Proper credentialing is crucial to prevent claim rejections and increase revenue for healthcare providers. This involves thoroughly evaluating new healthcare professionals before accepting them to ensure quality. Providing inaccurate information to insurance companies can often result in denials, so it’s essential to follow critical practices to avoid these issues. This guide is for those who have received a denial letter from their state or federal government. We would cover the main points of rejected credentials and how to fix them if your application was denied by mistake.
Why Is Physician Credentialing Crucial?
Credentialing is vital for physicians as it impacts their financial stability. Without proper credentialing, physicians cannot submit patient claims to insurance companies, resulting in potential claim denial and loss of reimbursement. An incomplete or inactive credentialing services status may lead to the physician or practice not receiving payments from the insurance carrier, treating them as out-of-network providers. Physicians must maintain active credentials and be in-network with the desired insurance companies to ensure they receive service payments. The success of a healthcare practice depends on accurate medical billing credentialing and efficient claim submission processes.
8 Tricks To Prevent Credentialing-Related Denials
Consider implementing the following crucial tricks to prevent credentialing-related denials and optimize income for your practice,
A comprehensive review of all new practitioners and providers
Credentialing new practitioners and providers are essential in avoiding future denials and maintaining accurate records. Hiring new practitioners and providers requires careful review and due diligence. The credentialing process should not be rushed, and the established standards must be consistently enforced. Any new physician or practitioner’s education history and resume should be thoroughly vetted, including contacting references and reviewing all records for accuracy. Neglecting these important steps can result in numerous denials in the future and even lead to issues with payers and public health institutions if the small practice later ends the relationship with the individual.
Update Important Documents
It is crucial to keep all certifications up-to-date, as many require revalidation and have strict standards set by insurance payers and public health institutions. Different organizations may have unique requirements, so it’s crucial to have a clear list of which companies need updates and when. This helps avoid confusion and ensure timely responses. Keeping track of the types of institutions, such as state-run or private, is also helpful, as federal health programs often have similar standards. Staying organized and updated is critical to avoiding confusion and ensuring timely responses. Maintaining a clear list of which companies require updates and distinguishing between different types of institutions, such as state-run or private, can help in this regard.
Be Time Conscious
Timeliness is crucial to avoid credentialing mistakes. Two areas where these mistakes often occur are when hiring a new provider and communicating with insurance companies for payment validation. Credentialing and enrollment is the process of verifying a healthcare provider’s qualifications and information with insurance companies to secure payment for services rendered. Rushing the credentialing process when hiring a new provider can lead to missed steps, resulting in denials. To avoid this, thoroughly review the new physician’s history, contact references, and ensure accurate record filing. To circumvent insurance credentialing denials, eliminate communication delays by taking responsibility for the company’s credentialing, but be prepared for payers to conduct audits.
Investigate Delays
When an insurance company discovers a credential error, reviewing it may take a long time. This can affect the practice of an active physician. If one company finds a mistake, likely, other companies will also. Failing to identify and fix the issue can prolong the time for payment verification.
Contact them if an insurance company takes longer than expected to review a claim. Explain that you are eager to resolve the issue and inquire about the cause of the delay. Even if the reason is not a significant problem, the fact that it took so much time suggests that a change is needed.
Be Prepared For Potential Delays
Predicting approval time from insurance payers or public health institutions can be challenging. Allow at least 90 days from the request to the expected approval to avoid a critical error. If approval takes longer, reach out to the payer for clarification. Having experienced personnel leading the billing team can increase the accuracy of work and wait time assessments.
Take a closer look at consistent issues.
If your service is encountering numerous rejections, prompt intervention is crucial. Generating a report that highlights frequent mistakes is often helpful. Document the root causes and pinpoint recurring trends. Once these patterns are recognized, focus on removing the source of the denials by eliminating the errors responsible.
Preventing Credentialing Rejections
Most credentialing rejections in insurance can be prevented by avoiding communication gaps between a healthcare provider and an insurance company or public health organization. For larger practices, handling the company’s credentialing process may be beneficial to save time and minimize file exchange and information requests. This approach, however, may also expose the company to payer audits. It is recommended to have a third-party audit performed by an external firm to reduce the risk of red flags during medical billing and claims reviews. Implementing effective denial management strategies can significantly improve the financial stability of a healthcare organization.
When to Seek Professional Assistance
You may need external support if your practice frequently faces rejections from insurance payers or public health organizations. In such cases, many practices opt to hire a billing and collection service to verify their providers’ credentials. This is particularly beneficial for small practices looking to expedite the collection process or for larger companies trying to avoid expensive audits. This solution is ideal for practices aiming to quicken their collection process to avoid costly audits.
At I-Med Claims, our expert team assists medical practices in optimizing their revenue flow. We are committed to preventing rejections, from small clinics to large physician offices. Our team is familiar with denials specific to your area, making the identification, analysis, and prevention of denials much simpler.
