Why Maintaining Credentialing Status Keeps Your Practice Profitable
Maintaining the Credentialing Status for Your Providers – it’s probably not the most glamorous task, but it’s one of the most important. Whether you’re just starting or you’ve been handling this responsibility for a while, maintaining credentialing status is crucial to keep things running smoothly. If you let this lapse, you’re looking at serious problems– nobody wants that, right?
What Exactly Does Maintaining Credentialing Status Mean?
Alright, so maintaining credentialing status involves ensuring your providers are always in good standing with the insurance companies. This is important because insurance companies require providers to be “credentialed ” periodically—usually every three years.
Re-credentialing means providers go through the credentialing process again to ensure nothing major has changed and that they’re still qualified to participate in the insurance network.
Simple enough, right? But here’s the tricky part: You must stay on top of it, or else your provider’s credentialing could lapse, meaning they’d no longer be part of the insurance network.
That’s a huge headache because starting from scratch takes longer than re-credentialing!
Knowing Your Credentialing Effective Date
So, how do you ensure your provider’s credentialing status stays current?
First, you need to know when they were initially credentialed. Every provider has an effective date with each insurance company. From this date, count three years—and that’s when they’ll need to be credentialed.
The timeline could vary if they were credentialed before or after joining your group, so it’s essential to track this from the start.
Make sure you have those dates documented somewhere easy to access, like an Excel spreadsheet (I know, who doesn’t love a good spreadsheet?). mark your calendar for 90 days before that date so you can start working on credentialing early.
Don’t Wait for the Insurance Companies to Remind You!
It’s tempting to rely on insurance companies to send you a reminder when credentialing is due. Sure, many of them will send a notification 90 days in advance, but what if that notification gets lost or, worse, sent to an outdated email?
That’s right – if the contact info for your provider isn’t up to date with the insurance company, those reminders may never reach you. And when re-credentialing is missed? It’s a nightmare.
So, take the initiative. Keep those dates and reminders in your calendar and ensure the person responsible for credentialing is on top of things!
Documentation, Documentation, Documentation!
You can’t have too much of it. If you’re responsible for maintaining the credentialing status of your providers, keep everything organized.
- The provider’s effective date
- Their contact info
- And, what’s coming up? Their continuing education (CE) records from the last three years. Trust me, you’re going to need that.
Not to mention their liability insurance cover page. Without these, you can’t re-credential a provider, and if you don’t have access to them – start early so you can gather all the necessary information in time.
What Happens if Credentialing Lapses?
Oh boy. If you let credentialing lapse, it can spell financial disaster for your practice. Why? Because without being credentialed, a provider can’t submit claims to insurance companies. No claims, no payments.
Now, you’re paying a salary for a provider who can’t see patients. Ouch.
But that’s not all. Some insurance companies may see this lapse as a red flag, meaning it could take even longer to credential the provider—or worse, they might not allow them to re-credential at all for a certain period.
Avoiding this mess is as simple as staying on top of your dates.
Setting Up a Re-credentialing Workflow: Your New Best Friend
Now that you know how critical maintaining credentialing status is, let’s get into the nitty-gritty of setting up a smooth re-credentialing workflow.
Think of it like a well-oiled machine – everything should be streamlined, repeatable, and organized so nothing falls through the cracks. If you’ve got a team of providers, you can’t just wing it every time a re-credentialing date rolls around, right?
The first step is to create a system—this will be your master plan for managing credentialing. This is where your love for spreadsheets, reminders, and tracking comes in handy.
Step 1: Track the Credentialing Effective Dates
As I mentioned, each provider has a unique, effective date with every insurance company. These dates need to be recorded somewhere you can access easily. I recommend creating an Excel or Google Sheet for this.
This sheet should have a column for every provider in your practice and each insurance company they’re credentialed with.
Here’s a simple layout:
| Provider Name | Insurance Company | Effective Date | Next Recredentialing Due | 90-Day Reminder |
|---|---|---|---|---|
| Dr. Doe | Blue Cross | Jan 1, 2022 | Jan 1, 2025 | Oct 1, 2024 |
| Dr. Doe | Aetna | Mar 1, 2022 | Mar 1, 2025 | Dec 1, 2024 |
Your effective date is when the provider was first credentialed; the next re-credentialing date is three years from that. Easy math, right?
And don’t forget the 90-day reminder! That’s when you’ll set a reminder on your calendar to start the credentialing process. This way, you’ll never be scrambling at the last minute.
Step 2: Set Up Calendar Alerts
I know we just talked about spreadsheets, but let’s not forget the trusty calendar! Make sure to set alerts 90 days before each credentialing due date. Use Google Calendar, Outlook, or whatever you prefer—just don’t rely solely on the insurance company to notify you.
You can also set multiple reminders, just to be safe:
- One for 90 days out
- Another for 60 days
- And a final one 30 days before the re-credentialing deadline
This gives you ample time to get all the paperwork and documentation sorted. Trust me; waiting until the last minute is the fastest route to panic city. 🚨
Step 3: Gather Documentation in Advance
Here’s the part that can sneak up on you if you’re unprepared. The credentialing process will require certain documents from your providers—even if not everything needs to be resubmitted, some key things still do.
Here’s what you’ll typically need:
- Continuing Education (CE) records for the past three years
- The provider’s liability insurance cover page
- Updated personal information (in case they moved or changed contact details)
Pro Tip: Get all this from your providers early. Don’t wait until the last week when it becomes a mad scramble to pull it together. Email your providers or schedule a quick meeting to ensure you’ve got everything on hand before the deadline. This way, when you’re ready to submit the re-credentialing application, all your ducks are in a row.
Step 4: Stay in Constant Contact With Insurance Companies
As much as we might wish insurance companies were super reliable, their communication skills can sometimes be less than ideal.
A good idea is to build a relationship with a provider relations rep from each insurance company. These people can be lifesavers when you’re dealing with re-credentialing issues.
But even if you don’t have direct contact, don’t hesitate to contact the credentialing departments at the insurance companies. If you’re unsure, you can ask for a list of effective dates and confirm when credentialing is due.
Be proactive. If something seems off or you haven’t received any communication regarding credentialing, make that call! It’s better to be safe than sorry.
Step 5: Follow Up, Follow Up, Follow Up!
Once you’ve submitted the re-credentialing application, don’t just sit back and relax. Follow up with the insurance company to make sure they’ve received everything.
And yes, I get it. Waiting on hold with insurance companies is the worst. But trust me, it’s worth avoiding the headache later on if they somehow didn’t get your paperwork.
Even after submitting, keep an eye on things—some insurance companies let you check the credentialing status online, so do that if it’s available!
Avoiding the Financial Loss: Why You Can’t Afford to Mess This Up
Remember, if a provider’s credentialing lapses, they essentially become “unemployed” – at least in the eyes of the insurance companies. That means they won’t be able to submit claims; if they can’t, they won’t get paid. Neither do you.
Even worse, some insurance companies may take their time before allowing the provider to re–credential—or they might refuse to credential them altogether.
Can you imagine the financial hit to your practice if your top provider suddenly can’t see patients for months?
So, yeah—re-credentialing isn’t just another admin task. It’s a critical part of keeping your practice running smoothly and your providers bringing in revenue.
Proactive Credentialing = Less Stress, More Success
In the end, maintaining the credentialing status of your providers comes down to being proactive, staying organized, and not letting deadlines sneak up on you.
Use spreadsheets and calendar reminders, and build relationships with insurance companies so you’re never scrambling at the last minute. Keep all necessary documentation handy, and always start the process early.
If you can follow these steps, you’ll save yourself a lot of headaches – and more importantly, you’ll keep your practice running smoothly without any gaps in revenue.
FAQ
What Does Maintaining Credentialing Status Mean?
Maintaining credentialing status ensures that providers remain in good standing with insurance companies through a periodic re-credentialing process, typically every three years. This process confirms that providers are still qualified to be part of the insurance network, preventing issues with claim submissions and payments.
Why Is It Important to Know Credentialing Effective Dates?
Each provider has an effective date for credentialing with every insurance company, marking when they were first credentialed. Knowing these dates is crucial because re-credentialing typically occurs every three years. Tracking these dates ensures that credentialing doesn’t lapse, preventing claims and payment processing disruptions.
Should I rely on insurance companies to remind me about Credentials?
No, it’s risky to rely on insurance companies to remind you about credentialing. While many send notifications, there’s no guarantee you’ll receive them, especially if contact information changes. It’s best to proactively track credentialing dates to avoid missing deadlines and facing costly delays.
What Documents Are Needed for Recredentialing?
For credentialing, you’ll need documents such as the provider’s Continuing Education (CE) records, liability insurance cover page, and updated personal information. Having these ready in advance ensures a smooth credentialing process and prevents last-minute scrambles to gather the necessary paperwork.
What Happens if Credentialing Lapses?
If a provider’s credentialing lapses, they can’t submit claims, leading to financial losses for your practice. Insurance companies may also take longer to credential the provider or deny re-credentialing altogether, resulting in extended downtime for the provider and significant revenue gaps for your practice.
How Can I Set Up a Credentialing Workflow?
A credentialing workflow involves creating a system to track credentialing dates, set calendar reminders, and gather necessary documents in advance. Use tools like spreadsheets and calendar alerts to manage the process, ensuring deadlines aren’t missed and your providers remain in good standing with insurance companies.
Why Is It Important to Follow Up With Insurance Companies After Recredentialing?
Following up after submitting re-credentialing paperwork is crucial to ensure the insurance company has received everything. Mistakes or delays can occur, and without follow-up, you may face credentialing lapses that can disrupt claims processing and payments, leading to financial losses for your practice.
Final Thoughts
Maintaining the credentialing status for your providers is essential to ensuring smooth operations and uninterrupted revenue flow. By staying on top of credentialing dates, gathering necessary documentation early, and proactively following up with insurance companies, you can avoid costly lapses that disrupt claims and payments. A well-organized credentialing workflow prevents last-minute panics and guarantees that your providers remain in good standing with insurance networks.
By reading this blog post, you’ve gained the tools and strategies necessary to implement a proactive approach to maintaining credentialing status, saving time, avoiding stress, and keeping your practice financially secure.