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How to Prevent Credentialing Denials and Protect Revenue
A provider can be fully qualified, licensed, and ready to see patients, and still be unable to receive revenue if they have not completed their provider enrollment process with every payer. Most people do not talk about credentialing denials the way they do with coding errors or claim rejections, but they cause the same damage to a practice's revenue.
Practices lose a lot of money for not having credentialing every year, without realizing where the problem is coming from.
Why Do Credentialing Denials Happen?
Credentialing denials often happen because practices submit an expired license to payers; there is missing documentation, or information that doesn't match across different records. Payers won't approve enrollment until every detail is complete and accurate.
That correction process also takes a lot of time, which affects new providers' already limited schedules to see patients. When payers deny credentialing, it's a lot of paperwork that stops practice from billing until the issue is resolved.
How Much Revenue Does Credentialing Denial Cost a Practice?
Practices do not always know the real cost of credentialing denial until their revenue is low. A provider who can't bill for a few weeks will lose revenue that is often hard to recover.
Multiply that across multiple providers, or a growing practice, and you will understand the importance of getting providers' credentialing on time. What looks like a minor administrative delay can often turn into thousands of dollars in unpaid billing.
What Are the Most Common Causes of Credentialing Denials?
Expired licenses or certifications are some of the most common causes of credentialing denials because many practices do not always track the timeline for renewal. Incomplete applications, such as missing signatures, unanswered questions, or sections left blank by mistake, are another issue.
Having different information across multiple documents or records also makes payers deny credentialing. This can also happen when important information like your name is spelled differently in two documents, or an address doesn't match what a payer has on file. These minor errors can increase when there is no expert monitoring the entire process.
How Does Provider Enrollment Connect to Credentialing Denials?
Credentialing and provider enrollment are not the same process, but they are linked. This means that if providers have a problem in one, it will affect the other. Also, payers will not approve a provider's enrollment until they verify their credentials. So, a delay in credentialing affects the approval of your enrollment.
What Role Do Provider Credentialing Services Play in Prevention?
Provider credentialing services prevent payer denials by ensuring a healthcare provider's licenses, certifications, and enrollments are accurate and active. Instead of leaving credentialing to any staff member, a practice should have a team of experts who process and track every application, deadline, and document requirement for every payer they work with.
Provider credentialing services identify expiring licenses and incomplete applications before submitting to payers. When practices handle credentialing internally without a dedicated team, they often miss important details that can affect payers' response and revenue.
How Can Practices Identify Credentialing Issues Before They Cause a Denial?
Practices can identify credentialing issues before they happen by carrying out regular audits of provider files. Checking license expiration dates, accuracy of documents, and ensuring every piece of information is the same across every system also helps ensure there is no denial.
Setting up automated reminders for renewal dates and not relying on your staff to remember when credentialing will expire also helps. A comprehensive review of the credentialing application before submitting also detects errors that were missed during the process.
What Should Practice Do When a Credentialing Denial Happened?
When a credentialing denial happens, the first thing to do is figure out why it happened. Many payers provide a specific reason for denying credentialing and understanding that reason gives you perspective on what needs to be fixed before resubmission.
Also, practice needs to appeal immediately after the issue is identified and corrected. Delaying this process can make it difficult to resolve because payers often have their own response windows.
How Often Should Credentialing Records Be Reviewed?
Waiting for a denial before reviewing credentialing often makes a practice lose revenue. Therefore, practices should carry out quarterly reviews to identify expiring licenses and outdated information. Annual reviews alone are not enough because a license or certification can expire in the middle of the year.
In Conclusion
Credentialing denials are often the result of issues that were preventable when the process is handled by professionals. Practices that consistently review their credentialing receive fewer denials and have consistent revenue.
Altermed RCM is a medical billing company that helps practices handle their credentialing and enrollment process. Our team of experts with many years of experience in the industry checks for errors and ensures every document is accurate before submitting the application to payers.
Frequently Asked Questions
The time it takes to resolve a credentialing denial often depends on the payer the practice is dealing with. Some payers process everything within weeks, while others could take months, especially if the original application had multiple issues. When an appeal is submitted with corrected documentation, the process of resolving the issue can be faster.
Credentialing denial often affects claims already submitted and can be tough to resolve. When a healthcare provider treats patients and submits claims before receiving credentialing approval, the claims will be denied because the payer has not given the provider permission or authority to bill.
Expired licenses are one of the most common causes of credentialing denials. This usually happens because nobody was tracking when the license needed to be renewed. Incomplete applications are another one; when a signature is missing, or a section in the application is not filled out, the application will automatically be rejected or denied.
Every payer has specific requirements for their credentialing application process, and failure to adhere to their regulations will result in denial. One payer might ask for a specific document, and the other completely ignores it. This is why it is important to track the credentialing process and payers' specific requirements when processing your application.
The best way for a practice to track multiple providers' credentialing status efficiently is by using a centralized tracking system. This could be a dedicated credentialing software or, at minimum, a shared, but actively maintained system everyone on the team uses. The goal is to identify renewal dates and incomplete applications automatically to correct the problem and meet every deadline.
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