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  • Writer's pictureEligibilityOneᵀᴹ

Prevent Claim Denials with Accurate and Timely Credentialing

In order to prevent claim denials, accurate and timely credentialing is essential to your practice.

Credentialing has a major impact on the revenue cycle as the slightest error or interruption in the process can result in claim denials, underpayments, and reimbursement delays.

And payments for services delivered are not the only thing at stake – you also risk losing the business of patients who don’t want to go out of network while you wait to be accepted by their insurance plans.

You can prevent claim denials and other damages to your revenue cycle through accurate and timely credentialing. By both avoiding credentialing mistakes and completing the credentialing and re-credentialing processes as quickly as possible, you can protect your practice’s cash flow and revenue integrity.

Below we outline just a few of the credentialing mistakes that can affect reimbursement by holding up credentialing applications and/or causing claim denials.

Avoid these mistakes that cause application processing delays or rejections:

  • Not allotting enough time for the credentialing process

  • Errors in credentialing application paperwork and contact information

  • Omitting required information or documentation from applications

  • Leaving form fields blank or not fully completing each form

  • Unexplained gaps in work history

  • Unresponsive or lagging peer references

  • Malpractice insurance for the practice a provider is leaving, rather than the one they are joining

  • Outdated or incomplete CAQH application

  • Lack of follow-up on application status

Avoid these credentialing-related billing and compliance mistakes:

  • Submitting a claim using physician or practice data that does not match what the payer has on file

  • Submitting a claim for an office location that is not in the payer’s system

  • Failing to confirm payers have the correct provider billing address

  • Forgetting to notify a payer when a provider terminates (e.g. resigns, retires), when the plan requires the practice to do so within 30 days of the termination

  • Not realizing that credentialed providers may need to opt-in to new plans that a payer has added

  • Not realizing that credentialed providers may need to opt-out of new plans that a payer has added, or they may automatically be included in them

  • Missing deadlines for CE requirements

  • Missing renewal deadlines for expiring certificates, licenses, insurance, etc.

These solutions can help ensure you avoid credentialing mistakes that impact the revenue cycle:

Prevent Claim Denials with an Annual Health Plan Audit

Conduct an annual health plan audit to verify your providers are participating in the correct plans, payers have been updated on your current roster of providers, and front desk staff understand the plans with which you hold contracts.

You should audit regularly to keep up with provider and front desk turnover and periodic changes to health plans. EligibilityOne provides a health plan audit service, which typically takes fewer than 30 days to complete.

Prevent Claim Denials Related to Ongoing Credentialing Maintenance

Additionally, you should continuously monitor your providers’ compliance with health plans. Even after providers are enrolled with payers, there are plenty of opportunities for reimbursement issues resulting from compliance violations and/or recredentialing/revalidation errors.

EligibilityOne tracks our clients’ expirables (e.g. certificates, licenses, malpractice insurance, CE credits) and our automated, real-time messaging alert system notifies practices and providers of upcoming deadlines 120, 90, 60, and 30 days prior to expirations.

Through deficiency management we can help you prevent claim denials related to avoidable compliance breaches.

Prevent Claim Denials by Outsourcing Credentialing

Outsource credentialing with EligibilityOne and we will prevent claim denials related to credentialing issues for you. Our Credentialing Specialists are experts in correctly and quickly completing all tasks related to credentialing and compliance for our clients.

We make sure you avoid the credentialing mistakes listed above and our credentialing technology solutions streamline the process to get you credentialed and recredentialed with your payers faster.

Contact us today to learn more about how our accurate and timely credentialing services can prevent claim denials and protect your revenue.


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