The credentialing/provider enrollment process can be complex and time-consuming, but it plays an essential role in practice reimbursement. Provider credentialing lapses and errors can significantly impact healthcare practice revenue. More specifically, when details are missed in provider enrollment/credentialing with network payors, claims may be denied by insurance companies, which results in delayed or lost revenue.
Reducing claim denials is more important than ever, as denials rose to 11% of all claims last year (up from 8% in 2021) according to the recent Crowe RCA benchmarking analysis. That translates to 110,000 unpaid claims per year for an average-sized health system.
Across our client partners, we find when healthcare organizations take steps to minimize credentialing errors, we see a 1-5% revenue lift due to reduced denials. The key to minimizing revenue loss from credentialing errors is a streamlined provider enrollment/credentialing process that follows industry best practices.
In this post, we discuss credentialing’s key role in healthcare reimbursement and tips to improve healthcare collections by optimizing credentialing/provider enrollment processes.
Credentialing’s Crucial Role in Reimbursement
Credentialling/provider enrollment is the process of registering healthcare providers with insurance companies, government programs, and other payors to ensure that they are eligible to receive reimbursement for the medical services they provide. It is critical for healthcare billing as it establishes provider credentials and authorizes them to submit claims for reimbursement.
During this process, healthcare providers must complete various forms and provide documentation to verify their credentials, such as:
- medical licenses
- hospital affiliations
- scope of practice
- disciplinary actions
- malpractice claims
- other relevant information
Once the provider enrollment application is submitted and approved, the provider is often assigned a unique provider ID used to identify the provider with each network in their internal system. Claim submissions will include the provider’s NPI (National Provider Identifier) and billing TIN (Tax ID Number) for the practice they are rendering services for.
Managing the payor/provider enrollment process requires an internal and/or external team of credentialing specialists to work directly with each provider to prepare all required information to submit applications to the payors.
On an ongoing basis, it is important to keep provider credentials up to date as every payor network has a unique set of credentialing standards required for a provider to participate/contract with their network. If credentials are incomplete or are not kept current—practice revenue will suffer.
Below are our top best practices for improving the provider credentialing process to boost practice revenue:
1. Make sure you are in-network with the correct insurance plans for your region and specialty.
The more payors you are in-network with for your local region and patient demographic, the better, as patients seek out in-network care. Additionally, being in-network with providers can reduce your contractual fees and improve your collections (since it is easier to collect from payors than patients). Make sure you have a solid provider enrollment process in place to establish in-network contract agreements with all local and relevant payors.
Be aware: If you move practice locations, your status does not roll over.
If you move locations, go out on your own from a group practice, or add a new clinic, you must notify all payors. If you begin seeing patients at the new location without updating your credentials, you will not maintain in-network status and will lose out on in-network billing for patients seen during your lapse in status. Have your credentialing team maintain your practice demographics (phone, fax, mailing address, service locations, billing/pay-to address). This will help you avoid missing a re-credentialing letter or not returning a data verification, which can lead to network termination.
2. Dial-in processes for onboarding new providers
These are some of our top “watchouts” for credentialling new providers:
Follow each payor’s application instructions down to the smallest detail. Taking time to understand all requirements (licensure, hospital affiliation, scope of work, etc.) will help prevent common credentialing denials. Even using an outdated version of an application could cause an application to fail, sending the practice/provider back to the end of the line. Other common reasons for denials include:
- credentialing a provider under the incorrect specialty/taxonomy,
- not classifying a provider correctly as a primary care provider (PCP) vs a specialist,
- neglecting to revalidate Medicare, state Medicaid plans,
- or trying to bill for a managed care program with the provider is not participating in their state Medicaid program.
Allow enough lead time for the enrollment process before a provider plans to see patients. The average turnaround time for most payors is 90-120 days after application submittal. Make sure you also leave enough lead time for malpractice/professional liability coverage to allow enough time for your insurance carrier to issue a certificate of insurance (COI) well in advance of the provider’s start date as it will be required for credentialing purposes.
3. Maintain, maintain, maintain.
Initial provider enrollment is just the first hurdle in the process. The next step is to remain in-network over time. Maintaining status is necessary because every payor requires that providers be retested/recredentialled regularly. The average network contract will have a term of 2–3 years with re–credentialing due before that period’s end to determine that you are approved for another 2–3–year term. You are also required to complete quarterly attestations either through your Council for Affordable Quality Healthcare (CAQH) profile, Availity profile, or directly through the payor’s instructed verification steps. Submitting copies of board certification renewals, license renewals or reporting any changes to your practice demographics such as address changes, payment address updates etc. are also required.
If your status lapses and your practice continues caring for patients, you will receive claims denials and need to retroactively attempt to collect bills from patients. This may also fray patient relationships if a patient expecting to pay in-network rates is not covered due to a provider credentialing lapse.
Make it a priority to monitor your re-credentialing dates, quarterly required provider data validations, and ensure your online directory listings for each of your participating plans are updated correctly.
Be aware: The No Surprises Act makes maintaining your credentialing information more important than ever as networks may term provider participation for non-compliance.
Credentialing maintenance plans should include:
- A process for re-credentialing providers (conducting background checks, verifying licenses and certifications, and reviewing performance data).
- Compliance monitoring to remain compliant with relevant regulations and policies such as HIPAA and Medicare/Medicaid regulations.
- Documentation management to maintain comprehensive records of all provider credentials, monitoring activities, and compliance with regulations and policies.
- Maintenance of practice demographics (phone, fax, mailing address, service locations, billing/pay-to addresses)
- CAQH profile maintenance (to ensure license renewals or other changes are attested efficiently.
4. Ensure your credentialing and billing team collaborate.
When the credentialing team has completed payor enrollment the billing team should be kept in the loop so that they can release, and process claims according to the effective date. Additionally, if your practice does experience claim denials, make sure your credentialling and billing teams work closely together to quickly resolve and resubmit claims to avoid delays or impacts to your patients and your practice. When a provider has a cohesive billing and credentialing team, it takes less time to relay information from one group to another (e.g., the list of networks/payors that the provider or practice would like to be contracted with, approvals/effective date tracking, and any claims questions/issues).
The Bottom Line: An Optimized Credentialling Process Can Drive Improved Practice Collections
The process of contracting with payors and keeping provider credentials current is complex. Busy front-desk staff and providers often do not have the bandwidth to keep up on the details and continual maintenance optimal provider enrollment and re-credentialling requires. Working with a specialized billing expert that provides credentialing services can help your practice focus more on patient care without losing out on revenue due to credentialing errors and denied claims.
At Resolv, our dedicated account managers and credentialing specialists ensure thorough and efficient provider enrollment, credentialling, and re-credentialing as well as quick resolution on payor issues. Whether you are just setting up your practice and want a smooth go-live or looking to optimize your current payor enrollment, NPI review, and managed care contracting processes, we can help. Learn more here.
About the Author
Veronica Enns, Credentialing Manager
Veronica Enns has over 12 years of experience in healthcare credentialing and administration. Today, she serves as Credentialing Manager working to efficiently help practices with their provider enrollment needs. Prior to joining the Harris Computer/Resolv Team, Veronica has worked in patient care and in administration of Diagnostic Imaging & Interventional Radiology practices giving her insight into the importance of network participation and accurate billing practices. Veronica and the whole team of credentialing specialists that support Resolv are truly invested in the relationships that are built with each practice.