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How Credentialing Mistakes Lead to Revenue Loss

Power of attorney for health care is a very time-consuming process. It involves several complex steps that must be done in the right way or it could lead to huge financial losses. Not only that, other legal complications may arise that could threaten the entire healthcare organisation. Processes like registration, compliance, planning, and the like must be done with complete authenticity and clarity. However, healthcare practices are inclined to slow down the credentialing process due to a lack of knowledge or expertise.

What is Credentialing?

“Credentialing” is how practitioners become approved providers through a hospital, practice, or healthcare facility. It verifies the medical care provider’s qualifications. Such as their education, medical experience, licences, and more. In practice, this is done by completing and reviewing forms and verifying basic information. And following established payer standards for participation.

In healthcare, physician accreditation is the process of organising and verifying professional records that qualify physicians to practise medicine. This contains their board certifications, hospital admitting privileges, education, malpractice insurance, professional references, work history, etc.

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Some Credentialing Mistakes Lead to Revenue Loss

Here are;

Time is Everything in Credentialing:

Enough time to get payer approval so your new provider can get reimbursed. This estimated lead time is necessary to initiate the registration process to successfully obtain registration of a new provider with individual insurance and facilities.

Failure to allow sufficient time to gather the documentation needed to prepare. And process claims and insurance approval before the physician sees patients will result in providers not being able to bill patients for services provided.

Keep in mind that the approval response of individual payers is determined by their workload. Some payers, especially government payers such as Medicare and Medicaid, may take 3-6 months to process.

CAQH Lapse:

CAQH or Council for Affordable Quality Healthcare Inc. is a California non-profit organisation. That acts as an online repository for all physician-provided credentialing data. Insurance providers access this data through CAQH, so it is important to keep the data current. Your staff should take the time to retest profiles promptly to avoid data loss.

Accuracy and Completeness:

The Physician Credentialing process involves verifying a range of documentation, and certifications. And licences to assess medical qualifications, graduation, residency, residency, career history, and malpractice details. Processing a credential application is a tedious task that requires the utmost care to ensure the accuracy and completeness of the information provided. Because even an involuntary error or typo in the submitted details can lead to unwanted delays and rework of the entire authorization process. An inaccurate or incomplete application or documentation will affect the timeline. And revenue stream for the physician or medical practice.

Inaccurate Information:

Credential denials can come from inaccurate information in the form of inaccurate documentation. Errors in trivial details such as a doctor’s email address, and even missing data. These can be detrimental to the verification process because not all accurate information is available to assess the legitimacy of the physician. This will hinder the accreditation process during which the doctor cannot provide any services. And cannot be reimbursed for the services provided.

Failing to Take Peer Review Activity Seriously:

Information provided as part of a peer review or investigation should be taken seriously. And evaluated as part of the credentialing process. Peer references can shed light on a doctor’s skills. And competencies that you cannot obtain simply by verifying her education, training, or licensure status.

Although physician accreditation can be boring, the process protects healthcare facilities from risk and non-compliance. A thorough and ongoing medical examination is crucial to avoid costly malpractice. A hurried process leads to missing information, errors, and delays in reimbursement. As healthcare regulations develop and credentialing requirements become more complex. Healthcare facilities must be proactive in updating their credentialing processes to avoid mistakes that put patients and themselves at risk.

Lack of Expert Support:

Even remotely related to the healthcare industry, one would know that medical billing. And credentialing amenities are the elixirs that keep practices financially healthy. But unfortunately, in the last few years, insurance certification services have become more difficult, but not impossible.

A lot of things can go wrong if you try to do accreditation internally in your practice, so it might not be such a great idea after all. Forcing staff to deal with time-consuming and massive paperwork robs them of valuable patient care time. They lack the skills and experience necessary to meet process standards.

Errors in the Enrollment Process:

Billing and payments are very much tied to the registration process. As a result, any deficiencies in this area could have an impact on how healthcare revenue cycle management is addressed. Let’s take a look at some of the most common mistakes that occur during the registration process.

Each insurance company has its station of rules. And procedures for adding new providers to its console, including deadlines, procedures, and rules. Unfortunately, failure to meet provider requirements is a common mistake in medical accreditation.

Each insurance company has its own set of bases for adding new providers to its panel, including dates, procedures, and criteria. Failure to meet provider requirements is a common medical record error.

Before registration, insurance companies may have several questions, explanations, and verification of the primary source. If facility staff is not given the proper responsibilities to handle these inquiries for you, it hinders the payment process.

Insurance companies may have various questions, explanations, and primary source checks before registration. If facility staff is not given the necessary responsibility to handle these inquiries for you, the entire process may be delayed.

Failing to Report Adverse Actions:

Physicians are required to report adverse events, such as licence revocation; exclusion from third-party programs. And interruption or voluntary relinquishment of medical staff membership, clinical privileges, or state or federal DEA licence. Hospitals and health systems will be held liable for physician negligence. Therefore, due diligence requires a background check to identify current and historical adverse events.


To avoid all these errors and oversights, it is important that healthcare practices consider measures such as outsourcing, digitization, and hiring qualified resources. They should focus on expertise in managing the entire credentialing process. However, managing all clinical activities can be frustrating. Precatalytic could serve as your trusted partner. Our experienced professionals focus on providing the best possible accuracy of accreditations before they are sent to insurance companies.

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