In the healthcare sector, maintaining standards is essential to ensure high-quality medical care is provided to patients. There is no room for treatment errors and costs remain optimum; that’s why credentialing is crucial. Credentialing is a quality assertion process among medical practitioners to bring down the incidence of medical errors. Provider credentialing involves a thorough verification of a practitioner’s educational qualifications, licensure, previous practices, training background, and more. Credentialing is conducted before getting hired to a healthcare facility or adopting a new insurance provider. But credentialing is not an easy process including endless documentation, follow-up, and credentialing in-house staff. Provider credentialing mistakes can lead to financial losses on services, delays in claim reimbursements, fines or penalties, exclusion from federally funded programs, and harm to patients. In this article, we discussed avoiding common provider credentialing mistakes which can help you to dodge malpractice suits and accreditation problems.
Lack of Credentialing Experts
Physician credentialing, also known as medical or provider credentialing, is a tedious process that requires precision, attention to detail, and patience. All certifications and licenses must be verified for every provider who administers services to patients. Depending on the size of the group practice, it might be required to verify the employment histories and qualifications of all providers within the practice. Each provider’s education, medical training, residency, licenses, as well as any certifications issued by a board need to be verified.
Properly credentialing every single individual is an enormous amount of work for a team to handle. Generally, providers try to manage the credentialing process on their own or they ask billing team members to handle additional credentialing responsibilities. Hospitals or healthcare organizations may not allocate adequate resources or staff to complete the medical credentialing process, resulting in lost revenue and stressed, overworked staff who are more likely to make mistakes.
Incomplete Enrollment Applications
The average physician enrollment application requires an overwhelming amount of information and data. Most of the times providers or their billing team fills only available information and keeps some of the fields blank. Insurance carriers will not process such applications and could communicate for required details. Failing to accurately fill out the application in its entirety causes delays in reimbursement and denial of claims. The best way is to call the credentialing department of the insurance carrier and confirm that they received your application with all the required details. If required get an acknowledgment from them and ask for approximate days to process your application.
Physician Treating Patients Before Credentialing
Practices may ask providers to start treating their patients before they receive credentialing status. Submitting a credentialing application is not sufficient, you have to complete this procedure successfully. Courts have ruled that hospitals can be held liable when a physician falsifies his credentials. In a frequently cited negligent credentialing case, an Illinois jury awarded the plaintiff nearly $8 million dollars when the patient’s foot had to be amputated due to damage caused by the operating physician who had not completed his 12-month podiatric surgical residency and was not board certified.
Failing to Complete Recredentialing or Revalidation
Healthcare practitioners need to renew their licenses and credentials on a regular basis, according to the laws of the state in which they practice. Initial credentialing and re-credentialing every three years ensure that healthcare physicians are up to date with their board certifications and licenses. When hospitals fail to stay on top of re-credentialing, it could lead to physicians and facilities performing services they’re not certified or licensed to perform. This creates the potential for negative patient outcomes, which can lead to expensive malpractice lawsuits.
Failing to Complete Background Check
Failing to disclose an adverse action is a serious oversight by any physician, but it is also the responsibility of a healthcare organization to conduct screenings for prior disciplinary actions with a thorough background check. It’s critical that hospitals and healthcare organizations verify credentials against a wide array of databases such as exclusion, sanctions, and debarment lists. It’s important to use a trusted source that pulls data from primary sources. The Office of Inspector General (OIG) exclusion list is one such source to screen against.
Physicians are required to report adverse actions, such as license revocation; exclusion from third-party programs; and suspension or voluntary relinquishment of medical staff membership, clinical privileges, or state or federal DEA licenses. Hospitals and health systems will be held accountable for a physician’s omission. Therefore, due diligence requires background checks to identify both current and historical adverse actions be performed.
Avoiding Common Provider Credentialing Mistakes
Although physician credentialing may be tedious, it’s essential for your practice to complete it for every provider as it safeguards practice against risk and noncompliance. Thorough and ongoing physician screening is critical to avoid costly negligent credentialing and malpractice claims. Rushing this process leads to missing information, errors, and delays in reimbursement. As healthcare regulations evolve and credentialing requirements become more complex, healthcare facilities must be proactive in updating their credentialing processes to avoid making mistakes that put patients and themselves at risk.
Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle services. Our credentialing experts are well-versed with the complete processes and required documentation for private and government payers. Our credentialing team continuously takes follow up on submitted application with payers to ensure any missing or additional details. If you need any assistance in the provider credentialing or revalidation process, contact us at info@medicalbillersandcoders.com/ 888-357-3226.
