What Are The Common Reasons For Provider Credentialing Denials

The problem of provider credentialing denials is one of the big challenges faced by healthcare professionals and organizations. These refusals occur when the insurance payers or healthcare networks decline the application by a provider to join their panel, and in most cases, this results in delayed payments and interrupted patient care. These problems are encouraged by common errors in credentialing (incomplete applications or expired licenses) and cause undue stress. In reality, the statistics indicate that over fifty percent of medical practices experience denials related to healthcare credentialing problems, with one out of three billing denials being direct results of errors in the credentialing processes. This blog talks about the major causes of such denials and provides you with useful tips that can make the process run without a problem.

With the development of healthcare, providers should remain attentive to prevent these pitfalls. As a new doctor joining a practice or as an administrator enrolling patients, the knowledge of these typical credentialing mistakes will help you to take action. We shall get into the details and start with the fundamentals of what credentialing involves.

What is Provider Credentialing?

Provider credentialing credentials the qualification, experience, and adherence to standards of a healthcare professional by the insurance companies, hospitals, and government agencies. It is a process that is demanded by payers such as Medicare, Medicaid, and the private insurers before services are reimbursed. The providers provide elaborate applications, which comprise education history, licenses, certifications, malpractice records, and work experience.

The process guarantees safety and quality care to the patients. Institutions such as the National Committee for Quality Assurance (NCQA) provide policies to which the payers are guided. Credentialing normally occupies 90-120 days, but is usually delayed due to mistakes. The re-credentialing is done every two to three years with an aim of ensuring compliance.

It is where healthcare credentialing problems begin because the providers did not pay enough attention to the scrutiny. Insurers compare the information with the initial sources, which include medical boards and the National Practitioner Data Bank (NPDB). Any irregularity raises red flags, and provider credentialing would be denied.

Why Do Provider Credentialing Denials Happen?

The provider credentialing denials are because the payers are committed to risk management and compliance with the regulations. They reject applications to ensure that their networks are not provided by unqualified or non-compliant providers. Usual causes are incomplete documentation, where payers will have to reject the claim until it is resolved.

The size of the problem is reflected in statistics. Moreover, poor credentialing procedures are a source of more than half of denials in medical practices, as reported in the industry. Not only will this stop revenue, but it will also burden the resources since appeals may take months.

In addition to the money, rejections interfere with work processes. New employees are not able to charge their services, resulting in lost revenues- in some cases, $100,000 per provider during delays. Errors in the credentialing processes exacerbate these problems and make small errors significant disasters. Getting down to details, we will discuss the most common mistakes.

What Are the Most Common Credentialing Errors?

There are a number of errors that providers and administrators make when credentialing. These typical errors in credentialing are simple oversights to system failures. The following are the best causes of provider credentialing denials that are supported by real-life observations.

Incomplete or Inaccurate Applications

Providers usually hand in the applications with missing parts or data entry errors. As an example, they fail to add board certifications or have outdated contact details. These are strictly denied by payers because half-completed forms are out of their procedures.

As an example, when a provider enters the wrong DEA number, the whole application hangs. These medical credentialing problems are time and resource-wasting because the resubmissions prolong the time.

Expired or Lost Credentials

The top of the list of denials is made up of expired licenses, certifications, or malpractice insurance. The providers tend to forget renewal dates and submit applications whose documents have expired. These are automatically denied by payers as they are considered risks of compliance.

Failure to Meet Deadlines

Credentialing is associated with rigorous deadlines, but providers do not submit their credentials on time or repeat the credentialing process. Particularly, new hires have problems when the practices delay the process.

One of the three leading healthcare credentialing concerns is the failure to meet deadlines. This mistake causes a delay in onboarding of weeks or months at a considerable cost to practices. In one instance, billings of $50,000 lost monthly can occur due to a delayed application to a specialist.

Unresolved Background Checks/Inquiries

Reviews demand more information from payers, which is not answered or postponed by providers. Verifications of the background that show hidden problems, such as past sanctions, Common credentialing errors also elicit rejections.

The lack of response to the inquiries of the insurers results in automatic refusal. To prevent such typical credentialing mistakes, providers should act in a timely manner.

What Can Providers Do To Prevent These Credentialing Process Mistakes?

To avoid provider credentialing denials, providers take a number of steps. To begin with, they initiate the process early enough – preferably 120 days before the start date of a new provider. This buffer takes into consideration other delays that are not planned.

This is followed by automation of tracking using credentialing software. Such software as CAQH ProView is a centralized software that helps to cut mistakes in applications. Checklists are used in practices to make sure that an entry is complete by verifying each field of an entry before sending.

Moreover, the providers have a renewal calendar. They remind us about licenses and certifications to avoid their expiration. Continuous training of employees reduces data entry errors and promotes expeditious reaction to payer queries.

It is also beneficial to outsource to experts. Companies dealing with complicated programs, and their reports indicate that the denial rates have decreased by half. Lastly, providers perform internal audits every three months to identify inconsistencies at the initial stage.

FAQ’S

Q1. What are the reasons healthcare credentialing problems have an impact on revenue?

Billings are blocked by denials, and the result is that there will be losses of 40,000-100,000 per provider when delays occur.

Q2. How long does the credentialing process take?

It typically spans 90-120 days, but errors can extend it to six months or more.

Q3. Can providers appeal denials?

Yes, they submit appeals with corrected information, though success rates vary by payer.

Conclusion

Denials of provider credentialing are annoying to all parties involved, but the solution is to know about it and do something about it. You now know the most common credentialing errors, including incomplete forms and missed deadlines, and how they lead to healthcare credentialing problems.

To reduce the risks, implement the discussed avoidance strategies, make a start early, apply tools, and conduct periodic audits. In this way, you have a smooth-running and consistent income. In case errors in the credentialing process remain, seek professional assistance. Be proactive, and you will even convert the rejections into approvals.