How Do the No Surprises Act Requirements Affect Compliance with Provider Directories?
Posted on Saturday, November 13, 2021
The No Surprises Act requirements go into effect in 2022.
Section 116 of the No Surprises Act, “Protecting patients and improving the accuracy of provider directory information,” seeks to safeguard patients from relying on incorrect provider data that can lead to surprise medical bills.
The No Surprises Act will directly affect all payers and providers who will need to assess their compliance procedures related to provider directories and information verification.
Here is what you need to know about how the No Surprises Act requirements affect compliance with provider directories:
Every 90 days, payers must verify providers’ information and providers must assist with this process by submitting regular updates.
When providers make changes to their information, online provider directories must be updated within 48 hours.
Providers whose information is unverified will be removed from online provider directories.
Essentially, providers will need to maintain their information with payers on about a quarterly basis beginning in 2022 or risk removal from online provider directories and lose the marketing presence that these directories provide when patients search for in-network providers online.
Contact us to start preparing for the No Surprises Act requirements.
The No Surprises Act requirements will help keep provider information current and improve the accuracy of provider directories. However, if you’re doing credentialing work yourself, these changes will require you and your staff to commit even more time and attention to credentialing and compliance.
Providers and payers need to prepare now for the new rules that begin in 2022.
Contact us today to put a plan in place that will ensure you and your providers comply with the No Surprises Act requirements, avoid removal from provider directories, and set the foundation for a successful new year!
When provider credentials expire, there can be serious legal and financial consequences for clinicians and their practices. Below we outline the effects of expired provider credentials and explain how you can avoid these negative outcomes.
Claim Denials/Lost Revenue – When provider credentials expire or are not updated, providers are deactivated by payers, their claims are denied, and the practice misses out on reimbursement for services rendered. This could end up costing the practice months of lost revenue since the re-credentialing process can take up to 180 days (or longer due to delays related to the pandemic).
Loss of Privileges – If providers’ credentials are not current, they will lose their hospital privileges. This also affects provider enrollment as providers must have hospital privileges at a participating network hospital in order to join and remain compliant with health plans.
Lawsuits/Liability Concerns – A provider may not even be aware at first that a credential has accidentally expired or might realize they have missed a deadline after it’s too late. However, practicing medicine without a valid license (including an expired one) or providing services that require certification which the provider has not renewed can open the door to lawsuits and legal ramifications for not only the provider, but the provider’s employer/facility as well.
Fines and/or Sanctions – If a provider continues to practice medicine as usual even though they have allowed credentials to expire (e.g., writing prescriptions with an expired DEA license), they and their facility may also face significant fines and/or sanctions. Likewise, failure to keep up with state continuing education requirements affects a provider’s medical license status and can cause the provider to be sanctioned by the state medical board. Additionally, the provider’s malpractice insurance rates may increase after receiving a sanction.
Higher Insurance Premiums – Allowing malpractice coverage to lapse may also cause the provider’s premiums to rise, and some insurance companies may decline the provider another policy if there is a previous gap in coverage. The provider will be required to report any lapse in coverage throughout their career.
Refusal of Future Contracts by Payers – Providers who have a history of lawsuits, legal penalties, fines, sanctions, lapsed malpractice insurance, and/or expired CAQH attestation may be rejected by some payers for future contracts.
Patient Retention Issues – Patients are extremely unlikely to choose an out-of-network provider. Providers who do not remain active with payers will fail to attract new patients and risk losing their existing clientele if they become out-of-network and/or must stop providing care until they are re-credentialed.
Extra Time and Work for Providers/Staff – It is much more inconvenient for everyone when provider credentials expire than if the provider had maintained their credentials by the appropriate deadlines. Extra effort and time will be necessary to reactivate the provider with health plans and obtain hospital privileges again.
How to Prevent Expired Provider Credentials & Their Consequences
Keeping track of provider credentials is time-consuming and complicated. It’s easy to miss critical deadlines and expiration dates when providers and practices try to manage this work themselves (for example, with filing cabinets, manual spreadsheets, and handwritten calendar memos that leave far too much room for human error and delays in information delivery).
Tracking of malpractice insurance coverage, CE credits, and practice services (e.g., Radiology and CLIA certifications)
We also offer a health plan audit service for larger facilities to ensure providers are participating in the correct plans and the provider roster is current. An annual health plan audit is essential for protecting a practice both legally and financially.
Prevent Expired Provider Credentials with CredentialingOne
What Do Medical Residents Need to Know About Credentialing?
Posted on Thursday, February 11, 2021
Medical residents should be proactive about credentialing during their final year of residency.
While you understandably have a lot on your plate as you finish your training, credentialing is one item you can’t afford to neglect during your job search. As the COVID-19 pandemic continues to adversely affect the job market, it’s imperative that you do everything in your power to prevent delays and obstacles to employment.
Credentialing involves verifying a provider’s qualifications (such as education, licenses, certifications, work history, and references). This includes primary source verification, which is the validation of a provider’s credentials through direct contact with the person or organization that originally issued the information.
2.) Credentialing can take up to 180 days (or more, due to delays caused by the current pandemic).
The credentialing process often takes longer than expected. There are numerous people and entities to contact, and you must factor in the time it takes to follow up with those who fail to respond in a timely manner.
Some healthcare organizations will not schedule your employment start date until they have received all credentialing paperwork from you. For example, you may not be able to start working until 120 days or more AFTER you’ve submitted all (complete and accurate) requirements. This is why it is crucial to start the credentialing process as a medical resident – so that you can begin earning your salary as soon as possible.
3.) You should begin gathering all your credentialing information and documentation now.
Having up-to-date and accurate information on hand will make the credentialing process much more efficient and less painful for you. If a potential employer, hospital, or payer needs any material from you, you want to be able to access it ASAP.
Take particular care to secure your professional references ahead of time. It’s a good idea to obtain more references than are required so that if one cannot be reached it won’t hold up the rest of your application.
4.) One of the biggest credentialing errors is missing or incomplete information.
When filling out your applications, be sure to complete them precisely and in full detail. Don’t leave out any information that is asked for, as mistakes and omissions will result in delays.
Before submitting it, check your paperwork multiple times and have another experienced professional look it over to make sure you are not missing anything. Then, make sure you follow up on the status of your application at least weekly. This will ensure you detect and resolve any deficiencies right away, since many states allow 60 days or more for payers to inform you of errors.
5.) Expect delays if you wait until the summer to start the credentialing process.
Remember, there are plenty of other medical residents completing their training at the same time as you. Payers are especially busy in the summer because they receive a lot of applications in the months following graduation. Get a head start on the competition by preparing your credentialing work now and avoid the application delays that will inevitably occur due to high volume.
Credentialing Services for New Providers
As you can see, credentialing is complex, time-consuming, and exhausting. As a medical resident or fellow, your time is precious. Adding a job search and credentialing work to an already packed schedule can seem overwhelming.
CredentialingOne is here to help. We can manage the entire credentialing process for you, so that you can focus your time and energy on completing your training and finding a job you will love.
New Year’s Resolutions for Providers and Practices
Posted on Friday, December 11, 2020
The year is coming to an end and it’s time to plan for a successful year ahead! Have you set any New Year’s resolutions for your practice?
These New Year’s resolutions for providers and practices can help you accomplish your goals in 2021 and beyond:
Set yourself up for credentialing, provider enrollment, and revenue cycle success with these New Year’s resolutions for providers and practices.
Conduct a Health Plan Audit
An annual health plan audit is critical to the success of your practice as it protects it from liability issues, boosts front desk collections, and helps keep providers from being deactivated by payers and having claims denied.
CredentialingOne offers a health plan audit service that determines whether your practice and providers are compliant with all your payers’ contracts and the insurance plans in which you’ve enrolled. For example:
Have you notified payers of a provider’s termination, resignation, or retirement within the timeframe required by the contract?
Have your providers opted in to any new plans added by a payer?
Have your providers opted out of any new plans added by a payer in which they do not wish to participate?
Start the year off right with a health plan audit to ensure your provider roster is current and all providers are participating in the correct plans.
Reduce Reimbursement Denials
In addition to an annual health plan audit, it’s essential to monitor your providers’ credentials throughout the year. Credentialing errors, such as expired certificates or missing CE credits, lead to reimbursement delays, denials, and underpayments.
Any time a provider or practice fails to accurately complete/update their credentialing, provider enrollment, or hospital privileging applications and documentation in a timely manner, they risk a significant loss in revenue. Unfortunately, this is all too common as the credentialing process is complex and it is very easy for items to fall through the cracks or to overlook important tasks like following up on applications.
Furthermore, we keep track of providers’ and practices’ expirables and our real-time, automated messaging alert system notifies you of any upcoming expiration dates so that you don’t miss a credentialing deadline that would result in denied claims.
Providers spend an alarming amount of time on EHR and desk work. On top of this, credentialing and provider enrollment are complicated, ongoing, and time-consuming processes that usually take longer and are more involved than the clinician expects. Completing just one application to credential a single provider with one payer takes about 8-10 hours; and most providers enroll in at least a dozen different health plans (each with its own unique application process).
4 Reasons to Start the Credentialing Process TODAY
Posted on Wednesday, November 11, 2020
It can be tempting to put off a complicated and time-consuming process like credentialing, but that is the last thing you should do!
Here are 4 reasons to start the credentialing process TODAY:
#1. The credentialing process usually takes longer than expected.
Credentialing can take up to 180 days, but generally the process takes 90-120 days, and contracting with payers can take 60-90 days (and any of these timelines may be extended due to delays caused by the current pandemic). It’s best to be as prepared as possible on your end so that you can make up for and anticipate delays from insurance companies or other entities involved.
For example, primary source verification must be completed by validating credentials for each provider through direct contact with the person or organization that originally issued each credential.
Since the credentialing process requires reaching out to numerous different contacts and following up with those who fail to respond quickly, it’s important to allot plenty of time to the work. The usual time a person will dedicate to each application is 7 to 9 hours from submission to effective date.
#2. Begin practicing and billing payers ASAP.
TODAY is the day! Contact us to start the credentialing process.
Any delays in the credentialing process can lead to postponements in employment start dates and/or reimbursement setbacks. Patients also are highly unlikely to seek care from an out-of-network provider.
Getting started now can make a huge difference to the success of your practice in 2021. The longer you wait on credentialing and payer enrollment tasks, the more you’ll cut into next year’s revenue and reimbursement. Plus, you may be setting yourself up for a lot of extra work that will be needed to resubmit any denied claims that could result from credentialing and payer enrollment holdups.
Use what’s left of 2020 to start the credentialing process so that you can spend the new year helping patients and growing your practice, rather than dealing with credentialing and reimbursement issues.
Prevent Medicare Fraud: Information for Providers & Their Patients
Posted on Wednesday, October 28, 2020
Many con artists and scammers see the COVID-19 pandemic as an opportunity to commit healthcare fraud. Providers can help prevent Medicare fraud and protect their patients from identity theft with the information below.
Prevent Medicare Fraud: Information to Share with Patients
Here are some tips and reminders to share with your patients:
Never give your Medicare Number or Medicare card to anyone other than participating Medicare doctors/pharmacists or a person you trust who may work with Medicare on your behalf. Protect it like you would your Social Security card and SSN.
Never accept offers for free medical care in exchange for your Medicare Number or other personal data. For example, scammers might claim they will send you a coronavirus test or masks if you give them this information – don’t do it.
What is the Difference Between Provider Credentialing and Provider Enrollment?
Posted on Friday, June 12, 2020
Many healthcare professionals experience confusion over the terms provider credentialing and provider enrollment, and justifiably so – there is plenty of overlap between them. However, understanding the differences will help you better navigate the complex credentialing process.
What is Credentialing?
Credentialing is the process of verifying a provider’s qualifications for practicing medicine. The provider’s education, licenses, certifications, work history, references, and more are validated through primary source verification (checking with the original source that issued each credential). Additionally, background checks of the provider’s financial, criminal, and/or social media history may be conducted.
Credentialing is completed as part of the hiring process, in order to obtain hospital privileges, andas a key step in provider enrollment.
What is Provider Enrollment?
Provider enrollment is the process of adding a provider to commercial and/or government health plans so that the provider/practice can be reimbursed for services provided to patients.
To join a commercial health plan, the provider must follow the payer’s specific application and credentialing process. If the provider is approved and signs a contract with the health plan, the provider will be considered “in-network.” This is very exhaustive work, yet the credentialing process is even more strict and detailed for enrollment with government health plans like Medicare and Medicaid.
Most patients will not seek care from an out-of-network provider. Provider enrollment is therefore not only essential to getting paid but also for attracting patients.
Provider Credentialing Vs. Enrollment – What’s the Difference?
Credentialing and enrollment both entail similar tasks related to the verification of a provider’s credentials, and credentialing is a part of provider enrollment. You can think of credentialing as an umbrella term used to encompass all instances where validating a provider’s qualifications is necessary – for the purpose of attaining employment, hospital appointment, and/or participation in health plans.
Because credentialing is a condition of hiring, granting hospital privileges, and contracting with payers, the work involved becomes very repetitive and laborious as each entity (the practice, hospital(s), and payers), must ensure the provider is qualified.
There is even more redundancy when you factor in the lack of standardization among health plans. Each payer has its own unique credentialing requirements and most providers will enroll in a dozen or more different health plans in order to remain competitive. This equates to a lot of time and paperwork – the average time it takes to credential one provider with one payer is 8 to 10 hours per application.
The repetition only continues as providers must renew their appointment with a hospital (usually every two years) and complete periodic recredentialing with commercial insurance companies and revalidation with government payers.
CredentialingOne can take care of this redundant and time-consuming work for you.
We handle everything – from completing documentation and submitting applications, to following up on them until each provider has an effective start date with each payer, to the ongoing credentialing maintenance needed to keep payers and practices compliant with health plans.
Additionally, we provide monthly monitoring and maintenance of documents, certifications, CE, and malpractice insurance, as well as automated alerts to ensure you never become inactive with a payer as a result of credentialing noncompliance.
To schedule a complimentary consultation on how we can help you with provider credentialing and provider enrollment, contact us today.
“Verification of an individual practitioner’s reported qualifications by the original source or an approved agent of that source. Methods for conducting primary source verification of credentials include direct correspondence, documented telephone verification, secure electronic verification from the original qualification source, or reports from credentials verification organizations (CVOs) that meet Joint Commission requirements.”
PSV requires detailed documentation, which should include:
Date the PSV was conducted
Method of verification (e.g. letter, fax, email, phone, website)
Agency and/or individual person contacted for verification and their contact information
The information that was specifically verified
Results of the PSV (e.g. questions asked and their answers)
Person who conducted the PSV and their signature
Why is Primary Source Verification Necessary?
Primary source verification is vital to accurate and credible credentialing. It is simply inadequate to accept information submitted by a provider or document photocopies at face value.
PSV protects your patients’ safety by helping to ensure your practitioners are qualified to care for them. Furthermore, it protects your organization from legal risks and compliance issues.
The Joint Commission has deemed some entities “designated equivalent sources,” meaning it considers them to provide information identical to that provided by the original source. Your options for PSV are contacting the original source or any designated equivalent sources.
You should only use secondary sources to verify credentials in cases where it is truly not possible to contact the original source (such as when the issuing agency or hospital has closed) and designated equivalent sources are unable to verify the information. For example, if an establishment is no longer in operation you may try contacting any successor organizations or find out where original documents may have been sent.
Primary Source Verification Services
PSV is a very involved and time-consuming process that entails manual, repetitive tasks that must be completed for EACH credential and for EVERY provider. Some designated equivalent sources also require payment to gain access.
Fortunately, CredentialingOne can contact/access each of these sources (original sources and/or designated equivalent sources) for you as well as document the completion of PSV for each of your providers’ credentials. We also monitor providers’ compliance, so you don’t have to manually track credentials and documentation and can ensure they’re renewed before they expire.
COVID-19: Resources for Provider Privileging During a
National Health Emergency
Posted on Monday, March 30, 2020
During a national health emergency such as that caused by the coronavirus, many facilities experience a provider shortage.
To combat COVID-19, you may need to expand your team of healthcare professionals by relying more heavily upon retired and volunteer providers, part-time clinicians, practitioners from other states, practitioners from other departments, and telehealth.
Provider Privileging During a National Health Emergency
During a health crisis, hospitals strive to grant privileges to these clinicians as quickly as possible while still protecting patients by providing them with qualified practitioners.
The federal and state governments, along with other regulatory entities, are temporarily adjusting some licensing and privileging requirements to accommodate the greater need for more providers and access to care due to COVID-19.
CredentialingOne can help you navigate any new and/or temporary rules and ensure your patients receive safe care from competent providers.
To start, we’ve compiled a list of resources to consult regarding provider privileging during a national health emergency:
Many regulations are temporarily changed for provider privileging during a national health emergency.
1135 Waivers – the U.S. Department of Health & Human Services (HHS) is authorized to issue waivers during the COVID-19 national emergency. You can find information on blanket waivers and how to apply for individual waivers here. You must send individual waiver requests to your CMS Regional Office, and office email addresses can be found here.
Medicare Telehealth – CMS has expanded Medicare telehealth to include a wider scope of services so that more patients can access care from home; see its FAQs and Fact Sheet.
States Waiving Licensure Requirements/Renewals – the Federation of State Medical Boards (FSMB) created this table along with links to the original sources declaring the changes in response to the coronavirus.
States Expediting Licensure for Inactive/Retired Licensees – the FSMB created this table, which includes links to states’ resource pages.
The Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP) – this program verifies registered healthcare volunteers’ credentials in advance, so they can respond more quickly to help in a crisis. (Hospitals should check with their insurance companies to determine how volunteer providers may/may not be covered by their malpractice insurance.)
For additional information, you can also contact your specific state medical association.
These resources may be updated as the COVID-19 situation progresses.
If you need further guidance on provider privileging during a national health emergency, please contact us – we’re here to help.
Prevent Claim Denials with Accurate and Timely Credentialing
Posted on Thursday, March 5, 2020
In order to prevent claim denials, accurate and timely credentialing is essential to your practice. Credentialing has a major impact on the revenue cycle as the slightest error or interruption in the process can result in claim denials, underpayments, and reimbursement delays.
And payments for services delivered are not the only thing at stake – you also risk losing the business of patients who don’t want to go out of network while you wait to be accepted by their insurance plans.
You can prevent claim denials and other damages to your revenue cycle through accurate and timely credentialing. By both avoiding credentialing mistakes and completing the credentialing and recredentialing processes as quickly as possible, you can protect your practice’s cash flow and revenue integrity.
Below we outline just a few of the credentialing mistakes that can affect reimbursement by holding up credentialing applications and/or causing claim denials.
Avoid these mistakes that cause application processing delays or rejections:
Avoid these credentialing-related billing and compliance mistakes:
Submitting a claim using physician or practice data that does not match what the payer has on file
Submitting a claim for an office location that is not in the payer’s system
Failing to confirm payers have the correct provider billing address
Forgetting to notify a payer when a provider terminates (e.g. resigns, retires), when the plan requires the practice to do so within 30 days of the termination
Not realizing that credentialed providers may need to opt-in to new plans that a payer has added
Not realizing that credentialed providers may need to opt-out of new plans that a payer has added, or they may automatically be included in them
Missing deadlines for CE requirements
Missing renewal deadlines for expiring certificates, licenses, insurance, etc.
These solutions can help ensure you avoid credentialing mistakes that impact the revenue cycle:
Prevent Claim Denials with an Annual Health Plan Audit
CredentialingOne’s accurate and timely credentialing services can prevent claim denials and protect your revenue.
Conduct an annual health plan audit to verify your providers are participating in the correct plans, payers have been updated on your current roster of providers, and front desk staff understand the plans with which you hold contracts.
You should audit regularly to keep up with provider and front desk turnover and periodic changes to health plans. CredentialingOne provides a health plan audit service, which typically takes fewer than 30 days to complete.
Prevent Claim Denials Related to Ongoing Credentialing Maintenance
Additionally, you should continuously monitor your providers’ compliance with health plans. Even after providers are enrolled with payers, there are plenty of opportunities for reimbursement issues resulting from compliance violations and/or recredentialing/revalidation errors.