Insurance companies process claims and reimburse healthcare providers for services rendered. Credentialing, primarily for reimbursement, has become the arduous, yet essential, first step of the revenue cycle. Credentialing can and does create bottlenecks due to the multifaceted nature of the processes and helps explain why healthcare practices often neglect it—whether it be improperly configured automation, institutional neglect, or a lack of knowledge as to how crucial it actually is. Here, we examine the primary obstacles that healthcare practices encounter in the field of insurance credentialing.
1. Protracted Review Timelines
When it comes to the payment delay of the healthcare revenue cycle, the gap in time that insurance companies take to credential providers is not something to be overlooked. In the realm of payment delay, nothing is worse than the tremendous time lapse in the healthcare revenue cycle due to insurance companies taking 60-120 days or more to check and decide on the documents. Because of the lack of capable insurance credentialing services or the absence of quality provider enrollment services, it is common for circular cash flow to occur.
2. Failure to Meet or Poorly Meet the Requirements
Credentialing is documentation. It is the process of gathering and synthesizing evidence of the existence of key components such as a license, a governing board certificate, a history of civil complaints and assessments of competence, records of prior employment, affiliations with certain institutions, etc. In the realm of civil complaints and assessments, a single deficiency can serve as a reason for returning the documents or requesting additional evaluations. For provider credentialing or physician credentialing services, it is customary for practices to allocate resources to outsourcing such provider credentialing or physician credentialing services.
3. Payer-Specific Requirements
In-house teams can become easily overwhelmed by the multitude of guidelines, forms, and submission portals created by each individual payer. Insurance credentialing companies and medical insurance credentialing services take the burden of managing payer-specific requirements.
4. Issues with CAQH and Portal Management
Keeping CAQH up to date and managing the payer portals can be extremely tedious and time consuming, and as a result, can lead to missed attestations or outdated information which can cause delays. Leading healthcare credentialing services utilize a comprehensive tracking system that ensures applications remain compliant and up to date.
5. Confusion Surrounding Provider Enrollment and Contracting
Most practices face challenges when attempting to distinguish between provider enrollment and credentialing and payer contracting. While credentialing confirms the qualifications of the provider, enrollment gives that provider billing rights. In the absence of sufficient coordination, a provider may credential and be left with substantial delays in the submission of claims. This phenomenon is attributed to the expertise of provider enrollment services in harmonizing both processes.
6. Ongoing Maintenance and Re-Credentialing
Most payers have floating time frames in which they will require providers to be re-credentialed with them. In large group and hospital settings, tracking these floating time frames is extremely difficult, which is why numerous organizations choose to outsource provider enrollment or make use of hospital credentialing services for enhanced control.
7. Challenges with Medicaid and Other Government Programs
The government programs require more documentation and compliance than other payers. Application errors can lead to audits and other delays. Medicaid specialists provide peace of mind in the event of an application denial.
8. Limitations on Staff and Resources
Credentialing can become an overwhelming burden as it requires trained personnel and organized recordkeeping. Smaller firms may not even be able to handle it. Credentialing firms offer access to such resources and personnel.
9. Disruption of Revenue Cycle
Delays in the process of getting credentialed result in delays in reimbursement. Claims can be denied or put on hold due to not having the correct status. Loss of revenue is a result of poor credentialing or insurance credentialing services.
Final Thoughts
Repetitive errors, time constraints, and the complexity of insurance credentialing cause the greatest obstacles to obtaining the correct insurance. The complexity of the process requires precise management in order to remain compliant with regulations. Specialized credentialing services have trained staff that focus on a single problem and can reduce the time taken to improve compliance.
