10 Credentialing Loopholes Depleting Healthcare Practice Income and how to fix them
In today’s world of healthcare, being financially healthy is as important as giving out quality healthcare services. However, many practices are unaware that they are losing money because of credentialing loopholes. Medical Credentialing is perhaps one of the most important processes in guaranteeing insurance payments and credibility of a practice, it entails confirming a healthcare provider’s qualifications. However, this process can and often does tend to be harrowingly careless which results in delayed payments, claim rejections or worst case scenarios legalities. There are the ten loopholes in the credentialing process discussed in this article that exist in the process and how to go about amending this so that the practices can maintain their revenue streams 1. Delay in Credentialing Service Providers There is a delay in reimbursing providers when they do not complete the enrollment process with insurance payers in time. Without adequate cash flow for weeks or even months, practices’ finances would be severely impacted, as a result. Solution: To do this, always start the enrollment whenever a new provider is recruited into your practice. Utilize automated systems to monitor the status of the enrollment and all follow ups instead. On a side note, engaging with a credentialing service provider tends to mitigate complications in regards to manual enrollment completion. By facilitating the passive enrollment of providers, some unneeded bottlenecks and variations in efficiency can be halted. Each provider’s enrollment progress can be frequently evaluated to make sure adherence to the procedure is strictly followed without skipping any stages. This high level of diligence is vital for practices that involve multiple providers as handling a dozen enrollments at the same time can be tough. 2. Lapsed Credentials Credentialing is more than a single event. Providers are expected to maintain their active status for their certifications participants, obtain the relevant licenses and be current in their insurance affiliations. If these credentials are not monitored and updated, denial of services or suspension of reimbursement will take place. Solution: Create appropriate reminders to check on credentialing expiries. Using a qualified credentialing software that automates one-time reminders to increase compliance will help. Regular credentialing reviews and follow-ups will help remain compliant. Moreover, engaging a staff member to be in charge for the credentialing renewals and setting timelines will help mitigate any lapses. e Team members can interact with the providers to make sure the application and the relevant documents are submitted on time. This approach avoids a decrease in income but also protects the Practice Image. 3. Claims With Wrong Information Being Filed The wrongful filing of NPIs, alongside using outdated addresses gives reason for claim adoptions that are illegitimate. These erroneous claims can be complex and time-consuming making the delays in payment almost inevitable. Solution: Put in place stringent and rigorous credentialing documentation guidelines that guarantee the reliability of the information provided. Also, consider employing credentialing software to assist in the verification of data. To ensure further accuracy, compose a coherent checklist targeted to credentialing submissions. This checklist confirms that all necessary information is correct and measurable. The inclusion of more frequent workshops for support staff can ensure that the value of accuracy is respected in the input of any information. 4. Not verifying the insurance coverage of patients Coverages are likely to be modified frequently and the patient’s coverage needs to be checked in conjunction to the services rendered. If not followed this will result in wasted resources and a loss of trust from the patients’ end. Solution: After every appointment, engage a third party in the verification of the previous insurance claim. Additionally find software that would help the accounting staff manage these insurance claim verifications every appointment. Likewise, lectures directed at the patients on the need to keep their insurance information current can curb this lapse. For example, regular letters to patients regarding their insurance coverage has positive implications. 5. Obtaining Re-credentialing The providers should apply for re-credentialing within the time limits set by the payers. In the event that these timelines are not met, the providers are suspended from the list thus causing lowered referral and income levels for the providers. Solution: A sufficiently qualified credentialing department should be assigned the administrative management of re-credentialing deadlines. Appropriate software with automated alerts, emails, or calls should be employed to facilitate timely renewals, and regular engagement with payers should be encouraged to prevent interruptions. Another useful approach is keeping a calendar for re-credentialing activities. Again, this calendar could provide for deadlines and reminders for deadlines to be prepared within certain periods of time. Regular internal short meetings on the upcoming events such as credentialing processes may further reduce this likelihood. 6. Payer-Specific Requirements have been Forgotten. Every payer of the insurance claims has a unique process of Credentialing. Ignoring these specifics can lead to denied claims and a short change in the administrative work effort. Solution: Check for requirements of each payer. Be prepared to train the staff regarding such variations and come up with a structured approach that will be effective in ensuring that workers are informed of the new requirements. These reviews of the payer’s requirements are conducted at regular intervals. Constructing a database for requirements, fulfilment periods and documentation needed by the payer will streamline the process. Getting a point person in charge of major payers would help your practice stay current with changes. 7. Gaps in Credentialing for New Hires have Not Been Addressed. Provider’s billing for their services cannot occur until the credentialing procedure is complete for the new employees. This means loss of potentially valuable revenue during the period of times when the employee is being orientated. Solution: Set up a pre-planned credentialing procedure aimed at minimizing delays for new employees. Start the credentialing new employees process by preemptively gathering required documents, and link up with qualified credentialing staff during the interview phase. Adding credentialing to the list of pre boarding duties ensures that the requisite measures are followed at the right time. At the same time, there should be a mechanism for