When a claim is denied because of a provider enrollment or credentialing issue, simply correcting and resubmitting the claim may not solve the underlying problem. Your staff first needs to determine why the payer rejected the claim and whether the problem involves provider data, enrollment status, effective dates, participation or another issue. Without that investigation, your team can waste valuable time repeatedly working the same claims.

This is where credentialing and revenue cycle management need to work together. Your billing team may be the first to see the denial, but your credentialing staff may hold the information needed to resolve it. Creating a shared response process can help your practice act faster and prevent similar problems from affecting additional claims.

Step 1 — Identify the Actual Denial Cause

Don’t label every provider-related denial a “credentialing denial.” Start with the payer’s explanation of benefits or electronic remittance information and identify the applicable reason and remark codes.

Then compare that information with your credentialing and enrollment records. Is the provider enrolled? What is the payer’s effective date? Is the provider linked correctly to your group or billing entity? Does the payer have the correct provider and practice information?

The goal is root-cause analysis, not simply resubmission. You need to know whether the problem originated with your practice, the enrollment process, the claim itself or the payer’s system.

Step 2 — Verify What the Payer Has on File

Your internal records may show that a provider was approved, but that doesn’t necessarily tell you what is currently loaded into the payer’s claims system. Contact the payer and verify the relevant enrollment information.

Ask specific questions rather than simply asking, “Is Dr. Smith credentialed?” Confirm the effective date, participation status, billing/group affiliation and other information relevant to the denial you’re investigating.

Document the response. Include the representative’s name, date, call reference number and exactly what was confirmed.

Step 3 — Compare Payer Information With Your Records

Once you know what the payer has, compare it with your internal credentialing information. This is where inconsistencies can become visible.

Look for mismatched effective dates, addresses, NPIs, taxonomy information, group affiliations or other provider data relevant to the claim. Determine whether an application, change request or other update was submitted and whether you have documentation showing when the payer received or approved it.

Don’t make assumptions based on what should have happened. Build your appeal or correction around what you can document.

Step 4 — Escalate the Problem With Supporting Documentation

If the payer’s information appears incorrect, determine the payer’s proper process for correction, reconsideration or appeal. Submit the documentation that supports your position and follow the payer’s specific requirements.

Relevant documentation may include credentialing or participation approval letters, enrollment correspondence, effective-date confirmations, contracts or other payer communications. Keep copies of everything you submit.

Create an internal deadline for follow-up. An appeal sitting in a payer queue without anyone monitoring it can become another source of delayed reimbursement.

Step 5 — Look Beyond the Individual Claim

A provider enrollment issue rarely affects only one claim. Once you identify the root cause, determine what else may be affected.

Run a report for other claims associated with the same provider and payer during the relevant timeframe. You may discover multiple unpaid or denied claims connected to the same enrollment issue.

This turns denial management into revenue protection. Instead of fixing claims individually as they appear, you can identify the full financial exposure and address the underlying cause.

Don’t Ignore Medicare Revalidation

A missed Medicare revalidation deadline can create a much larger problem than a single denied claim. CMS warns that failing to revalidate on time may lead to a hold on Medicare reimbursement or deactivation of Medicare billing privileges.

If billing privileges are deactivated, CMS says the provider must submit a complete Medicare enrollment application to reactivate them. CMS also states that Medicare will not reimburse services during the period in which billing privileges were deactivated.

That makes prevention especially important. Regularly check the CMS Medicare Revalidation List and make upcoming due dates part of your credentialing workflow rather than relying solely on notices.

Use Denials to Improve Your Credentialing Process

Every enrollment-related denial gives you information about a potential weakness in your workflow. Don’t close the issue as soon as the individual claim is resolved.

Ask why the problem occurred. Was provider information entered incorrectly? Was a change not reported? Did no one follow up on an application? Did the billing department begin submitting claims before the effective date was confirmed?

Document the root cause and decide what needs to change. A five-minute process review after resolving a denial can prevent dozens of similar claims from following it.

Track Credentialing-Related Denial Trends

Your billing team probably tracks overall denials, but consider creating a separate category for confirmed enrollment and credentialing-related issues. That makes it easier to see whether the same problems are recurring.

Track denials by payer, provider, reason and root cause. Then review the information with your credentialing and billing teams regularly.

This can reveal patterns that aren’t obvious when employees work claims individually. A recurring issue with one payer, provider type or internal process is a signal that your practice needs a broader fix.

Cross-Train Your Billing and Credentialing Teams

Credentialing and billing shouldn’t operate in separate silos. Each team needs enough knowledge about the other’s work to recognize when a problem crosses departmental lines.

Teach billers what information credentialing maintains and when to escalate a provider-related claim. Teach credentialing employees how enrollment problems appear downstream in claims and reimbursement.

This shared knowledge can shorten the time between identifying a problem and fixing it. It also reduces the chance that each department assumes the other is responsible for investigating the issue.

Use Training to Prevent Problems Before They Reach Claims

Credentialing requirements can be complex, and payer and Medicare enrollment rules don’t remain static. Relying entirely on knowledge an employee picked up years ago can leave your practice vulnerable when requirements change.

Ongoing training gives your staff an opportunity to update their processes before an outdated practice causes a reimbursement problem. Training is especially valuable when multiple employees share responsibility for provider enrollment, billing and practice management.

The objective should be practical application. After training, ask your staff what needs to change in your current workflow and assign responsibility for implementing those improvements.

Make Credentialing Part of Your Revenue-Cycle Strategy

Credentialing isn’t finished when an application is approved. It is an ongoing process that includes maintaining provider information, monitoring enrollment, managing expirations, completing revalidations and responding quickly when payer records don’t match yours.

Treat those responsibilities as part of revenue-cycle management. Give leadership visibility into unresolved enrollment issues, upcoming deadlines and confirmed credentialing-related denials.

The practices that do this well aren’t simply better organized. They’re better positioned to prevent administrative problems from becoming reimbursement problems.

Keep Your Practice Current With an All-Access Pass Your practice has to keep up with much more than credentialing. Medicare requirements, payer policies, CPT and ICD-10 updates, compliance regulations and the Medicare Physician Fee Schedule can all affect how your staff performs their jobs and how your practice gets paid. Healthcare Training Leader’s All-Access Pass gives your entire team access to practical training designed specifically for the challenges physician practices face. Your staff can stay current on credentialing, reimbursement, billing, coding, compliance and other regulatory changes without purchasing training one topic at a time. Give your team an easier way to keep learning throughout the year—and help your practice respond to important changes before they turn into denials, compliance problems or lost revenue.

 

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