wearing hearing aids to having to wear hearing aids, right? So that’s a change in status that can directly affect patient care. And in the case of one doctor out of Florida. He ended up perforating a bowel because he didn’t hear somebody saying something.
So he injured a patient. Right. Because it was a change. And that can all be tracked through credentialing and peer review. So that’s, and [00:11:00] monitoring one of the reasons. And monitoring. So things change. Education changes. The students and the doctors that are coming outta school now are learning very different techniques and equipment than doctors who’ve been practicing for 30, 40 years.
So, I don’t know, Shannon any other biggest
Shannen: consequence. Yeah, I know. I, Nyleen’s always gonna talk to you about privileges all day. ’cause she, that is her passion. That’s, I know. Yes. I’m gonna talk to you about monitoring and background checks and making sure, sanctions and making sure that yes, you do a background check when that provider first comes on. But there’s a lot of people that don’t. Like Nyleen said, this is my buddy. They come in and we’ve been, we’ve known them forever. But then you find out, you do a background check. They’ve had three W DWIs, or whatever that is.
You start seeing patterns on behavior that can directly affect your surgery center and then you unknowingly. Because you’re not doing due diligence or bringing in a risk to something that you’re trying to [00:12:00] grow very hard and you don’t wanna do that. And so that’s what I say. I say do your initial background checks, which are very important, but every time on re-credentialing, background checks should be included as well because things change in that area.
And you want to know the risk that are in your surgery center.
Erica (2): Sure. Those are such interesting examples, like especially the hearing aid. I would never even consider something like that being part of credentialing. I just think, are your licenses up to date? You have all your credit, are we good there?
Kind of what? It sounds like most people think you’re just checking the box and you’re not really thinking of all these other.
Criteria that go into it. Yep. Yeah, exactly. Yeah. So you guys recently launched your own podcast credentialing Chronicles to cover this.
Yes. Why did you feel it was important to do so?
Nyleen: All right, Shannon, you start off.
Shannen: Yeah, definitely. I love credentialing and the one thing about credentialing is that we are all held, all medical staff [00:13:00] professionals, that’s what we fall under, are held to a very high level of con confidentiality and privileged data.
- And so because we’re high held to those very high standards, there’s really not a way or an avenue to talk about it. You really can’t go to your husband and say, oh my God, guess what? This da da. He don’t understand what you’re talking about. You really can’t disclose any names.
And so it just becomes like this loop of just keeping it in your head and just moving on with your life. But at Credentialing Chronicles we decided that, Nyleen and I could talk about situations that help medical staff professionals, number one. Because we can talk about cases that have been adjudicated or public finding records.
So they’re not actually providers that we’ve credentialed. They’re all public records, so nobody can ever say, you guys, are out here giving confidential information. And then with that case or that episode that we’re talking about, we try to break it down into how does this help medical staff professionals?
How does this help providers? Because if a provider gets. Caught up in something, has to disclose something. How [00:14:00] do they go about that? That’s a very sensitive topic. And then on the other hand and the most important hand, how do patients protect themselves? And, you see the doctor coming outta Columbia university that the universities had to pay $750 million because of what he’s done to female patients.
We literally are covering that on episode nine, coming up this week about how he did this and what he did. And Nyleen really just throws out all the tea, all the gossip on that case. And then, but again, we wrap it up at the end on how we can really help. I.
Nyleen: Yeah. And the thing is if you go, even just through our first few episodes that we’ve done, one of the examples is like drinking while intoxicated.
We highlight the example of, look, there’s a doctor who didn’t survive getting a DUI. In other words, it was life. It was life ending, changing, career ending anyway. Changing. And then you have a doctor who did all the hoops.
And so we go through all these hoops that she had to do in order [00:15:00] to go back into a doctor in good. Standing. And then we give you an example of a current case of a doctor who just got arrested. This is everything she had to do. And the doctor was arrested at six and she was at work at eight 30.
You can’t make that stuff up. Wow. Yeah, so this is the kind of stuff we wanna talk about, but most importantly, we wanna bring awareness to the fact, that when you walk into an emergency room, when you walk into a surgery center, you feel confident that the doctor, you’re going to. C, the doctor that has a white coat on or scrubs is really qualified to do what they say.
And there’s a group of people out here that have been trained Yes. And studying, yes. Get certifications to make sure that we’re doing this according to all the regulations, all the federal regulations. Exactly. All the state regulations. And the accrediting bodies to make sure that you as a patient are safe.
So we wanted to create a safe space to gossip about it, [00:16:00] make it fun, but also make it interesting and learn, and hopefully the public learns something. And we get everyone engaged into this beautiful, most amazing thing called credentialing.
Shannen: Exactly.
Erica (2): I love it. So putting my patient hat on, if I do know I’m gonna have surgery in a few weeks is Google my one and only friend here?
Or what other services do I have to make sure the doctor is credentialed?
Shannen: Great question. Number one whatever state you’re in, you’re able to go to that medical board and actually look up your doctor. And so, number one, you wanna go there and make sure that your doctor, it’s a simple name search.
You don’t need a lot of information. And you can see does your doctor have current board actions passed? Board actions. Again, not all medical boards played by the same reporting statutes. But it’s a good start. The other thing, go ahead Nyleen. What else did we talk about on the show?
Nyleen: You’re the one who showed me, which I didn’t know about this, so talk to her about [00:17:00] the Google Alert. ’cause I think that’s the coolest thing ever.
Shannen: Yeah, that’s the other thing is the Google alert. You go in there, any doctor that you’re seeing, you want a Google alert, the practice name, the go the doctor, and if he is or she is found in A DUI and it does come out and they have the body cam footage of your doctor taking a sobriety test.
You’ll be able to see that because that’ll come out on YouTube and you’ll get that Google alert.
Nyleen: Hey, and I’m just saying arrest records are completely public, Yes. If you go to your county and you type in a name it’ll come up their arrest records. So you can definitely search that. The other thing is too, is don’t go by the first page in Google.
So there’s a doctor right now that if you Google him. First page of Google has everything positive, all of the, oh, he’s a wonderful doctor. And when you get to page two, you find out, ooh, there’s actually like 19 open lawsuits against this person. So there’s, it’s really interesting [00:18:00] that you can do that.
And just remember, these are public and you can. Get any case that’s settled and it’s public. If you have the Freedom of Information Act or whatever, you can get anything that you want.
Shannen: One thing Erica, I’d like to add really quick, because we, me and Nyleen were talking the other day is about plastic surgeries and we’re doing a little series on the plastic, and I would say for plastic surgery, you all make sure you go out there and check their board, like not the medical board but their board certification.
That is a free verification and you want a board certified plastic surgeon, not these run by the night doctors that are, you’re seeing. Are killing people out there right now. Literally currently,
Nyleen: yes. Yes. Plastic surgery. Beware.
Shannen: It’s crazy
Nyleen: Plastic surgery gone wrong.
Yeah.
Shannen: Well, when you go down the rabbit hole, Erica, it, it is Alice in Wonderland and you are just taken aback by all the information out there. It’s crazy.
Erica (2): Yeah, I can imagine. All right. [00:19:00] We do this every week with our guests. What is one thing our listeners can do this week to improve their surgery centers?
Nyleen: Love your nurses that take care of you. Bring in something to your surgery center after you had surgery and you don’t remember what happened. Just know that they took really good care of you. So go say thank you to the nurses and the team that took care of you.
Shannen: And I would say you, y’all ain’t gonna like my answer. I would say to do a random audit on your credentialing file.
Nyleen: Amen, sister. Okay, I’ll double that one
Shannen: and do a random audit on your monitoring program. And I know that seems crazy and I know it’s like, what? Who wants to do extra work? But when you’re really looking at it.
From an auditor perspective and from wanting to keep, ensure that your compliance is up to date and that you’re on point, that is the best thing that you could do for your surgery center, is to ensure that there are no [00:20:00] credentialing issues and that if anybody comes in there to look over your items, that they see that you take care of this department as well as you’re taking care of the surgery and the, all the things that are done in the or.
Erica (2): Perfect. Yeah. I love it. Thank you both so much for coming on today. I really appreciate it. Definitely thank.
Erica (2): HSC Pathways recently released 12 benchmarking reports with each report, taking a deep dive into one single specialty at a time, comparing data from 2023 to 2024. Using our own unique data set from our clients, we were able to extract data points so that anyone in the industry could compare themselves to their peers.
Two quick disclaimers. We only pulled data from clients who gave us permission, and we omitted any extreme outliers. So today we’re focusing on cardiovascular, asc. And this data represents 9,179 unique cases across [00:21:00] 108 cardiovascular centers. Here’s a quick summary of the 10 metrics we looked at. The first was, or block utilization.
So utilization jumped from 27% in 2023 to 32% in 2024, which is a major gain. But even with that improvement, there’s still lots of room to grow. Many top performing centers considered 70% utilization to be their, the ideal med benchmark that they hit. While the numbers we’re currently seeing are obviously significantly lower than that, it does make sense considering this is a newer specialty and physicians, payers and patients are all still getting comfortable with doing these procedures in an outpatient environment.
On the flip side though, pre-authorization rates dipped from 26% down to 21%. That’s concerning since missing authorizations can delay or even cancel cases, and it’s a reminder that ASCs always need to verify and use integrated [00:22:00] payer tools which can help streamline this process and reduce denials.
Another metric that we looked at was insurance verification. So surprisingly, cardiovascular ASCs are outperforming the industry here significantly boasting a 92% insurance verification rate versus a 78% a industry average. So that obviously means fewer financial surprises and fewer last minute cancellations.
And really, automation here is the key. So many centers are verifying coverage when the case is accepted. Again, the morning of surgery and then at the beginning of every month to catch lapses as well. So this is really cool to see this 92% insurance verification rate, and I’m excited to look at next year’s numbers to see if we could even get higher than that.
And while we’re mentioning cancellations, those are improving too. The cancellation rate drops slightly from 21.4% to 20.6%. Obviously that’s very [00:23:00] small, but we’ll take it at, it’s a very encouraging shift. Patient decision is still the top reason making up 44% of cancellations followed by reschedules. So patient cancellations to obviously to some degree are very much so out of our control.
But there are things we can do, especially in this case. I wonder if there was like a sub reason under patient cancellations if it was concerns like safety concerns, financial concerns, whatever it might be, because some of those patient cancellations maybe can be mitigated simply by more patient education or more communication.
Again, some cancellations are inevitable, but others like missing labs or scheduling conflicts can be avoided with better systems and proactive communication. One pain point though was patient deposit collection rates. So those took a hit from 2023 to 2024, falling from 75% to 66%.
That is a major revenue leak, so collecting patient deposits is hard, no doubt about it, but [00:24:00] you can make it easy for patients to understand what they owe by texting and emailing very simple, straightforward estimates to them. You can also offer convenient ways to pay ahead of time, ideally one to two weeks before the procedure.
All of that just builds trust and helps avoid day of cancellations. All right, let’s talk billing. So one of the biggest efficiency wins in the cardiovascular data that we saw was days to bill. So days to bill dropped from 11 days post data service in 2023 to eight days in 2024. That’s a huge deal. Faster billing just means faster reimbursement.
And this could potentially mean we’re just seeing. A cleaner integration between EHR and billing systems and maybe just a more disciplined approach to coding and charge entry. And that brings us to claim denials. So another win here, denial rates dropped from 18% to 15%. So still not perfect, but definitely trending in the right direction.
Centers that track denial patterns [00:25:00] and address them quickly are the ones getting paid faster and more consistently. So we really wanna keep a close eye on these denial rates. Are there any trends? Why are things getting denied? Is it specific payers? Is it physicians, is it procedures? And really the more you can hone in on that, the more improvement we can see here.
I do think with cardiovascular being an emerging specialty, there’s gonna be a lot of pushback and a lot of red tape. And these payers are gonna make this as, as difficult as I can, unfortunately. So I think you’ve really just gotta keep a close eye on e. All of these metrics, but especially around like prior auth requirements, insurance verification, claim denials, all of that good stuff.
And then on the revenue side, net revenue per case did dip slightly from $4,849 in 2023 to $4,733 in 2024. So definitely not a massive drop, but just one worth watching. Ongoing financial reviews and strong reporting tools can help keep this [00:26:00] metric steady or even push it upward and just help you identify and fix these revenue leaks.
Now even with that slight. Dip though. Cardiovascular procedures when it comes to net revenue per case are still the second highest. So, I think it’s only total joints that is ahead of cardiovascular. So while we hate to see a dip, overall in the big picture of all specialties, this is still significantly higher than the majority.
And finally, case volume held steady. So cardiovascular ASCs are averaging 20 cases per month, which is consistent with 2023. Stability is great, but leaders should keep an eye on growth opportunities, especially as demand continues to rise in this specialty. So there you have it. 10 key data points that should help paint the picture of how this emerging specialty is performing.
I know I flew through that pretty quickly. So if you’re interested in more data points and use cases or just wanna follow along head to our website, go to the resources, drop [00:27:00] down and choose either data benchmarks by specialty or state of the industry report to get your hands on even more data.
And as always, I’ll include all the links directly in the podcast episode notes so you can easily find them. And that officially wraps up this week’s podcast. Thank you as always for spending a few minutes of your week with us. Make sure to subscribe or leave a review on whichever platform you’re listening from.
I hope you have a great day, and we will see you again next week.