5 Medical Credentialing Process Pitfalls To Avoid in 2022

The medical credentialing process (also known as physician credentialing or provider credentialing) is a tedious, resource-hungry, and time-consuming exercise. Just like physical exercise, it is not something you do once-off, and then it is done and dusted. It is a necessity in your medical practice, whatever the size of your operations, that requires continuous attention.

Medical credentialing is required for physicians and the, nurses, physician assistants, and therapists. Basically, everybody involved in attending to patients need to go through the process of verifying their credentials.

There are certain credentialing process pitfalls to avoid and, if neglected, could lead to detrimental ramifications to your business, such as loss of income and lawsuits in extreme cases.

Sounds easy, right? So why the big fuss?

The need for Credentialing

Credentialling errors lead to financial losses in the form of delayed claims reimbursements, penalties, and exclusions from federally funded programs. In the worst cases, it could lead to harming patients and malpractice lawsuits. This is not just a scare tactic but a real possibility.

Harm to a patient could have been avoided when it was discovered that an operating physician had not completed his 12-month podiatric surgical residency. He was also not board certified. The patient’s foot had to be amputated due to damage inflicted by the physician, which led to an 8 million dollar claim. Credentialing would have prevented this tragedy from happening.

But let’s look at the other part of the glass that is half full. Credentialling, albeit a legislated necessity, does have plenty of advantages for your business- especially when it comes to growth potential. Once approved and placed on the list of in-network providers for insurance companies, you become more visible to potential clients in your area.

Not only does it instill trust in your practice, but patients will prefer to go with practices that are covered by their respective insurance companies. In a previous article, we produced an extensive list of the advantages of proper credentialing that might be worth a glance.

Medical Credentialing Process Pitfalls To Avoid

Previously, we mentioned that it is a resource and time-consuming task but let’s dig a little deeper into that statement and look at some of the reasons why we say so.

The insurance credentialing process could take anything between 60 to 90 days, with another potential 30 days to be expected for the contracting phase. Medicare enrollment takes, on average, 41 days. Any error in the application, lack of following up, or omitted documentation could drag out the process even more.

Over the last decade, we became aware of certain pitfalls that prevented clients from achieving successful and time-efficient credentialing. Suppose you decide to take on this stomach-churning task by yourself. In that case, we highly recommend you pay attention to the following credentialing process pitfalls to avoid.  

  1. Know your State’s Regulations 

We discussed state regulatory requirements in one of our previous articles. It is vital that we point out once more as there is still confusion in the market about what it entails, leading to delays in the credentialing process. 

The most important thing to remember is that there is no one-size-fits-all regarding medical credentialing. States have different laws regarding credentialing, and it is essential to know what your state requires. Some states do have reciprocal agreements, which means that the credentialing in State A is allowed in State B. This is not the case across the board. You could save yourself a lump of time by finding out first before starting the process. 

Every state has specific requirements for different sectors in the medical field. Chiropractors, for instance, must pass specific state exams, NBCE exams or both, and this is required in all the states. For example, only 17 states license naturopathic physicians.

Discovering your specific state laws and requirements and what reciprocal agreements are in place is where professional service providers with experience within this field could save your practice time and effort. 

  1. Gather your documentation

The information in the Council of Affordable Quality Healthcare’s (CAQH) database must be accurate, or it will delay the credentialing process. Studies show that 85% of applications have some type of information error, such as outdated, missing, or inaccurate information. 

Be attentive when collecting information the first time. It will speed up the process and save you time and effort in the long run, as mentioned in one of the previously published articles. State credentialing can take between 90 to 150 days, and you wouldn’t want unnecessary delays caused by submitting inaccurate information. 

Each individual tasked with patient healthcare in your practice must go through the process. Each individual needs to submit educational qualifications, employment history, training, certificates, residency, and licenses, and sometimes even CPR or RBT certifications are required. Again, it becomes vital to master the first step mentioned above -knowing your state requirements- as the documentation required differs from state to state.

  1. Submit your application

It is required that a pre-application be submitted, depending on the practice or insurance network. This filtering mechanism entails a background check to block medical personnel that wouldn’t qualify for medical credentialing. The focus is on criminal records and disciplinary actions, records of disciplinary actions, and board certifications.

Once past the pre-application process, you are now ready to submit all the required information. Again you must do this correctly during the first try to prevent delays. The longer the credentialing process takes, the longer time it would take before your services can become billable.

In one of our previously published articles, we went into the details of joining networks for the first time and how they assign effective dates. For your convenience, here is an extract from that article. It is a physician credentialing checklist that could help you tick all the boxes of the credentialing process.

  • Educational history and transcripts. 
  • Current medical license, DEA registration, and board certification. 
  • Work history. 
  • Evidence of continual malpractice coverage. 
  • Personal immunization records. 
  • Personal health history. 
  • Professional and personal references. 
  • Explanation of any gaps in work history. 
  • Hospital privilege or hospital affiliations 
  • CAQH enrollment 
  • Letters of recommendation 
  • Copy of resume  

Yes, tiresome indeed. And then, after jumping through all of the hoops, crossing all the t’s, and dotting all the i’s, something trivial could still cause a delay. This brings us to our next pitfall…

  1. Don’t forget to follow up on your application

You might think that you can just go about your days now and wait for the green light of approval, but many of our previous clients had to learn the truth the hard way and will warn you of another pitfall. The world of credentialing is not perfect, and you need to be cautious throughout the process. 

As mentioned in one of the other checklist articles, it is vital that you do a follow-up immediately after submitting your application. This is to ensure that the application is indeed in progress and there isn’t anything missing. There had been incidents where insurance companies didn’t inform the individual about errors in the application, which delayed the already lengthy process.

  1. Know your timelines and plan accordingly

Sadly, credentialing from insurers has been reported to take as long as six months. As mentioned before, some insurance companies require credentialing before payor contracts and payments are allowed. Knowing the exact details regarding the issuing of the effective dates of the insurance companies goes a long way when it comes to planning future cashflows.

In a previous article, we revealed the specific timelines to be expected for the various stage gates of the process. Here is a summary of what to expect if you do the credentialing process by yourself: 

CAQH NumberCompleting and submitting documents online can take up to three hours
NPI NumberApplication for NPI number may take thirty minutes (NPI for individuals, NPII for organizations)
Insurance credentialing60 to 90 days
Insurance contracting30 days
State credentialing90 to 150 days

Conclusion: Consider hiring an experienced team and avoid those pitfalls

You probably realized by now what we meant right at the start when we said that credentialing is a tedious process. It is a mind-numbing process, and its convoluted nature creates many pitfalls that could lead to a subsequential loss in time and revenue. 

If you still prefer to go on this treacherous journey by yourself, we suggest that you study our previous articles as well (linked at the bottom of this page), which could alleviate some of the pain on your way forward.

The ideal solution would be to leave this process in the hands of a reputable professional company specializing in the medical credentialing field. Neolytix has dedicated personnel with vast experience who go through these time-consuming processes daily, leaving you and your personnel to focus on more pressing matters within your organization and shortening the credentialing process.