Providers: Are You Losing Revenue Due to Bad Credentialing?

Bad credentialing can hurt your practice in ways you might not expect:

Immediate Financial Impact

When your credentialing isn’t in order, insurance companies won’t pay for services rendered. It’s that simple. Even if you provide excellent care, even if the patient has valid insurance, if you’re not properly credentialed, you’re essentially working for free. And unlike some billing issues, these denials typically can’t be appealed or resubmitted once the credentialing is fixed.

Lost Opportunities

Many providers don’t realize how credentialing issues can limit their patient base. Insurance companies regularly update their provider directories, and if your information isn’t current, you might not show up in searches. That means potential patients who could benefit from your services might never find you. In today’s competitive healthcare landscape, can you afford to be invisible to potential patients?

Administrative Burden

When credentialing problems arise, your staff spends countless hours trying to fix them. Not just an inconvenience; a real cost to your practice. Every hour your team spends untangling credentialing issues is an hour they could have spent on far important tasks.

I bet at least one of these will sound familiar:

Missing Renewal Deadlines

Credentialing isn’t a one-and-done process. Each payer has its own renewal timeline, and keeping track of these deadlines can be overwhelming. Miss a renewal deadline, and you might face a gap in coverage. Meaning, services provided during that gap won’t be reimbursed.

Incomplete or Inaccurate Applications

It’s amazing how one small error on a credentialing application can cause major headaches. A transposed digit in your NPI number, an outdated phone number, or a missing signature can delay the entire process by weeks or even months. During that time, you’re either not seeing patients from that insurance company or providing services you can’t bill for.

Failure to Update Information

Did you move offices? Get a new phone number? Change your name? Any change in your practice information needs to be reported to every insurance company you work with. Many providers don’t realize how crucial this is until claims start getting denied because their information doesn’t match what’s on file.

Not Understanding Payer-Specific Requirements

Each insurance company has its own credentialing requirements and processes. What works for one payer might not work for another. For example, some payers require additional certifications or training documentation that others don’t. Missing these payer-specific requirements can lead to delays or denials.

Beyond the obvious impact of denied claims, credentialing problems can create a cascade of financial issues:

Patient Satisfaction and Retention

When patients get stuck with unexpected bills because of credentialing issues, they’re not happy. Unhappy patients tend to find new providers. Even if you eventually sort out the credentialing problem, the damage to your patient relationships might be permanent.

Staff Morale and Turnover

Your administrative staff bears the brunt of credentialing problems. They’re the ones who have to deal with frustrated patients, spend hours on the phone with insurance companies, and try to fix issues that could have been prevented. This added stress can lead to burnout and turnover, which creates its own set of costs.

Opportunity Cost

While you’re dealing with credentialing issues, you’re not focusing on growing your practice. The time and energy spent fixing these problems could have been invested in marketing, improving patient care, or developing new service lines.

Here’s how to protect your revenue through better credentialing practices:

Create a Credentialing Calendar

Develop a comprehensive calendar that tracks all your credentialing deadlines, including:

• Initial applications
• Renewals
• Revalidations
• Required updates
• Expiring certificates or licenses

Use this calendar to set reminders at least 90 days before any deadline. This gives you plenty of time to gather necessary documentation and submit applications.

Implement a Standardized Process

Don’t leave credentialing to chance.

Create a standardized process that includes:

• Checklists for each payer’s requirements
• Document collection procedures
• Quality control measures
• Follow-up protocols
• Emergency procedures for urgent situations

Invest in Technology

Consider using credentialing software or services that can:

• Track deadlines automatically
• Store documents securely
• Generate alerts for upcoming renewals
• Maintain accurate provider information
• Create reports for monitoring and compliance

Designate a Credentialing Specialist

If your practice can afford it, having a dedicated credentialing specialist can be a game-changer.

This person can:

• Own the entire credentialing process
• Build relationships with payer representatives
• Stay current on changing requirements
• Identify and address issues before they impact revenue
  

Here’s how to maximize this resource:

Regular Updates

Don’t wait for the quarterly attestation reminder. Make updating your CAQH profile a monthly task. This ensures that when payers pull your information, it’s always current.

Complete Documentation

CAQH allows you to store all your credentialing documents in one place.

Take advantage of this by:

• Uploading all required documents promptly
• Setting reminders for document expirations
• Keeping contact information current
• Regularly reviewing stored information for accuracy

Authorized Access

Make sure the right people in your organization have access to your CAQH profile.

This might include:

• Practice managers
• Credentialing specialists
• Administrative staff
• Billing department representatives
  

Instead of waiting for credentialing problems to impact your revenue, take these proactive steps:

Regular Audits

Conduct quarterly audits of your credentialing status with all payers.

Check for:

• Upcoming renewals
• Missing information
• Outdated documents
• Accuracy of provider directories
• Participation status in all needed networks

Build Relationships

Develop relationships with provider relations representatives at your major insurance companies.

Having a contact person can be invaluable when:

• You need to expedite credentialing
• There are problems with your application
• You require clarification on requirements
• You need to check on application status

Document Everything

Keep detailed records of all credentialing activities:

• Submission dates
• Communication with payers
• Follow-up attempts
• Changes to provider information
• Renewal dates and requirements

Monitor Claims Closely

Watch for patterns in claim denials that might indicate credentialing issues:

• Sudden increases in denials from specific payers
• Claims denied for provider not recognized
• Out-of-network processing when you should be in-network
• Denials for incorrect provider information
  

Have a plan ready to minimize revenue impact:

Immediate Actions

When you discover a credentialing issue:

1. Contact the payer immediately
2. Document the problem and all communication
3. Request expedited processing if available
4. Determine impact on scheduled patients
5. Create a plan for handling affected appointments

Communication Strategy

Develop a communication plan for:

• Affected patients
• Staff members
• Referring providers
• Insurance companies
• Other stakeholders

Financial Impact Mitigation

Consider options for minimizing financial impact:

• Payment plans for affected patients
• Cash pay options with insurance submission by patient
• Referral to in-network providers when necessary
• Documentation for future appeals if possible
  

Stay ahead of the curve by preparing for these emerging trends in healthcare credentialing:

Digital Transformation

The future of credentialing is digital.

Expect:

• More automated verification processes
• Blockchain-based credential verification
• Real-time status updates
• Integration with practice management systems

Standardization Efforts

Industry groups are pushing for more standardized credentialing processes:

• Universal applications
• Standardized renewal timeframes
• Consistent documentation requirements
• Streamlined verification processes

Increased Scrutiny

As healthcare costs continue to rise, expect:

• More frequent audits
• Stricter verification requirements
• Enhanced monitoring of provider information
• Greater emphasis on ongoing compliance
  

Here’s your action plan:

Assess Your Current Status

• Review all provider credentialing files
• Identify any gaps or upcoming deadlines
• Check provider directory listings
• Audit recent claim denials for credentialing issues

Create Your Infrastructure

• Develop your credentialing calendar
• Implement tracking systems
• Assign responsibilities
• Create standard operating procedures

Train Your Team

• Ensure all relevant staff understand the process
• Provide access to necessary resources
• Establish clear communication channels
• Create accountability measures

Monitor and Adjust

• Regular review of processes
• Track credentialing success metrics
• Adjust procedures as needed
• Stay informed about industry changes
  

Additional Resources

For more information about protecting your practice’s revenue through proper credentialing, consider these resources:

• Your state medical society’s credentialing guidelines
• CAQH ProView tutorials and user guides
• Insurance company provider relations departments
• Healthcare administrative consulting services
• Professional credentialing organizations