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Top 3 Credentialing Issues in Healthcare

Apr 8, 2024 1:15:11 PM / by Altruis

Top 3 Credentialing Issues in Healthcare

Credentialing is an essential part of any successful healthcare practice. It prevents valuable revenue loss for your practice and protects your patients by ensuring all providers and facilities are contracted to provide services with your insurance plans.

While credentialing presents an opportunity to collect maximum revenue when done properly, it sometimes provides a barrier to smooth collections at some practices. This article addresses common reasons why credentialing is not always in harmony with collecting and why you may find greater success with revenue cycle management services that provide credentialing as a service.

What Is Medical Credentialing?

In healthcare, credentialing involves verifying healthcare provider qualifications and enrolling them with the insurance plans. This vital step ensures every provider has the necessary credentials to offer the medical services patients need and that the insurance plans will reimburse you for those services.

Effective credentialing protects patients and helps a medical practice avoid regulatory problems, insurance conflicts, and risks of liabilities and lawsuits. It also allows a busy healthcare practice to secure valuable reimbursements for services rendered, which keeps it thriving for the community’s benefit.

Credentialing involves checking the provider’s background, education, residency, training, licensure, insurance details, and any special certificates or qualifications they need to treat certain patients.  It also involves enrolling and recertifying regularly with the insurance plans to ensure there are no lapses in payments.  

One technique for checking these details is using the standards set by the Coalition for Affordable Quality Healthcare (CAQH). The CAQH provides a uniform credentialing program for all U.S. providers, plans, and sources of reimbursement.

When a company partners with an outside provider for revenue cycle management services, the partner may handle some or all of the credentialing tasks.

Common Healthcare Credentialing Issues

Are certain credentialing issues common at your practice? Do credentialing challenges prevent you from collecting? Here are some of the most common problems with fast, accurate credentialing.

1. Missing Credentialing Deadlines

Don’t procrastinate when it comes to getting the process started! In a best-case scenario, physician credentialing can be completed in about 90 days. Worst case situations can see that time doubled. As soon as you know you’re bringing a new physician on board, estimate a 120-150 day window for getting all credentialing completed – and try to beat it.

2. Submitting Inaccurate Information

Be sure to go through each payer’s application closely and supply all required information to ensure that everything is accurate. Around 85 percent of all medical credentialing applications contain missing, inaccurate, or out-of-date information. The only way to meet the optimal 90-day credentialing time is to get each application right the first time.

3. Failing to Catch Expired or Outdated Information

Be sure to monitor when credentials expire with each plan.  Stay on top of this and re-attest your providers in advance to prevent them from going non-par.  This will ensure that your revenue is not negatively impacted by a lapse in credentialing.

When credentialing goes wrong, you don’t get paid. Key reimbursement sources like Medicare, Medicaid, and commercial insurance plans have strict requirements and won’t issue payments when providers aren’t properly credentialed and verified.

Training and education will help your associates stay informed about the latest credentialing procedures, but it’s hard to find time for training at an extremely busy health center. Instead, you can hire Altruis to handle your credentialing while you stay focused on patient care.

Additional Top Revenue Barriers

Here are some additional credentialing issues your healthcare facilities may be dealing with:

Patient Eligibility

According to the Healthcare Financial Management Association (HFMA), just 6% of patient balances over $200 are eventually collected. Non-eligible patients account for a large portion of uncollected balances. The HFMA attributes this to “an outdated revenue cycle” with reactive collection practices that aren’t synchronized with the goals of modern healthcare revenue generation. 

This brings up the issue of measuring what matters in healthcare revenue cycle management (RCM). For example, consider the difference between focusing on gross charges vs. net collections. The gross charges are a poor reflection of your practice’s financial health. What ultimately matters is the net amount collected from the patient and their coverage sources.

Patient eligibility sits at the core of this issue because if patient eligibility isn’t done properly, the claim will be denied.  Correcting the issue and resubmitting the claim delays payment for services.  

For patients who truly aren’t eligible, it’s unlikely that you’ll ever collect — unless they become eligible later through retroactive coverage. Collecting retroactive revenue involves looking back at old charges to see if patients have become eligible and now have the right credentials for coverage and reimbursements.

Incorrect Coding

When it comes to coding, very little coding education is provided in medical school. Even your practice’s most experienced providers and top leaders may have very little experience with coding. Plus, coding changes and updates happen constantly.

Does your organization have a complete and accurate library of medical codes or use Certified Coders? This is one of the biggest benefits of revenue cycle management services — skilled resources that provide medical codes you can trust to be applied correctly. Coding audits should also be conducted quarterly. 

Stay ahead of new coding changes that could impact how quickly and accurately your revenue cycle operates. The latest changes include new International Classification of Disease (ICD) codes, diagnostic codes, coding terminology for drugs and biologicals, behavioral health payment reform, and street medicine billing in California.

Coding and Credentialing Success With Altruis Revenue Cycle Management Services

Altruis assists you with coding and credentialing. Ease the stress and pressure of coding challenges and make it easier to run your practice profitably.

We help our partners accomplish proactive, effective credentialing and coding through an industry-leading collaborative approach. We’ll scale our solutions to fit your needs, creating a customized process that leads to the highest possible revenue for your practice.

To learn more about creating a harmonious relationship between your credentialing and coding, please contact us for a free billing assessment.

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Topics: credentialing issues


Written by Altruis

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