Data & Deadlines: The Ongoing Importance of Credentials

Health plans require all in-network physicians, whether part of a small practice or a large health system, to submit current credentials to the Council for Affordable Quality Healthcare (CAQH) database. While it may sound simple, creating a new application is a highly manual, time-consuming task, and the required quarterly updates for re-attestation can be onerous. CAQH requires extensive credentials including education, residency, internships and peer references. To show these credentials, hours must be spent uploading copies of licensing information, board certifications, DEA registration and insurance certificates.
Responsibility for maintaining and ensuring the accuracy of physician credentials typically falls on the shoulders of medical staff services coordinators or the office manager, although large health systems with hundreds of physicians may require full-time, dedicated staff to ensure CAQH compliance. CAQH sends email reminders 30 days prior to the expiration of documents, and expiring attestations. The quantity can be overwhelming even for a small practice. For a staff member whose job includes many responsibilities, it is easy to forget or overlook one of the many emails.

Re-credentialing is required by the health plans every 2-3 years and typically takes 90 to 120 days. CAQH is an integral part of the re-credentialing process. If a provider misses the quarterly deadline, the risk of falling out of network with multiple payers looms. Plus, the provider will be unable to see or bill patients, disrupting the revenue cycle and costing money in the long run.

To address the challenges providers face with CAQH, TriZetto Provider Solutions developed an end-to-end credentialing solution for all third-party insurance, governmental and CAQH payers. Our dedicated team takes provider data, reviews it for accuracy, ensures it is current and either initiates the CAQH process or verifies credentials for re-attestation. Having worked with payers and providers for nearly 40 years, we know exactly what will cause credentialing delays or denials and how to avoid them. Our process is accurate and efficient, which is especially important given the manual nature of CAQH. Having a dedicated team allows us to stay ahead of quarterly deadlines and prevent providers from being inundated with email reminders.

As payer technology and healthcare regulations continue to advance and become more complex, TPS can alleviate the headaches and associated costs of ongoing credentialing requirements. Our plans are affordable for a wide range of providers from group practices to large health systems, and currently we are offering pricing specials through the end of 2020.
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