Avoiding Denials Related to Credentialing and Product Participation: Today’s Tips, Tomorrow’s Changes

Twenty years ago, payers had different credentialing apps for enrollment. They were often paper, filled out by hand and mailed or faxed to payers with the same 60 to 180 day processing times as today. In the early 2000s, several states adopted uniform applications which helped some the varying paperwork, and CAQH was introduced as a single repository of information for providers to enter credentialing data and payers to retrieve it electronically. It took quite a few years, and over the past decade most major payers have adopted the use of CAQH, but the processing time has not improved much, if at all, after all these years. Most credentials can be verified through electronic queries by a payer in a matter of hours while peer references and work history verification may take a bit longer. So why does it still take so long to complete the credentialing process and why is the accuracy of information not better than it is?  This article is intended to get providers thinking about how they can work toward establishing a new standard for the credentialing process.
While there is still a need to make sure that all the basic payer credentialing is done to ensure your medical practice minimizes loss of revenue for being non-participating, there are some activities or options on the horizon that will hopefully make these processes more efficient and less cumbersome on your practice. In this article, we will do a quick recap of steps you can take today to ensure your providers are participating, but we will also talk about topics that are just becoming available or are in development. Providers are encouraged to engage in these options and become part of a solution rather than just griping about the process. All of the stakeholders – providers, payers, employers, government agencies and patients – can benefit if the process is improved.
Current Review and Fixes
Regardless of whether you are a small office or a large group practice, take these steps to ensure your providers are credentialed, linked to all of the payers, and also all the products (HMO, PPO, Med Advantage, Medicaid, Exchange, etc.) with which you believe your practice is contracted. Take note that a number of factors may have changed since you last contracted or credentialed your providers. Factors such as a payer merger, missed re-credentialing notice, payer policies or amendments may have impacted the status of your providers’ participation in certain plans.
  • Research Project: Contact each payer and network and confirm whether every provider is (These may seem elementary,  but specificity is key to getting the correct status)
    • Credentialed (and through what date)
    • Linked to the Group TIN and NPI 
    • Linked to a Contract  that is tied to the practice TIN (ask if contracts are individual or group)
    • Linked to specific products (ask for individual product names)
    • Linked to all the practice service locations at which the provider will work (some payers may deny based on locations not being linked to a provider, while other payers may not apply this type of denial policy)
    • Effective Date for credentialing and participation with each product
  • Claims Denials Review: Look in billing data for denial trends for being non-par by provider, by payer, by product.
  • Review payer online directories to see if your providers appear at correct practice addresses for each of the products for which the practice is contracted. (This is optional but serves as a validation, especially if claims are denied for being non-par and yet the directory steered patients/members to your provider.)
  • Based on the above research and denials review, if you discover a provider is not credentialed, not contracted, and/or not linked to the practice’s TIN, contract or specific products:
    • Ask the payer how to best rectify the problem, how long the process will take and what effective date can be expected. If the error is clearly on the payer’s part, insist on a retro date.  If not payer error, retroactive effective dates are rarely granted by commercial plans, but ask if this is possible.  If a retro date is granted, ask if claims will need to be resubmitted or if a reconciliation process can be initiated on claims underpayments.
    • Follow up on the recommended steps and be sure to verify receipt of requested documentation
  • IPA/PHO: If your providers are contracted through an Independent Practice/Physicians Association or Physician Hospital Organization
    • Typically the IPA or PHO has been delegated credentialing by the opted-in payers for the providers for which the IPA contracts, so just one credentialing submission to the IPA/PHO is needed for all of the plans for which the provider or practice has opted-in.
    • Some IPAs and PHOs will credential physicians only, and not mid-levels such as NPs, PAs, PTs. If payer policies require these mid-levels to be credentialed then the practice needs to submit directly to the payer.
  • CAQH or other state-mandated portals: Be sure these are kept current and re-attested timely, including contacts, locations, remit addresses, and uploading of accurate documents that might expire (License, DEA, Certificate of Insurance (COI), Board Certificate, etc.). When payers pull this information or documents and they are inaccurate it can cause the provider to fail initial credentialing or re-credentialing. 

While still quite cumbersome for now, if you find you are experiencing denials related to a provider’s non-par status and you follow the simple steps outlined above, you should be able to identify and rectify denials related to credentialing, contracting and linking to products and locations for commercial plans. Hopefully, the future will bring efficiencies that will make credentialing less cumbersome, less redundant and easier to maintain. Below are some initiatives to be aware of that will help bring change.
The Future: Government Plan Enrollment for Medicare, Medicaid and Tricare
Is it time for a change to reduce redundant and lengthy processing times? You Decide. In 2018, changes in government contractors for both Medicare and Tricare have only accentuated the inefficiency in having duplicative processes for enrolling providers in government plans that take far too long to process. Influencers like Medical Group Management Association (MGMA) and CAQH have noticed, and have become involved in defining more efficient means to use a single process for all government plans. Practices need to join such organizations to make their congressional leaders aware of the resources, costs, delays and lost revenue that are associated with the current manner processes.
While each of the Medicare jurisdictions’ contractors use PECOS and the same forms across the country to process credentialing applications for groups and individuals, these contractors typically have 180 days to process the applications. The transition in February 2018 in Southeastern states from Cahaba to Palmetto has led to maximum processing times being taken. Medicare contractors usually grant the requested effective date on applications as long as the application is received within 30 days of the effective date. Providers are not allowed to submit these same applications more than 60 days prior to the requested effective date. While applications are processing, providers can only get scant information about the status of an application, and if there is a request for further information or documentation it might inconsistently come by USPS mail, email or fax, causing concern by the submitter about the possibility of missing a development notice.  In the meantime, practices are seeing patients in good faith and suffering the cash flow consequences by not being able to submit and be paid for claims until the Medicare approval and reassignment documents are received.
Effective January 1, 2018, Tricare contractors changed for many states, except in the Southeast. UHC was ousted from the West Region, HealthNet was awarded the West Region, HealthNet gave up the Northeast and “assigned” its agreements to Humana Military that picked up the Northeast Region and kept its Southeast Region to now be the Tricare East contractor for the Department of Defense. The assignment of the HealthNet agreements and credentialing status of the associated providers for Northeast states was helpful, however, communication regarding if and how that assignment worked or finding someone at HealthNet or Humana Military to confirm that the practice was all set prior to January 1, 2018 was not optimal. And for providers in the West Region, there was no assignment of the UHC agreements to HealthNet, requiring providers to start from scratch to be contracted and credentialed, a process that takes several months.
Medicaid populations and needs vary from state to state, so it may make sense to allow states to have some autonomy with regard to how to run their respective Medicaid plans. Some states are more efficient than others, but most plans are difficult to maneuver through. In most states there are Medicaid managed care organizations (MCO) run by private insurers that are awarded contracts, but for a provider to enroll in these MCOs, a Medicaid number is usually required and delays in Medicaid enrollment at the state level further delay the effective date for the MCOs.
Since all of these plans are government plans, perhaps there needs to be some consideration for a centralized single application credentialing process for these three programs, or at least for the two CMS plans, Medicare and Medicaid. If you agree, reach out to your representatives and ask that they review the redundant and inefficient processes that exist today.
Delegated Credentialing
If your practice is large or associated with a hospital facility that has staff already adhering already to NCQA or Joint Commissions standards for facility privileges, consider asking the payer or network to delegate the credentialing function to the practice. A separate delegated agreement beyond the agreement for reimbursement of professional services is usually involved. A few payers may require NCQA Certification but many do not, instead requiring that you and your verification staff will follow the guidelines and be subject to periodic audits by the payer. Your practice would submit a roster to the payers to load your credentialed providers effective on the date each provider was approved as indicated on your roster. The advantages are enormous, one of which is the reduction in the time it takes to credential providers. Be sure that your agreement has a timeframe in which a payer must have the rosters loaded after receipt and be sure your billing staff is made aware of the effective dates and any billing waiting period.
Software Options to Manage Credentialing and Payer Enrollment
Numerous options are available for practices to manage the workflow related to enrolling a provider in networks. CAQH is used more and more by payers as the key source of information to manage provider enrollment and credentialing and re-credentialing. It is imperative to keep provider information and documents up to date to avoid payer inquiries for missing information and the possibility that a failure to respond could lead to disenrollment of a provider and, thus, claims denials. CAQH is working on a number of initiatives to further improve the enrollment process. One of these is the CAQH Enrollment Hub where providers can manage EDI, EFT and ERA set up. While not all payers are accessing this yet, there are select payers now requiring this for certain functions such as electronic funds transfer. The login for the Enrollment Hub will work for the practice as a whole, rather than utilizing a provider-specific login. 
If a practice has 1 to 5 providers, it may be possible to manage the many steps to enroll providers and maintain credentials without software. But even for a practice with as little as 3 providers, it may be helpful to have credentialing workflow software to manage the process, especially if the person responsible is accountable for additional functions.  Having software to manage the process can also add to continuity if the person handling credentialing leaves the practice or moves on to other positions. There are numerous options available for practices that handle their own payer credentialing and enrollment. Among them are the Echo OneApp, used by this author for 11 years, as well as Intellisoft, new comer Modio Health and others. A few of these have the ability to map information directly to enrollment portals or applications (rather than filling them out manually) and can query sources like licensing boards, OIG and DEA. They can remind you of expiring documents and can alert you when you need to follow up on a submission step. Shop carefully for the software and modules that best suit your practice, as it is usually very difficult to transition to another system at a later date.
Bundled Payments
There are credentialing considerations if you are getting involved in bundled payments programs. Let’s say you are an orthopedic practice and decide you will negotiate prices with payers. Perhaps you are hoping for a single fixed price for certain joint replacements that covers the cost of all services in an episode of care (everything from pre-screening to rehab, with surgery, anesthesia, imaging and labs included). If you are embarking on one of these shared savings and you are the bundler, the payers might require that you select providers already credentialed by the payer or you may be accountable for all providers needing credentialing. Be ready for this credentialing responsibility to meet payer requirements.
Payer Provider Directories: How are You Listed?
Many practices choose not to credential mid-levels and yet they want patients to be able to schedule appointments with the mid-levels. Additionally, a few payers do not credential certain provider types. By credentialing your mid-levels, they can be listed in directories for plan members to find them and know their services will likely be covered.
Another issue related to directories and credentialing stems from multi-location practices. Many practices opt to list all locations for all providers in credentialing documents. Since some payers will deny claims if the location of service is not consistent with a provider’s locations submitted for credentialing and enrollment, there is an incentive to list all locations. This leads to providers being listed in online directories at locations where a patient/member cannot make an appointment, which disappoints the member. CAQH has recently added a field to indicate a location may be covered by the provider or the provider may have limited availability, qualifying this information for directory purposes.
Wrap Up
Credentialing is a necessary process to ensure stakeholders have correct information in the process of steering members to vetted providers of care, processing claims, administering quality programs and more. The credentialing process has come a long way in the past 15 years but there are still great strides to be made in streamlining, reducing redundancy and shortening the timeframe in which the process is done. While some of the industry leaders take pride in identifying solutions and preparing for the next round of improvement, practices should strive to become more actively involved by working toward the completion and maintenance of accurate provider data, while also voicing opinions to upper management for commercial plans and to congressional leaders for government plans, to stimulate change that will improve processing nuances and the end product.
Learn more from Penny by listening to her credentialing webinar.

Penny Noyes is President & CEO at Health Business Navigators, a payer contracting and credentialing consulting firm based in Kentucky.

Blog Comments

Great Information Given From This Site About The Manage Credentialing and Payer Enrollment,The Future of Government Plan Enrollment for Medicare.
1/23/2020 4:32:06 AM

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