Be proactive about your credentialing to avoid denials

Insight Article


Shannon Geis

If your providers are being denied on out-of-network claims or are seeing reductions in benefits because they are considered nonparticipating, it’s an indication of credentialing issues, says Penny Noyes, CHC, MGMA member, president, Health Business Navigators, Bowling Green, Ky. She discussed ways of avoiding denials and credentialing issues in her session, “Avoiding Denials Related to Credentialing and Product Participation,” at the MGMA 2016 Annual Conference. 

Noyes says the most common reasons for a provider being considered nonparticipating include not being credentialed or re-credentialed, credentialed but not linked to the contract, or credentialed and linked to the contract but not to all the payer’s products.

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To address these issues with your credentialing, Noyes recommends running a report of all your claims to figure out what’s going on. “Sometimes the billing staff doesn’t notice the trends,” she says. “That’s why reports can be so helpful.”

To ensure your report is useful, make sure you are capturing the denial reason codes. “If you can capture everything in one place, then you can see the full picture,” Noyes says. And figure out what holes need to be patched. “You’ll be able to pinpoint and drill down on the issue,” she explains. 

To build out your report, Noyes recommends gathering an inventory of all your contracts and provider information, including:

  • A list of payers or networks and products

  • All your location information (if you have more than one clinic)

  • Each provider’s name, date of birth, national provider identifier and Social Security number

You also should collect provider start dates, Provider Transaction Access Numbers, CAQH ProView logins and providers’ previous practice information, in case a provider is credentialed but linked to a different organization.

Once you have collected this information, Noyes says to contact each payer or network you are contracted with to ask if each provider is credentialed. If a provider is not properly linked or not credentialed, find out what needs to be done to fix the issue.

Once you have created your report, it should be easy to understand what steps to take to address your credentialing issues, Noyes says. Make sure you follow payer instructions for credentialing and follow up with the process regularly; update and maintain CAQH; and set up alerts to make sure you know when to follow up or when information needs to be updated.

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Address common mistakes
Noyes says that one of the most common credentialing mistakes practices make is not keeping the CAQH ProView database up to date and attested. “Make sure supporting documents are correct and the most recent,” Noyes says.

Similarly, Noyes often sees practices with Medicare revalidation issues. “Be proactive and verify your validation ahead of the due dates,” she says. Knowing when your documents expire and setting up alerts to remind staff and provider of expiration dates can go a long way in keeping your credentialing in good shape, explains Noyes. 

If a provider is nonparticipating with a particular payer or product due to credentialing issues, make sure schedulers know not to schedule patients with those payers or products until the issue is fixed to avoid additional denials. “The front office is a key part of the information chain that is often forgotten about,” Noyes says. 

Other considerations
If your practice has more than 10 providers, you probably want to consider using credentialing software to assist with your tracking and workflow, Noyes says. But, she warns, “The software isn’t going to do everything for you. You still need to be diligent and follow up with payers.”

And if you are a large group with 100 or more providers, Noyes recommends you seriously consider requesting that your practice be delegated to do its own credentialing. “This eliminates some of the back and forth between you and the payers and can make your credentialing process much faster,” Noyes says. But you would also be subject to auditing by payers. 

By being proactive about your credentialing and tracking your contracts, you can stop issues with claims denials quickly or avoid them all together, Noyes says.

About the Author

Shannon Geis
Shannon Geis
Staff Writer/Editor MGMA

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