Medical Credentialing & Enrollment: Mistakes and Mishaps

IN A NUTSHELL:

• Simple mistakes can delay payment
• Overworked staff a common cause
• Compliance delays also costly

Health care facilities have a legal responsibility to verify a provider’s identity, education, work experience, malpractice history, and license verifications to protect patients from unqualified providers. Although most health care facilities have specific processes in place to ensure the success of the credentialing process, hiccups can happen and the consequences can be costly.

Mistakes and mishaps:

• A provider misses the deadline to submit information
  During peak hiring seasons, department heads often lose track of who is coming on board. In these situations, a provider can be granted temporary privileges or provisional services. This interim period allows a provider to work for several weeks or sometimes months while hospital staff members work to complete the credential management and privileging process. However, this strategy can cause a tremendous revenue burden. The enrollment process, which takes up to 90 days if not longer, can’t happen until a physician is fully credentialed. Until a provider is fully enrolled, no payments can be processed. No matter when a provider starts working at a medical facility until the health plan awards the provider an effective participation date, all claims must be held.
• Relying on limited staff and administration
  Health care credentialing is a time-intensive process that requires staff members to be meticulous patient. Medical Credentialing can take up to 55 days on average per provider. The long list of paperwork, including education, licenses, work history, and more must be verified for every type of provider. With hundreds and sometimes thousands of practitioners at a hospital, the credentialing process for every individual can be a tremendous administrative burden for any single staff member or even a small team to handle. Medical facilities often make the mistake of not designating a substantial amount of resources to complete the medical credentialing process. The result is lost revenue and stressed overworked staff.
• Submitting incomplete applications
  Most provider enrollment applications require an overwhelming amount of information and data. This is in addition to the credentialing process. If a provider does not complete the application in its entirety it can cause delays in the revenue cycle and potentially a denial of enrollment in the health plan.
• Failure to update professional information as required
  Medical providers need to renew their licenses on a regular basis, which can vary depending on the state in which they practice. Additionally, a provider may be required to take continuing medical education courses. When medical facilities fail to keep their credential management current, it could result in physicians performing services they are not licensed to perform. This creates the potential for negative patient outcomes resulting in expensive malpractice lawsuits.

Learn More:

White Paper | Health Care Credentialing: Methods, Management, and Cost

White Paper | Provider Credentialing vs. Provider Enrollment: Differences and Solutions

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