It is not startling to learn credentialing denials are a leading cause of non-payment. For health centers, the challenge is more difficult because each individual provider needs a participating National Provider Identifiers (NPI) with top payers as well as one for each facility location.

The Medical Group Management Association (MGMA) published an article indicating more than half of the surveyed group practices have seen a post COVID uptick in credentialing denials.  Below are credentialing challenges from the article followed by a PMG recommendation for consideration.

 “Long delays in processing new provider applications. “[L]atency 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.”

Recommendation: Every payer has a credentialing committee meeting at least monthly, sometimes biweekly. Know the dates and be the “squeaky wheel” affirming each payer’s credentialing staff that your providers are fully prepared to be approved; i.e., no missing data or questions regarding participation status viability. A complete application sitting just a week or two too long can result in the application failing because it is now “too old” to assure information is current.

“Lack of communication from payers to medical practices. Many practice leaders… [say] …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.”

Recommendation: Reiterating above. Don’t wait for trouble to get to know the credentialing team at your payers. AND, you should know each credentialing committee has local doctors on the committee. Maybe you could get a doc from your health center on the committee!

“Frequently changing and varying requirements. The proliferation of sites and contacts among payers — and lack of standardization… — often creates a mess when it comes to… [healthcare] organizations accessing and updating files with payers.”

Recommendation: If you don’t have a credentialing organization chart (e.g., something as simple as “X” axis for providers and “Y” axis for payers) or software to track/convey which NPIs are (are not) active, you need it. AND, setting reminders for recredentialing/re-enrollment is essential to maintain active status. This is not simple nor for the faint of heart.

“Closed networks/issues with new plans. [Providers] are getting increasing numbers of responses from payers that… 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.”

Recommendation: This smacks of healthcare gerrymandering; i.e., payers selectively limiting networks affording them opportunity to deny claims (often for the most vulnerable) because providers are “out of network” or “non-participating.” Remember that most states have “any willing provider” clauses requiring payers to accept providers willing to accept their fee schedules. Couple that with health centers being in Health Provider Shortage Areas (HPSA) and this is an avoidable challenge for health centers.

 “Outright discrepancies. [P]ayers… have dropped providers from their [participating status] … causing claims to be processed out of network. Other[s] have been placed in the wrong taxonomies by the payer...”

Recommendation: First and foremost, make certain employed providers sign an attestation that CAQH is accurate/current as this is a source or info for most payers. Remember, staying on top of enrollment/credentialing/privileging status requires tedious and consistent follow up. Instead of trusting what your health center believes to be accurate/current in terms of participation status, survey major payers. Use your health center’s provider roster to verify every NPI’s enrollment status and timeline for renewal, recredentialing, and/or re-enrollment.

A health center does not need to outsource credentialing, enrollment, and privileging as long as they have a bullet-proof process to get things done well. If uncertainty exists, contact PMG Credentialing or another qualified professional to obtain a gap analysis or determine how a partnership might benefit your team.