Almost 70 percent of claim denials, including provider credentialing, are preventable. However, healthcare organizations are continuing to lose thousands of dollars every month due to small credentialing mistakes since such errors are not detected until the revenue cycle has been ruined.
In this article, you will learn a breakdown of the most common credentialing errors that are damaging your revenue cycle, why they occur, and most importantly, how your organization can prevent them. No matter what practice management, medical billing company, provider, or whether you are in an in-house administration team, this knowledge of these credentialing issues safeguards your reimbursements, decreases claim denial, and accelerates payer enrollment.
What Is Medical Credentialing? (And Why It Matters for Your Revenue Cycle)
Provider credentialing (also known as medical credentialing) is the process of establishing the qualification of a provider, including education, licenses, certifications, work history, exclusions, and adherence to payer requirements.
It underpins:
- Provider enrollment
- Accurate reimbursement
- Conformity to credentialing standards.
- Preventing exclusion screening offense.
- Strauss’s revenue-cycle management.
Whether the credentialing process is sluggish, incomplete, or mismanaged, your revenue cycle is hit instantly.
Dr.Harris was a new employee in a small clinic. He began with high spirits, but in two months, he realized that his payer credentialing with large insurance firms is not yet finalized, impacting his financial health. Contingents of claims, checks in suspension, and petitions denied.
When the problem with the Credentialing mistakes was resolved, the clinic had lost more than $42,000 in reimbursement merely because the paperwork was late and erroneously learned more about revenue cycle management.
This practical case study confirms the following:
“Credentialing is not a piece of paper; it is a very important revenue-cycle process.”
Top Common Credentialing Mistakes That Hurt Your Revenue Cycle
The following represents the breakdown of the most expensive areas in the healthcare sector to be credentialed and ways to prevent such problems.
- Incomplete or Outdated Provider Information
Among the largest causes of Credentialing mistakes delays is so simple the providers frequently provide incomplete information.
Missing items include:
– Expired licenses
– Malpractice insurance certificates of yesteryear.
– Gaps in employment history
– Missing signatures
– Incorrect NPI or CAQH data
A single field that is missing will put your payer enrollment on hold for weeks.
1. How It Silences Your Revenue Cycle.
– Delays reimbursements
– Causes claim denials
– Forces habits of writing off any charge of uncredentialed providers.
How to Fix It
Standardized credentialing checklist, frequent reminders, and credentialing software that notifies you that you have not submitted all the data before submitting.
2. Failure to Maintain Your CAQH Profile
CAQH should be revised every 120 days- most of the practices will forget this. CAQH is important for payers to do automated verification.
How It Silences Your Revenue Cycle.
– Payers freeze the enrollment process.
– Slows down credentialing authorisation.
– Introduces satisfactory gaps in effective dates.
Solution
Have one credentialing specialist follow the re-attestation of CAQH and automate the reminders.
3. Later/Wrong Payers Enrollment Applications.
Each payer has different:
- forms
- timelines
- credentialing standards
- documentation rules
Delays of weeks come as a result of submitting the wrong version-or to the wrong fax number or email.
Revenue Cycle Impact
– Denials usually come in the form of a provider not enrolled.
– Delayed EFT enrollment
– Thousands of payments were lost in advance.
Solution
Automate credentialing processes and keep an internal repository of new payer forms and enrolment schedules.
4. Failure to conduct Monthly Exclusion Screening.
According to federal law, the providers must be checked against:
- OIG Exclusion List
- SAM.gov
- State exclusion lists
Failure to do so will subject your practice to civil fines, and your payments may be terminated by payers.
Revenue Cycle Impact
– Risk of audits
– Immediate claim freezes
– Legal penalties
Solution
Perform automated exclusion screening on a monthly basis.
5. Disregard of Recredentialing Deadlines.
Payers need recredentialing every 2-3 years. Failure to meet the deadline amounts to immediate deactivation.
Revenue Cycle Damage
– Provider is not put on the payer network.
– Zero reimbursement before readmission.
– Can take 90–180 days to fix
Solution
Establish automated credentialing warnings to all providers 6 months prior to expiration.
6. Failure to Track Credentialing Applications.
Most of the healthcare practices are based on emails and spreadsheets, and this results in:
- Lost documents
- Missed deadlines
- Confusion among the admin staff
Impact
– Delays in approvals, lack of organization in workflow, and a high-denial rate.
Solution
Credentialing software with dashboards, reminders, and real-time application tracking is used.
7. Presentation of Claims in advance of Credentialing Authorization.
There are those practices that start billing as soon as a provider commences work. This causes:
- Denied claims
- Retroactive appeals
- Lost revenue
Solution
Check before paying the bill. Assuming that it can be retroactive, document all the details and follow up on the approval timelines.
8. Weaknesses in Communication between Credentialing and Billing Teams.
The credentialing and billing departments are usually independent of each other, hence forming:
- Wrong payer IDs
- Incorrect provider types
- Coding inappropriate taxonomies.
- Delayed EFT setups
Revenue Cycle Impact
– 40 percent or more rejections in case of poor communication.
Solution
Conduct cross-departmental meetings weekly and provide billing with the current payer enrollment information.
9. Failure to hire qualified credentialing experts.
Credentialing is a complicated process- and giving it to office employees who do not know it best usually results in:
- Frequent errors
- Lost applications
- The credentialing process is extremely slow.
- Incorrect payer enrollment
Solution
Get certified medical credentialing experts who are conversant with credentialing requirements and payer regulations.
10. Failure to use credit rating automation tools.
Paper-based credentialing requires weeks and exposes the possibility of mistakes even more.
Impact
– Slow onboarding
– Paperwork duplication
– Lost documents
– Missed deadlines
Solution
Implement credentialing software automation and digital forms, automated alerts, and tracking of compliance.
CTA
Sick of having long credentialing times undermine your revenues? Enroll your payers and simplify your process with the help of certified credentialing experts, and book a free consultation today and clear out denials before they occur.
📞 Call Now: 888-495-3786
📧 Email: Info@providerscarebilling.com
How to Protect Your Revenue Cycle From Credentialing Errors
Protecting your revenue cycle against credentialing errors: these are the best practices.
- Have current CAQH profiles.
- Carry out monthly exclusion screening.
- Monitor all payer enrollment requests.
- Automate it using credentialing software.
- Each thing should be performed by medical credentialing experts.
- Begin the credentialing process 90-120 days prior to the start date of the provider.
Conclusion
Credentialing mistakes might not appear to be a big component of your business, but it has a direct and strong influence on your healthcare revenue cycle. Even simple errors, including old documents, deadlines, or slow action in enrolling payers, can slow down the reimbursements and raise the number of claim refusals.
Through structured work processes, automation of credentials, and qualified credentialing experts, the practices would prevent avoidable and expensive errors and remain in compliance. Enhancing your credentialing process can guarantee quick payouts, easy onboarding, and a good financial status. In the modern-day healthcare provider system, precise credentialing is not a choice, but a necessity.
FAQS
What are the registration errors that impact the revenue cycle management?
Wrong information about a patient, lack of insurance details, and incorrect eligibility checks tend to result in refusal and late payments.
What are the two items that payers take as common mistakes in credentialing a physician?
There must be gaps in employment history as well as incomplete or inconsistent documentation, which are significant warning signs to payers.
What do you feel are the three most typical errors on a claim that will result in denials?
The most frequent reasons behind claim denials include wrong patient data, wrong insurance data, and coding or billing mistakes.
What are the 4 P’s of the revenue cycle?
The 4 Ps are Patient, Provider, Payer, and Process- each of them is critical to a smooth reimbursement.
What is the new RCM invoice rule?
According to the new rule, there will be increased compliance and faster reimbursement of payers by the use of clearer, standardized, and transparent invoicing.
