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Did you know that about 54% of medical practices report denials related to provider credentialing and enrollment?
These denials occur when a payer refuses to reimburse a healthcare claim. They can be categorized as either hard denials (claims that are not payable) or soft denials (claims that can be corrected and resubmitted).
Regardless of the category, a denial can cause significant financial setbacks and operational headaches for providers.
So, how can this be solved? By improving credentialing and enrollment efficiency.
Not sure how to do that? We've got you covered.
In this blog, we’ll discuss top considerations and implementation strategies for improving credentialing and enrollment in the healthcare industry.
As you read, you’ll learn:
- Common reasons for claim denial assessment for credentialing & enrollment application
- Analyzing the financial impacts of inefficient credentialing & enrollment
- Top six considerations for improving credentialing and enrollment efficiency
- Implementation strategy
Let’s get right in
How can you perform a claim denial assessment for provider credentialing and enrollment?
It begins with identifying reasons for denials, categorizing them based on common themes or causes, and then promptly resubmitting corrected claims.
You can’t do all of these without developing a robust tracking mechanism to monitor the status of denied claims and ensure timely follow-up.
When a prevention mechanism is established, it minimizes future denials by addressing root causes through:
- Improved documentation
- Coding accuracy
- Compliance with payer requirements
This approach optimizes revenue cycle efficiency and maximizes reimbursement for healthcare providers.
8 common reasons for claim denial assessment for credentialing & enrollment
Provider credentialing and enrollment are undoubtedly important aspects of the healthcare revenue cycle, but they can also be pretty complex. Even minor oversights can lead to claim denials.
By recognizing and addressing the reasons for denial claims, providers can:
- Reduce the risk of denials
- Streamline operations
- Ensure a smoother and more efficient revenue cycle
So, what are these reasons? Keep reading to find out.
1. Data Integrity and Validation Failures
Claims are often denied due to discrepancies in provider data. These discrepancies include incorrect National Provider Identifier (NPI) numbers, tax IDs, or even misspelled names.
A recent study even indicated that provider eligibility was among the top 3 reasons claims are denied.
Although minor, these errors can cause ineligibility issues, which have tremendous repercussions. Some of these repercussions include reimbursement delays and additional administrative burdens.
2. Non-Compliance with Payer-Specific Protocols
Just as different countries have different specific laws and regulations, different payers also have particular requirements for credentialing and enrollment.
Failure to comply with these payer-specific protocols will lead to claim denials. Some examples of these requirements are
Some standard payer-specific requirements include:
- National Provider Identifier (NPI) Submission: Many payers require the correct NPI to be submitted during both the enrollment and claims process. Incorrect or missing NPI numbers can lead to claim denials.
- Board Certification or Specialty Certification: Certain payers may require providers to maintain specific certifications, such as board certification in their specialty, for credentialing approval.
- Provider Licensing and Renewal Documentation: Payers often need up-to-date state licensure and renewal documentation. Failure to provide current licensing information can result in denied claims or delayed enrollment.
- Proof of Malpractice Insurance: Some payers require providers to submit proof of adequate malpractice insurance coverage, specifying certain coverage limits to meet their standards.
- Site Inspections or Accreditation: For some payers, providers may need to undergo site inspections or submit documentation proving that their facilities meet specific accreditation standards (e.g., Joint Commission accreditation)
- Background Checks and Sanctions: Many payers require providers to pass background checks and confirm they are free from sanctions or disciplinary actions by regulatory bodies such as state medical boards
A good way to avoid this is for providers to stay informed about the specific requirements of each payer they work with. This can include anything from documentation standards to specific procedural protocols.
3. Authorization and Pre-Certification Breakdowns
Missing or delayed authorizations can lead to claim denials, especially in cases where payer protocols require pre-approval for certain services.
Providers must establish clear procedures for obtaining and documenting authorizations and pre-certifications to ensure compliance.
For instance, healthcare institutions like hospitals can create a protocol for a team member to double-check all patient authorizations before submitting a claim.
Additionally, they can also use automated systems that track authorization status and send reminders to prevent breakdowns in this area.
4. Credentialing System Lapses
Providers with expired or insufficient credentials are at high risk for claim denials.
Documents like expired licenses, certifications, or other necessary credentials can trigger automatic denials from payers. To avoid this, providers must ensure that all credentials are current and meet the required standards.
They’d also want to audit regularly and set reminders to help manage credential expirations and renewals, thereby reducing the likelihood of denials.
5. System-Level Duplicate Detection
Duplicate claims or enrollment applications can trigger automatic denials, as payer systems are designed to detect and reject duplicates.
This issue often arises from human error or inefficiencies in the claims submission process.
Healthcare institutions can avoid this by ensuring that all staff are trained to identify and correct duplicate submissions before they reach the payer.
6. Network Configuration Errors
Claims for out-of-network providers are automatically denied, making network configuration errors a significant concern.
Providers must ensure that they are correctly listed within payer networks and that their services are covered under the payer’s plans.
When providers regularly verify the network status and communicate with payers, they are better able to prevent network-related claim denials.
7. Timing and Submission Protocols
Each payer has specific timeframes within which claims must be submitted. Failure to adhere to these deadlines can result in automatic denials.
To avoid this, healthcare institutions should establish strict protocols for timely claim submission and use tracking systems to monitor deadlines.
8. Enrollment System Synchronization Issues
If a provider’s enrollment status is not current with the payer, claims can be automatically denied. This issue often arises due to:
- A lack of communication between the provider and the payer
- Delays in updating enrollment information in the system
To avoid this, healthcare institutions and hospitals should regularly synchronize their enrollment data with payer systems.
They should also ensure that any changes in provider status are promptly communicated and updated.
Analyzing Financial Impacts of Inefficient Credentialing & Enrollment
Delays in credentialing or enrollment can lead to major revenue loss. On average, a one-day delay in provider onboarding can cost $10,122 for just one doctor.
Multiply that by the number of new doctors who are inefficiently enrolled and credentialled per day. You see that it runs into tens of thousands and millions of dollars.
Moreover, the administrative burden associated with correcting denied claims or resubmitting enrollment applications can be costly and time-consuming.
It’s worth noting that these financial implications extend beyond immediate revenue loss. Continuous inefficiencies can strain relationships with payers and potentially result in long-term financial instability.
For instance, recurring denials can create cash flow issues, affecting a provider’s ability to invest in necessary resources or expand services.
Therefore, healthcare companies must regularly assess their credentialing and enrollment processes and identify areas for improvement to minimize financial risks.
Top 6 Considerations for Improving Credentialing and Enrollment Efficiency
Now, how can the healthcare industry improve its credentialing and enrollment efficiency?
Here are some of the top considerations to keep in mind:
1. Are there recurring issues with specific payers or providers?
By analyzing denial trends, providers can address root causes and implement targeted solutions.
Examples of these trends include: frequent mismatches in provider credentials, repeated issues with specific payers, or recurring problems with timely submission.
2. Has there been a recent change in payer requirements or platforms?
Payer requirements and platforms are constantly evolving, and staying updated on these changes is crucial.
Providers should ensure that their staff is aware of any new requirements or system changes that could impact credentialing and enrollment.
3. Are providers' credentials up-to-date and accurately documented?
Regular audits of provider credentials help ensure that all necessary documentation is current and accurately recorded.
This practice can prevent denials related to expired or inadequate credentials.
4. Is the process for handling new providers or locations well-defined?
A clear and well-defined process for onboarding new providers or adding new locations can help in streamlining credentialing and enrollment activities.
This process can include having a standardized checklist for required documentation and timelines.
5. Are there frequent communication gaps between payers and providers?
Effective communication between payers and providers is important for resolving issues related to credentialing and enrollment.
This can be achieved by establishing regular communication channels and protocols that help address any discrepancies or delays.
6. How does the organization manage changes in staffing or provider roles?
Providers should have a system in place to quickly update payer systems with any changes in staff or provider roles to avoid delays or denials.
Implementation Strategy: Why Choose Assured?
Choosing the right enrollment and credentialing software can improve the efficiency and success of your claim denial assessment.
An example of such software is Assured. We offer a comprehensive solution designed to address the common challenges faced by healthcare providers and organizations in credentialing and enrollment.
- End-to-End Workflow Automation: Assured automates every aspect of the credentialing and enrollment process, from application submission to final approval, reducing manual errors and speeding up processing times
- Advanced Data Validation and Compliance: Assured’s platform integrates advanced data validation tools that automatically check for compliance with payer-specific requirements, reducing the risk of claim denials
- Real-Time Monitoring and Alerts: With real-time monitoring and alert systems, Assured ensures that you are always informed of any issues that could lead to denials, allowing for proactive management
- Customizable Reporting and Analytics: Assured provides customizable reporting tools that allow you to generate detailed reports on credentialing and enrollment performance, enabling data-driven decision-making
By adopting Assured, you can enhance the technical efficiency of your credentialing and enrollment processes, leading to fewer denials, increased revenue, and more streamlined operations.
