More than half of practices report credentialing-related denials on the rise in 2021

Many medical practices working to recover financially from a year and a half of pandemic disruption cannot afford further issues with revenue flowing in, but healthcare leaders who responded to the latest MGMA Stat poll say denials related to credentialing are a growing issue for their practices.



More than half (54%) of medical practices report denials related to provider credentialing have increased thus far in 2021, while 41% say they have stayed the same and only 5% note these denials have decreased this year.

The poll was conducted Aug. 24, 2021, and had 425 applicable responses.

Regardless of geographic location, onboarding new providers and completing payer credentialing can be laborious and frustrating for the medical practice team and providers themselves. The most common responses from practice leaders experiencing increased denials include:

• Long delays in processing new provider applications. Several practice leaders report that the time lines to get new providers credentialed with payers are growing longer and seemingly “take forever,” as one practice leader noted. This latency in payer response time often results in claims from providers — who have otherwise submitted full, accurate applications — being rejected. In some cases, payers are taking as much as 100 days to provide an effective date for a new provider and not allowing for any retroactive claims following approval.
• Lack of communication from payers to medical practices. Many practice leaders who responded to the MGMA Stat poll noted that they encounter “long wait times and no correspondence if there are problems” when they reach out to check on application status or deal with errors.
• Frequently changing and varying requirements. The proliferation of sites and contacts among payers — and lack of standardization among them — often creates a mess when it comes to provider organizations accessing and updating files with payers.
• Closed networks/issues with new plans. Several poll respondents noted they are getting increasing numbers of responses from payers that their networks are not accepting new providers. Others note that new plans from some insurance companies will not include providers and subsequently deny claims for being out of network.
• Outright discrepancies. Many practice leaders said that they’ve encountered payers that have dropped providers from their group from a network, causing claims to be processed out of network. Other respondents said providers have been placed in the wrong taxonomies by the payer. These errors then require outreach to the payer to get them corrected, causing delays in proper claim processing.

This comes despite several waivers in Medicare provider enrollment being introduced in 2020 to provide relief to medical practices during the COVID-19 pandemic. The Federation of State Medical Boards also has several resources relating to waived licensure requirements during the pandemic and other emergency measures.

According to a 2019 Merritt Hawkins survey on physician inpatient/outpatient revenue, a one-day delay in provider onboarding can cost a medical group $10,122. These denials, in addition to holding up payments to providers, are often much more labor intensive for the practice. As noted in a September 2019 MGMA Stat data story, a simple denial can take a seasoned biller two to eight minutes to work, whereas a complicated denial — often involving prior authorization requirements — can take up to an hour to work, especially due to long on-hold times with payers.

Do you have any best practices or success stories to share on this topic? Please let us know by emailing us at connection@mgma.com.

Free webinar on provider onboarding and enrollment

When it comes to provider onboarding, credentialing and enrollment, medical practices need proven strategies and solutions that accelerate the enrollment process, decrease costs and increase revenue. Although provider credentialing and enrollment can be tedious, claims will not get paid without them. MGMA’s free on-demand webinar, “Maximize Your Revenue with Timely Provider Onboarding and Enrollment,” will help you develop an efficient, streamlined onboarding, credentialing and enrollment process within your organization to help save you time and money. Attendees will learn best practices in automation of functions and elimination of manual tasks that reduce time to revenue and improve provider satisfaction, allowing your team to focus on other priorities. 

New online seminar

Without a proper foundation of accurate credentialing, revenue can be lost or delayed, liabilities can emerge, and the organization’s bottom line can be negatively impacted — not to mention bottlenecks on healthcare professionals’ time, as well as coverage and referral issues. MGMA offers a three-hour, on-demand online seminar, "Provider Credentialing 360: Tools and Knowledge to Maximize Your Revenue" to guide attendees through best practices for information technology and human resources considerations for the credentialing process. Attendees will receive interactive provider templates and tracking tools to use in their practices.

Learn more at #MPE21

Join us Oct. 24-27 in San Diego for the Medical Practice Excellence: Leadership Conference. On Day 3, Les Jebson, MHA, FACHE, FACMPE, executive director, Texas A&M Health, will present “Streamlining Provider Onboarding and Credentialing.” This interactive presentation will share best-practices and insights for making measurable improvements to these processes, including optimizing communications, information technology and human resources to tackle the credentialing process and make a providers’ transition into a new practice as painless as possible. [Note: This session also will be available during the #MPE21 Digital Experience (DX), Nov. 16-18.]

JOIN MGMA STAT

Our ability at MGMA to provide great resources, education and advocacy depends on a strong feedback loop with healthcare leaders. Sign up for MGMA Stat and make your voice heard in our weekly polls: Simply text “STAT” to 33550 or visit mgma.com/stat. Polls will be sent to your phone via text message.

Additional resources

• MGMA Benchmarking Data — Understand the past and present to propel your practice into the future with industry-leading data analysis, reports and surveys.
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• Medical Practice Excellence: Leaders Conference — Connect with industry-leading experts and peers to learn and grow. In-person Oct. 24-27 in San Diego, or Digital Experience (DX) Nov. 16-18.