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You would be wrong to assume that the credentialing process is over once a provider has been accepted into a payer’s network. In fact, providers are required to undergo routine screening and license verification to maintain compliance and provide quality care to their patients. This process that involves periodic screening and verification is what we call recredentialing. 

Recredentialing process is done to verify the training and qualifications of a provider and notify healthcare organizations if fraud or abuse is found. Now it is no secret that undertaking the credentialing process is no easy task. It can be time-consuming and burdensome. However, the cost of neglecting the procedure can be much direr. 

Hospitals and similar healthcare organizations are staring at revenue losses in the upwards of millions on litigation, delayed payments, and civil monetary penalties without recredentialing. 

Now that you know how important the process of recredentialing is, we will take a deep dive into the subject to make sure you learn everything there is to know about it. 

So without much further ado, let’s get started. 

Read More on Importance of Medical Credentialing

  How Many Time Does a Provider Need to Be Recredentialed?

The answer to this question will vary from state to state. In most American states, the provider must be credentialed immediately when hired. Later, they must undergo re-credentialing every two years. There are exceptions to this rule, however, as some states like Illinois require providers to be recredentialed every three years. 

To know exactly how often a provider needs to be recredentialed, it would be wise to check state laws and regulations that apply to your healthcare organization. 

  The Initial Requirements for Recredentialing

First and foremost, it is the responsibility of the healthcare organization to notify the doctors and nurses working under them at least 60 days before the recredentialing due date. Providers should be given access to all applications online. Remember, the recredentialing process varies from state to state and can take months to conclude. 

To expedite the process, we recommend keeping the necessary documentation on file. We also suggest preparing organization-specific requirements well ahead of time. If the process is too overwhelming to handle, we recommend you give us at DENmaar a call and our credentialing specialists will be happy to shoulder the recredentialing process on your behalf.

  Information Verified During Recredentialing

A traditional recredentialing process will entail the verification of the following documents:

• •     Drug Enforcement Administration or Controlled Dangerous Substances Certification
• •     State Licenses
• •     Board Certification
• •     Malpractice Claims History
• •     Work History
• •     Recent Malpractice Insurance Coverage
• •     Medicare and Medicaid Sanctions
• •     National Provider Identifier Number (NPI)
• •     State Sanctions and Restrictions on Licensure and Limitations on Scope of Practice. 

  What Happens When an Application is denied?

A provider is notified with a written notice that includes the reason for denial in case their application is rejected by the credentialing committee. Providers have the right to submit an appeal contesting the denial. The provider must request reconsideration in writing within 30 days of receiving a denial. 

The written request must be submitted along with the necessary documents. The reconsideration will be scheduled within 60 days. Remember, the provider has no further option if his or her claim is denied a second time. 

Learn More on How to Avoid Payer Rejection During Enrollment

  Getting Recredentialed Without a Hassle

Issues with recredentialing are more common than you would assume. That being said, there are ways by which you can make sure those issues never arise during your procedure. To begin with, healthcare organizations should maintain evidence of a provider’s application in a secure credentials file. They should also adopt a system that keeps all relevant information current. 

However, the only guaranteed way to make sure you don’t fail with recredentialing is to seek help from credentialing specialists in the industry like DENmaar. DENmaar has been helping healthcare organizations across the United States with credentialing provider enrollment for decades now. As such, we have the talent, resources, and insight needed to handle the complex process of credentialing at the behest of your healthcare organization. 

You can get in touch with us now to learn more about DENmaar’s recredentialing services. 

Getting enrolled into an insurance company’s network isn’t an easy task. Throughout the process, you’ll find that you have very little control over the outcome of the entire proceedings. You’ll find yourself at odds with the insurance companies whose network you so desperately want to join. Chances are that things might not pan out as you’d hoped. 

Payer rejection is a reality that most providers do not want to ever encounter. Sadly, hearing a straightforward ‘No’ from payers after a very lengthy application process is more common than you can imagine. Most of the times providers have no clue what led to the rejection. What exactly went wrong that warranted the denial of an application? You’ll probably never know. 

You can take solace in the fact that you are not the only healthcare provider in America that had to go through this ordeal. Getting paneled is not easy. It isn’t impossible either or as complicated as most people spell it out to be. There are a few steps or measures a provider can take to overcome a denial during enrollment. 

This article will give you a peek at those tips, but first… let’s understand why application denials even happen in the first place. 

  Reasons for Insurance Panel Denials

You have to understand that insurance companies have the ultimate power to set and adjust the number of providers they accommodate into their network. Payers want to save costs for themselves while at the same time trying to fulfill the promise of better healthcare that they’ve made to their enrollees. As such, payers have a plethora of reasons to deny applications. 

They can reject an application because of an error in the application, wrong or missing information, or if the provider doesn’t meet the dictated qualification criteria. Payers may also reject an application if they are currently not accepting providers belonging to a specific demographic.

Read More: Importance of Medical Credentialing

Other typical reasons for payer rejection maybe because of the following:

• •     Failure to meet provider standards as dictated by the payer. 
• •     Over-saturation of a provider type pertaining to a service area or community.
• •     The provider failed to comply with the payer’s conditions of participation.
• •     The provider failed to meet requirements pertaining to out-of-state enrollments. 

  Persistence is Key to Overcoming Payer Rejection

Normally it’s typical of providers to simply give up once their application has been rejected. However, what they aren’t aware of is that they still have time to turn the tides in their favor. There are, in fact, a ton of things you can resort to in a bid to overturn your rejection. We know this can be daunting. As such, we highly recommend hiring a credentialing specialist to advocate at the behest of your case in front of the payers. 

To begin with, try to request a face-to-face meeting or a conference call with the decision-makers to clearly convey your case. Remember, persistence is the key. Do not take ‘no’ for an answer. Reach out to the authorized personnel in the payer’s office to understand why your application was rejected and what you can do to fix the situation. 

You can use LinkedIn to find the right people to talk to. For instance, go to LinkedIn and search employee titles under the payer’s company name. Try to connect with provider management representatives and initiate a conversation with them. 

Most of the time, the reason behind denials has to do with the provider type. In such a scenario, providing more information even though the payers haven’t asked for it can make a lot of difference. Convey the demographic and the patient population you serve as a healthcare provider. This is more important if the demographic is related to any of the following:

• •     Non-English-speaking communities.
• •     Rural
• •     Disabled
• •     Geriatric
• •     Pediatric
• •     Chronic Condition

  Steps to Take for Simple Provider Enrollment

You can try several things to get yourself enrolled successfully on the insurance company’s panel. A few of the things you can try are as follows:

• •     Get letters that convey support from the community you serve. 
• •     Seek a second-level appeal from a decision-maker or manager of the insurance company. 
• •     Suggest a trial period where you will only serve a select number of patients, offering free comparison analysis when that period has concluded.
• •     Make use of a phone instead of email or letters to clearly convey your message. 
• •     Request a face-to-face meeting and set up a conference call. 
• •     Compose a letter that shines a positive spotlight on the services of your practice or clinic. 
• •     Host an in-service visit to help payers better understand your services. 

Learn more on Medical Credentialing Process

Getting paneled with an insurance company is no child’s play. It is an excruciatingly long process with multiple moving parts. One wrong move and you must undertake the entire enrollment process all over again, which can be both time-consuming and costly. As such, it is in your best interest to seek the help of credentialing specialists to guide you throughout the process. 

This is where DENmaar’s provider credentialing services come into play. DENmaar is home to highly qualified credentialing experts that shoulder the responsibility of provider enrollment on your behalf. We do not rest until your place on the payer’s panel is secure. 

To learn more about our credentialing and provider enrollment services, we recommend you contact us today. 

Medical Credentialing can be defined as a process of verifying whether a healthcare provider is capable of performing his duties. This often complex and long procedure involves checking the credentials of a provider such as his or her education, residency, licenses, certification, training, etc. This makes credentialing a fundamental process, which is undertaken to help medical organizations against revenue losses and patients against poor-quality healthcare.

As such, medical credentialing is integral to the success of a healthcare practice. No healthcare practice, clinic, or hospital can hope to succeed without undergoing the medical credentialing process. 

Regardless of whether you are running an established practice or are new to the game. Credentialing is something we at DENmaar recommend all medical practices take care of as soon as possible. To further convince you about the overwhelming merits of credentialing, we would like to shed light on a few facts about credentialing that every medical practitioner and enterprise should know about.

So without much further ado, let’s look at all of them.

1) Credentialing is Important to Prevent Revenue Losses

As someone running a medical practice, you must understand how important credentialing is to your enterprise’s revenue cycle. It is imperative to get credentialed if you expect to treat each and every patient that crosses the threshold of your medical practice. You have to be enrolled with insurance companies to get reimbursed for the care you provide.

It is highly recommended that new providers wait to treat patients until their credentialing process is complete. Moreover, established physicians themselves cannot treat their patients or receive payments from insurance companies for the care provided if their credentials have lapsed. They will have to wait until their credentials are again approved and verified to expect reimbursement for their services from insurance companies.

So both credentialing and re-credentialing are important to maintain the integrity of a healthcare organization’s revenue cycle. Timely credentialing ensures that a medical practitioner or practice is enjoying an optimal influx of revenue for the care they are providing.

2) Boosting Patient Confidence

As we mentioned before, the most important purpose of credentialing is to assure patients that the doctor and nurses in charge of their medical care are qualified to do their job and thus can be trusted with their care. Credentialing gives patients the peace of mind they need as they essentially put their lives into somebody else’s hands.

With credentialing, patients can rest easy knowing there was a rigorous process involved to verify the merit and experience of the healthcare provider taking care of them. The credentialing process can be a great way to identify deceitful providers and prevent them from defrauding patients.

3) Accuracy is Non-Negotiable with Documentation

Even minor errors during the documentation of your credentialing process can cost you dearly. It is extremely important to be careful when filling in important information that is mandatory for credentialing. There is an extensive amount of paperwork involved, which must all be executed accurately and in a timely manner.

Entering the wrong details, missing out on key information can delay the credentialing process for weeks. Worst case scenario, your application is rejected and you have to go through the entire credentialing process all over again. Suffice to say, this can be extremely frustrating. Hence, we recommend getting the documentation part right on your first go itself.

We also recommend having all the necessary paperwork in place as dictated by the National Committee for Quality Assurance. As such, you will have proof of due diligence and records, which can come in handy in the event of a claim’s denial or audit.

4) Follow-Up and Begin Early

Credentialing is an excruciatingly long process. The entire process can take somewhere around 90-120 days to conclude. So we recommend you start as early as possible to get credentialed in order to start inviting patients to your practice. You can hope to expedite the process by making sure all paperwork is taken care of and all details are filled incorrectly.

Make sure you follow up as frequently as possible with your verification sources. Request them to send you verification responses immediately. Follow-up throughout your credentialing process, right up until your application is approved. Do not stop until you’ve secured your enrollment.

5) Credentialing and RCM Go Hand-in-Hand

As Credentialing can help prevent revenue losses, it is only natural to draw a connection between it and a medical organization’s revenue cycle. Poor credentialing will result in delayed payments, claim denials, loss of revenue, and a number of other issues that harm an organization’s revenue cycle. In other words, credentialing helps keep the revenue cycle running, and as such, should be taken seriously.

The Bottom Line

Credentialing is extremely fundamental and no medical organization or practitioner can afford to ignore it, lest they don’t seek success in the ever-volatile and evolving healthcare industry. That being said, the credentialing process isn’t exactly child’s play. It can be time-consuming and dauntingly complex.

Most practitioners simply do not have the resources, time, or skill needed to handle the process efficiently. Fortunately, this is where we at DENmaar become so valuable. Outsourcing your healthcare credentialing burden to us will help your practice save time and money.

DENmaar is home to a team of credentialing experts who handle all the nitty-gritty details of the credentialing process at your behest, making sure you submit accurate claims and secure your enrollment with insurance companies to start treating patients.

From documentation to frequent follow-ups, we’ll take care of it all. You can contact us today to learn more about DENmaar’s medical credentialing service.