Avoiding Common Credentialing Pitfalls

Medical credentialing is a simple process, at least on paper. You send information about a provider’s qualifications – work history, education, certifications, licensure, and so on – to a payer for review and verification. After they go through a thorough vetting process, the payer confirms the provider and begins reimbursing him or her for services rendered.

In reality, it is not nearly that easy. In fact, according to the New England Journal of Medicine, the medical industry wastes about one BILLION dollars a year just due to the lack of standardization and coordination of administrative policies and procedures. That’s a large figure, and it speaks to the amount of waste tied up in supposedly simple administrative activities.

With that in mind, here are 10 common mistakes when it comes to credentialing and enrollment and how to avoid making them.

Not Allocating the Necessary Staff

Credentialing is a labor-intensive process. You need people to manage the workflow, enter the data, fact-check the reporting, and the list goes on. Not having the appropriate allocation of staff can lead to mistakes, which will lead to delays, which will ultimately impact your revenue.

Avoiding this mistake boils down to not underestimating the amount of work credentialing at your practice requires. Dedicate a resource to submitting, monitoring, and maintaining provider credentials with your payers, centralize the credentialing function for your organization if you have multiple locations or lots of providers, or outsource your credentialing workflow to industry experts who can spare the resources to manage it.

Not Challenging Delays

Even if everything is 100% accurate, you will still experience delays from payers due to their backlog of applications. Challenge these delays. Confirm with your payers that your applications are received, follow up to ask for a status, and even provide copies of FedEx and/or email receipts. As the saying goes, the squeaky wheels get the grease. By staying on top of your payers, you can ensure that the process moves forward as quickly as it can.

Letting CAQH Lapse

CAQH profiles need to be re-attested, updated, and the credentialing contacts kept current. By being proactive and updating CAQH right when you receive an updated insurance, license, or DEA document, you can avoid delays.

Not Creating a Sustainable Process

Develop policies and procedures to help manage your credentialing process. They should address the “who, what, when, and where” of commercial and government payer credentialing.

For example, you may want to require providers to maintain a current profile in the CAQH database. Since it houses most of the information needed for credentialing, if a physician keeps his or her profile up to date, then the person responsible for credentialing can access information from one central location, limiting the need to hunt down items from various sources. Make sure your process is clearly understood by staff and repeatable every time credentials need updating.

Failing to Build Relationships

Strong relationships with payers and plans are key. That way if there are problems or issues with a provider’s application, you can pick up the phone and resolve them in real time, instead of waiting for a letter or, even worse, receiving no communication at all.

Good relationships can also allow an organization to be more proactive. Having a strong rapport can be helpful on many levels. If you have a good relationship, the rep might give you a heads up when things are changing so you know ahead of time instead of after sending in all the information.

Not Knowing How Plans Work

Commercial plans are different payer-to-payer and state-by-state, and what may work for one may result in delays for another. Understand the individual requirements and nuances for each of the plans you work with and the regulations for your state – particularly when it comes to timely credentialing laws – to avoid problems.

Sending Incomplete Applications

One of the most common mistakes associated with credentialing is a lack of attention to detail. Application errors lead to delays and potentially denials. A typical credentialing application will ask for practice address, phone, fax, contact information, services provided, copies of your licensure, employment history, average patient profile and any records of past legal troubles regarding your medical practice.

Starting Too Late

Many practices get started too late, which can be a matter of success and failure for your practice. At a minimum, you want to give yourself at least 90 days. Realize that you are working on someone else’s timeline – your payer’s.

The responsiveness of the payer to your application will be determined by their workload and their motivation to add new providers to their network. In short, the process is probably going to take longer than you think, so build in extra time and get started early.

Not Following Up

Even if you are not experiencing a delay, still make every effort to contact your payers and follow up on the process. Once again, squeaky wheels get the grease. It is to your benefit to stay in front of your payers and ensure that they are processing your applications. Make follow-up a routine and stick to it until the application is approved and participation is secured.

Not Seeing the Big (RCM) Picture

Credentialing and enrollment are the starting point for your practice’s whole revenue cycle. A weak credentialing effort can have serious financial ramifications for your practice. The price you pay is lost revenue, unhappy patients, delayed payments, out-of-network services, and denials, combined with coverage and referral issues. It is important that you do not lose sight of the revenue cycle during this process.

Credentialing can be frustrating and cumbersome, but, by providing it the attention that it deserves and understanding that it is the foundation upon which your revenue cycle is built, you can minimize the common mistakes that ultimately cost your practice money.

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