Provider Recredentialing: How to Avoid Costly Delays

The provider recredentialing process can be a source of revenue leak for healthcare organizations. Learn how to avoid costly delays.
A rehabilitation specialist holds a clipboard while standing inside a clinic with exercise equipment in the background. Illustrating the topic of provider recredentialing.

For medical billers and clinicians, few things are more frustrating than credentialing issues.

Delays in provider recredentialing can wreak havoc on your practice’s revenue and cause denied claims, reduced patient care access, and even legal repercussions. Timely recredentialing is crucial for maintaining smooth operations and ensuring uninterrupted revenue flow.

What Is Provider Recredentialing?

In the healthcare field, credentialing involves verifying a provider’s qualifications, experience, and professional background to ensure they are competent and qualified to deliver safe and effective care.

Provider re-credentialing is the ongoing evaluation of a previously credentialed provider to ensure they continue to meet the qualifications and standards required by your practice, payers, and regulatory bodies. This periodic review helps protect your practice from potential risks and ensures that your patients receive the best possible care.

Typically, providers need to be recredentialed every 2-3 years. However, this timeframe can vary depending on:   

  • State laws and regulations.

  • Specific requirements of health plans or payers.

  • The provider’s specialty.

Check the specific requirements for your practice and providers to ensure compliance.

What Does the Renewal Process Involve?

Here’s a breakdown of the typical recredentialing workflow, which is quite similar to the initial credentialing process:

1. Provider Notification

You should notify your providers (ideally at least 60 days) before their upcoming recredentialing deadline. This gives them ample time to gather necessary documents and address any potential issues before the deadline approaches, reducing last-minute rush and errors.

2. Application and Primary Source Verification (PSV)

Providers complete an application with updated information and supporting documents such as licenses, certifications, and malpractice insurance. Verify this information with licensing boards and professional associations, ensuring all details are accurate and up to date to meet compliance requirements.

3. Submission to CAQH Provider Data Portal

The CAQH Provider Data Portal is a centralized hub for streamlining credentialing across multiple health plans. Submitting your providers’ data here can significantly expedite the process, as it consolidates information and reduces the need for repetitive submissions to various payers.

4. Approval, Denial, and Appeal

Once everything is verified, the payer reviews the application and may approve or deny the provider’s recredentialing. In case of denial, there’s usually a process to appeal the decision, allowing providers to address any issues and resubmit their applications for reconsideration.

Common Challenges in Recredentialing

While the recredentialing process may seem straightforward on the surface, practices often encounter significant hurdles, especially if they’re growing quickly. Here are some common roadblocks:

Time Intensive Processes

  • Gathering documentation, verifying information, and communicating with different parties can be incredibly time-consuming, especially for larger practices with multiple providers. 
  • According to the Medical Group Management Association (MGMA), it can take 90-180 days from submission of provider application to credential verification and approval.

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Document Storage and Accuracy

  • Missing or inaccurate documents are a leading cause of delays in the credentialing process.
  • Organized and accurate provider data management streamlines the credentialing process and minimizes the risk of errors.

Collaboration Between Stakeholders

  • Smooth communication between you, the provider, administrative staff, and payers is crucial for a seamless process.
  • Effective collaboration ensures all parties are on the same page, reducing the likelihood of misunderstandings and delays.
Partnerships

Task and Deadline Management

  • Keeping track of multiple deadlines and tasks for various providers can be overwhelming. 
  • Implementing task management systems and setting clear priorities can help ensure no critical due dates are missed, keeping the credentialing process moving smoothly.

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The Cost of Credentialing Delays and Errors

The consequences of an inefficient re-credentialing process go far beyond administrative headaches.

Delays or errors in these processes can lead to significant financial and operational challenges for healthcare organizations, including legal penalties, denied claims, and lost revenue.

Legal Penalties and Fines

Missing deadlines or re-credentialing requirements can result in hefty fines from state medical boards or accrediting bodies. Repeated violations may even lead to losing accreditation or licensure, impeding the organization’s ability to operate.

Denied Claims

If a provider’s credentials lapse, they may lose network privileges with insurers, leading to denied claims for services rendered. This results in lost reimbursement, increased administrative burden, and potential damage to the organization’s reputation.

In-Network vs. Out-of-Network Status

Credentialing helps determine whether a healthcare provider is classified as in-network or out-of-network with insurers, directly impacting your practice and patients’ access to care. In-network providers benefit from negotiated rates, direct reimbursement, and increased patient access, leading to higher patient volume and stable revenue. Out-of-network providers face higher patient costs, limited reimbursement, and reduced patient volume, resulting in less predictable income.

Impact on Revenue and Patient Billing

Credentialing delays can threaten your practice’s revenue by preventing providers from practicing, leading to canceled appointments and reduced patient volume. The resulting administrative strain can also confuse and frustrate patients, eroding the organization’s financial health and ability to deliver quality care.

Optimize Your Provider Credentialing Workflow

Provider recredentialing is essential to maintaining regulatory compliance, patient safety and satisfaction, and financial health.

While it can be complex, the right tools can simplify the process. By automating tasks like expirables management and document storage, you can enhance efficiency, reduce errors, and ensure providers remain credentialed.

Ultimately, a well-managed credentialing process safeguards your practice’s financial health and reputation while allowing providers to focus on patient care.

Software like Raintree’s credentialing management solution can help your practice automate and centralize:

Blogs are created for educational and informational purposes only.  The information provided does not constitute or, is not intended to constitute, legal or medical advice. When you read this information, visit our website, or access our materials, you are not forming an attorney-client, provider-patient, or other relationship with us.

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Last Updated:
September 19, 2024

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