Overview
Medical credentialing is undeniably important. It ensures patients receive care from practitioners with the right credentials to treat them with the highest level of care possible. Therefore, payers are undoubtedly particular about ensuring care providers are rightly qualified. They do so by following a stringent system of checks when a medical claim is filed to look for the proper credentialing.
Unfortunately, maintaining the right provider credentials to avoid payment denials and delays can be like trying to continually hit a moving target. This is especially problematic for larger healthcare organizations that consistently onboard new care providers. Below is a list of medical credentialing best practice tips that can help.
Credentialing-Related Denials Are on the Rise
As necessary as medical credentialing is to protect patients, payers, and providers, denials due to credentialing can be frustrating. According to a poll conducted in 2021 by the Medical Group Management Association (MGMA), credentialing-related denials have grown far more common in healthcare. As many as 54 percent of practitioners reported an uptick in payer denials due to credentialing issues.
The issue is credentialing processes and requirements have evolved over the last few years. Additionally, many groups set regulations and standards that govern how credentialing should be done. This can make keeping current and new providers properly credentialed a laborious process that involves a lot of administrative effort. When healthcare organizations already spend $39 billion annually on regulatory compliance administrative tasks, it is easy for credentialing tasks to fall by the wayside. When credentialing practices are overlooked, this doesn’t just lead to denied payments, but also a lot of wasted, valuable time for providers.
12 Tips for Medical Credentialing Best Practice
1. Start the Licensing Process Early
For new practitioners, starting the licensing process as soon as possible is critical for a flawless transition from educational programs to practicing. Different licensing processes apply to different types of providers, and each can take a different length of time to complete. For example, PAs (Physician’s Assistants) must obtain certification from the National Commission on Certificate of Physician’s Assistants. This certification process can involve several steps, including verifying education and citizenship and may require peer references.
2. Keep All Physician Contact Information Up to Date
Something as simple as a wrong address for a provider or peer reference can cause problems with medical credentialing. Therefore, be certain that all contact information for physicians or other providers is updated periodically. If clear lines of communication are not available for any given provider, this can slow down processes when a provider’s credentials are up for question by a payer.
3. Outsource Medical Credentialing Services
Medical credentialing can be a time-consuming process. Additionally, slight missteps in the process lead to frustrating issues later. Therefore, working with a medical credentialing service provider like PrognoCIS may be one of the best credentialing tips you can follow. When you outsource provider credentialing with a service like PrognoCIS, a medical credentialing specialist assesses credentials on file for providers within the organization and makes sure everything is recorded as it should be.
4. Know Your State’s Regulations
State regulations for medical professionals can vary in terms of credentialing. This is especially important if your organization has providers that transition from one state to another to provide services. If credentials for that specific state are not updated, this can lead to problems once claims are filed to receive payments from payers for services rendered.
5. Track Credentialing Applications
Once credentialing applications are submitted to an insurance company or organization, be sure to track the progress of that application. Don’t hesitate to check in with an insurance company to find out where an application is at in the acceptance process. It is not uncommon for payers to set aside applications that are missing information and then delay alerting providers in a timely manner.
6. Avoid Common Errors
As simple as it sounds, an important medical credentialing best practice tip is to be mindful of common errors. Common errors are most likely to disrupt the credentialing process with a provider. And, Physician’s Practice states that as many as 85 percent of credentialing applications are missing must-have information the payer has to have to process the application. This can include:
- Lack of peer reference contacts or contact information for those contacts
- Improperly filled-out credential forms or missing information
- Submitting an expired NPI or DEA number
- Missing gaps in malpractice history
- Lack of clinical history documentation
- Data entry typos or mistakes
7. Keep Digital Files
Hard copies of credentialing files are important but keeping at least one digital file where all credentialing documents can be stored is just as vital. This is an important medical credentialing best practice to remember because it can save a lot of time later. When a payer requests credentials, you will have one clear file where everything is digitally available. Be sure to include diplomas, state licenses, DEA documents, passports, driver’s licenses, and anything else used for credentialing experience or identity.
8. Obtain a Dedicated DEA Number
DEA (Drug Enforcement Administration) numbers are mandated for providers to prescribe medication. Providers typically need a number for each state they intend to provide services, but requirements can vary. It can take several weeks for applications for DEA numbers to be processed after submitting an application through the DEA website.
9. Get an NPI Number
National Provider Identifiers (NPIs) are assigned to care providers, but the provider must also make sure to keep NPI information up to date. If a provider does not have an NPI or their information is not accurate, this is a common reason for the claim to be denied by payers. Therefore, any time a practitioner’s status changes, the National Plan and Provider Enumeration System (NPPES) must be updated through the NPPES website.
10. Request Procedure Logs & Clinical History
Clinical history is a common requirement for proof of work history in healthcare. To prove clinical history for any provider, be sure to request procedure or activity logs and keep them on file. Whichever department is responsible for billing for a provider’s services can usually offer an activity log that can be used for clinical history documentation.
11. Examine Malpractice Claims
An extensive record of previous claims filed, records of insurers, and policy numbers for malpractice insurance should be kept on file with credentialing information. Make sure new providers have a certificate of insurance on file as well.
12. Track Progress Using Advanced Software for Monitoring
A provider’s credential file can involve licenses, numeric identifiers, and forms of identification that face expiration dates. In the event these documents expire without notice, this can generate problems with credentialing. Be sure to track expiration dates on each provider’s credentials in the organization. This ensures that documents soon to be out of date are updated in a timely manner without disruptions.
Trust a Medical Credentialing Specialist to Help
Even with medical credentialing best practice tips, the credentialing process is complicated and time-consuming to navigate. Bringing in an expert with credentialing experience brings new efficiency to the process. If you would like to know more about medical credentialing support, consider PrognoCIS credentialing for assistance.
