Friday, February 23, 2024

Avoiding Healthcare Credentialing Mistakes in 2023

Avoiding Healthcare Credentialing Mistakes

he process of healthcare credentialing requires a lot of resources and labor. It’s not a one-time thing like exercise but a constant requirement in medical practice.

Medical credentialing is essential for practitioners, nurses, medical assistants, and therapists. Basically, anyone working with patients needs to validate their credentials.

It’s crucial to make sure the credentialing process is correct. These mistakes can harm your business by causing financial loss and even lawsuits in the worst cases.

Why Credentialing is Important

Mistakes in credentialing can lead to financial losses, like late payments, penalties, and cancellation of funding. In some cases, it can harm the patients and lawsuits. So this is not just a scare tactic but a real possibility.

Let’s consider a situation where a patient’s foot had to be amputated because the surgeon didn’t complete their residency and lacked proper certification. This led to an $8 million lawsuit. If the surgeon had the right credentials, this could have been avoided.

Besides being a legal requirement, credentialing offers several benefits for your organization, especially for future growth. Being accepted and listed as an in-network provider by health insurers increases your visibility to potential clients in your area.

Avoid These Mistakes in Healthcare Credentialing

Healthcare insurance credentialing can be lengthy, taking around 60-90 days and an additional month for contracting. Medicare enrollment typically takes about 41 days. In addition, any mistakes in the application, lack of follow-up, or missing paperwork can further delay the process.

In the past decade, we have identified several common mistakes that hinder clients from achieving efficient and timely credentialing. Further, The credentialing process for primary healthcare physicians and other specialties may have similarities but can also differ based on each specialty’s specific requirements and qualifications. However, You must know this to avoid these pitfalls in credentialing.

Know The Law In Your State

Each state has its rules for medical credentialing, so it’s essential to understand what your state requires. Some states have agreements that allow credentials from one state to be accepted in another, but not all states have this. Therefore, finding out beforehand is a good idea to save time.

Different medical fields have other criteria in each state. For example, chiropractors must pass state tests or NBCE exams in all states, while homeopathic physicians are only licensed in 17 states. Credentialing specialists who know these regulations can help your organization save time and money by researching each state’s rules and agreements.

Gather all the documents together

The credentialing process will be delayed if the information in the Council of Affordable Quality Healthcare (CAQH) system is inaccurate. Research shows that 85% of software has information problems, like wrong, missing, or old data.

Pay close attention when collecting data for the first time. It will help in the smooth flow of the process and save valuable time in the long run. Avoid unnecessary delays caused by providing incorrect data, as state healthcare credentialing can take 90 to 150 days.

Every employee in your clinic who cares for patients must go through the process. They must provide details about their education, work experience, training, qualifications, address, and licenses. Sometimes, certifications like CPR or RBT are also required. Understanding the state standards, the first step mentioned earlier is crucial because documentation requirements differ from state to state.

Submit The Application

Depending on the clinic or insurer network, you may need to complete a pre-application. This process undergoes a background check to ensure only qualified medical workers come forward. In addition, they examine criminal records, punishments, suspensions or expulsions, and board certifications.

Once you finish the pre-application, you can submit all the necessary information. It’s vital to do it correctly the first time to avoid delays. The longer the healthcare credentialing process, the longer it will take to charge or bill for the treatment/services.

To help you during the credentialing process, here’s a checklist:

  • Gather documentation and educational qualifications.
  • Have your healthcare license, DEA clearance, and state board certification ready.
  • Provide details about your professional experience.
  • Show your immunization records.
  • Share your personal medical history.
  • Prepare personal and professional references.
  • Explain any gaps in your job history.
  • Provide information about hospital privileges and affiliations.

Keep Checking The Status Of Your Application

Remember to check how your application is doing. It’s essential to follow up right away after you submit it. This ensures that your application is being processed and nothing is missing. In addition, some insurance companies need to inform people about application issues, which makes the process even longer.

Follow the deadlines and Plans

Understand your due dates and make plans accordingly. Unfortunately, it usually takes at least six months to get approved by health insurance providers. As mentioned earlier, some insurance companies require approval before signing contracts. Knowing the details about when the insurance companies’ policies start can help you manage your finances better in the future.

Final Thoughts

Know your deadlines and plan accordingly. Sadly, getting approval from health insurance providers typically takes at least six months. As previously mentioned, certain insurance companies demand support before signing contracts or receiving payments. Understanding when the insurance policies come into effect can assist you in better managing your finances down the road.

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