Credentialing is a critical process where new medical practices are licensed to allow insurance payers to give them consent to bill for services. Nevertheless, numerous new practices are faced with frequent credentialing mistakes that result in delays, payer refusals, and the denial of claims.
These mistakes may create disruptions in the revenue cycle as well as patient care. These pitfalls need to be learned and prevented to achieve a seamless approval of the credentialing process. This blog will focus on the best credentialing errors new practices commit, common payer rejection reasons, and beneficial tips in avoiding credentialing failures. Even small steps taken early on can guide your practice to make you successful in your enrollment process and avoid unnecessary delays, which are expensive.
What Is Credentialing in a New Practice?
Credentialing in a new medical practice is a formal procedure of evaluating the qualifications, experience, and professional experience of healthcare providers with a view to approving their status to provide services before insurance payers can offer reimbursement credits. This entails gathering and reviewing necessary materials like medical licenses, board certifications, education history, liability insurance, and work credentials to ascertain adherence to the payer and regulatory standards.
Credentialing in new practices is the basis step that will allow the hospitals to become part of insurance networks, get authorization to provide care, primarily to the patients, and shorten the need to comply with legal and industry standards.
Why Credentialing Is Essential for Revenue and Compliance
It is also essential to know why credentialing is crucial to healthcare providers before we look at its most common errors. Credentialing is an official verification mechanism by which providers are validated in line with the required qualifications and standards as mandated by insurance payers, regulatory bodies, and healthcare facilities.
The main reasons why credentialing is essential are:
- Insurance Reimbursement: Providers should be accredited to invoice insurance companies and get compensation for services rendered. Claims are denied regularly without proper credentialing.
- Patient Confidence: When patients know the provider and they have been authorized in their insurance coverage, they usually trust them and seek care.
- Regulatory Compliance: Credentialing is a common requirement under both state legislation and facility policies as a compliance strategy to ensure quality and safety.
- Revenue Integrity: Incorrect or partial credentialing may lead to widespread delay in payment, which negatively affects the financial sustainability of novel practices.
The effective use of credentialing not only results in time-eligible reimbursements but also creates a basis of credibility for the professionals, both to the payers and to the patients. On the other hand, the mistake of credentialing can cause significant losses in revenue and efficiency in operations.
Common Credentialing Mistakes New Practices Make
1. Missing or inaccurate documentation filing.
Incomplete of inaccurate documentation is one of the most common credentialing errors. The payers will demand certain and verifiable ones, such as:
- Current medical licenses
- Board certifications
- DEA registration
- Malpractice Insurance certificates.
- Resume or curriculum vitae (CV).
- Absolute Hospital Affiliations and Privileges.
2. Not knowing Payer-Specific Requirements
All payers possess distinct enrolment criteria and forms, and non-full compliance will lead to the application being denied. New practices usually presuppose that a single credentialing application would be appropriate to all payers, which is not true. As an illustration, Medicare must have enrolment on PECOS, and certain non-government insurers have proprietary portals or provide credentialing to third parties.
Failure to do what is needed by payers during application development results in recurring refusals and piecemeal credentialing.
3. Ineffective Monitoring and Management of Credentialing Applications
The credentialing processes can take 90 to 180 days or above, and most new providers do not have effective tracking mechanisms in place to keep their status as a tracked process. The failure to receive follow-ups results in a lack of requests for any further information or slowness in receiving requests, thereby increasing credentialing failures.
4. Improper or out-of-date provider information
The credentialing processes can take 90 to 180 days or above, and most new providers do not have effective tracking mechanisms in place to keep their status as a tracked process. The failure to receive follow-ups results in a lack of requests for any further information or slowness in receiving requests, thereby increasing credentialing failures.
5. Neglect or Underestimation of CAQH ProView
CAQH ProView is a database of credentialing commonly used by most payers. The new providers do not construct and update their CAQH profiles individually or issue authorisations to allow access to the information by the payers. Such oversight leads to delays as the payers cannot access the necessary details to get the required details, and this extends credentialing time and chance of rejection.
Knowledge of the tasks of CAQH and timely updates of the profile will avoid numerous payer rejection causes.
6. Absence of Training or Experience in Credentialing
Credentialing is a professional administrative operation that presupposes understanding payer regulations, necessary documents, and time frames. Most of the new practices leave staff with little or no training on the work of credentialing or underestimate the amount of work required.
The absence of dedicated and knowledgeable staff or outsourcing credentialing experts ensures the growth of credentialing errors and acts as a source of expensive credentialing failures.
7. Failure to plan for Recredentialing and Ongoing Maintenance
Credentialing does not take place once. Payers require providers to be recredentialed every 2-3 years. Recredentialing deadlines cannot always be traced under new practices, and in effect, lapses in credentialing prevent reimbursements or cancel provider networks.
Such disruptions can be avoided by adopting a continuous monitoring mechanism.
8. Not Verifying Credentialing Approval Before Billing
It is another error to believe that credentialing is not done until formal payer approval is received. Billings are occasionally initiated before active enrolment is ascertained, and such standages lead to claim refusals and payment delays.
How to Avoid Credentialing Mistakes: Best Practices for New Practices
Establish a Credentialing Checklist and Documentation Review Process
Make up a working list describing every needed paper in accordance with every payer, and check all documents in your checklist before submission. The frequency of credentialing file audits will prevent errors and inaccuracies.
Individualise Applications by Payer
Learn necessary credentialing requirements due to a specific payer, obtain those requirements via research or consultation, and apply them. Ensure that payer websites, manuals, or contacts are used.
Use a credentialing Tracking System
Introduce credentialing software or spreadsheets to track the dates of submission, follow-up, expiry dates, as well as streaks to renew. Consistent tracking should be done by handing out responsibility to a credentialing coordinator.
Start Credentialing Early
Start the process of credentialing early, before the patient service start dates, not less than 90-120 days. This will give them buffer time to rectify or resubmit a submission they may be asked to do by the payer.
Keep CAQH Profiles and Authorisation
Upon request, update CAQH profiles with up-to-date information and respond swiftly to the attestation requests. Preemptively grant access to all the payers who require an interface with your profile to speed up the processing.
Maintain Provider Information up to date
Periodically verify every provider-related financial information, like licenses, addresses, and employment records, to confirm the updated status of credentialing said documents.
Credentialing, Monitoring, and Planning
Follow calendar reminders to remember recredentialing dates and file renewal applications long before they come up, so you don’t run out.
Check Enrolment Corroboration Pre-billing
Submit claims only with a formal notification of credentialing approval, and check payer portals for enrollment status occurrences.
Payer Rejection Reasons and How to Address Them
Knowledge of common reasons behind payer rejections can assist new practices in ensuring that they do not fall into common traps:
- Poor records: Turn work in without forms.
- Lapsed license or insurance: Refresh and retransmission of existing documents.
- Information mismatch: Matchmaker applications to keep providers on track.
- Lacking signature or authorisations: Get a complete signature of forms.
- Lack of accomplishments in background investigation or sanctions verification: Share payer screening mandates.
Conclusion
Credentialing errors tend to occur when new medical practices but can be adequately avoided by carefully tending to the preparation issue, grasping the specifics of the payment systems, and paying careful attention to the follow-up.
Best practices will reduce errors in credentialing (through submission of applications early, compliance with payer requirements, strong document management, and frequent monitoring of recredentialing), and speed of cycle of practice revenue. Credentialing quality guarantees not just payer approvals to new providers but also produces a faster claims-processing cycle and better continuity in patient care.
FAQ - People Also Asks
What is a credentialing issue?
It refers to the direct confirmation process of a provider with the source. This is where it all goes wrong, however, because of a dependence on photocopies or scanned reports instead of actual verification. Lack of verification of all critical credentials. Failure to monitor the expiration dates and renewal conditions.
What are three Key pieces of information needed for credentialing?
The initial step in credentialing is the gathering of the necessary documents and data, such as educational certificates and licenses, residency completion records, and work history.
What is CAQH?
The Council on Affordable Quality Healthcare (CAQH) is an organisation brought into existence by health plans nearly 25 years ago with the idea of making healthcare work better.