An accuracy meter hits Level 100… prevent claim denials with accurate and timely credentialing.

Prevent Claim Denials with Accurate and Timely Credentialing

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CredentialingOne Blog

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:

  • Not allotting enough time for the credentialing process
  • Errors in credentialing application paperwork and contact information
  • Omitting required information or documentation from applications
  • Leaving form fields blank or not fully completing each form
  • Unexplained gaps in work history
  • Unresponsive or lagging peer references
  • Malpractice insurance for the practice a provider is leaving, rather than the one they are joining
  • Outdated or incomplete CAQH application
  • Lack of follow-up on application status

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

An accuracy meter hits Level 100… prevent claim denials with accurate and timely credentialing.

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.

CredentialingOne tracks our clients’ expirables (e.g. certificates, licenses, malpractice insurance, CE credits) and our automated, real-time messaging alert system notifies practices and providers of upcoming deadlines 120, 90, 60, and 30 days prior to expirations.

Through deficiency management we can help you prevent claim denials related to avoidable compliance breaches.

Prevent Claim Denials by Outsourcing Credentialing

Outsource credentialing with CredentialingOne and we will prevent claim denials related to credentialing issues for you. Our Credentialing Specialists are experts in correctly and quickly completing all tasks related to credentialing and compliance for our clients.

We make sure you avoid the credentialing mistakes listed above and our credentialing technology solutions streamline the process to get you credentialed and recredentialed with your payers faster.

Contact us today to learn more about how our accurate and timely credentialing services can prevent claim denials and protect your revenue.


By Stephanie Salmich

Outsource credentialing with CredentialingOne in 2020.

Why Outsource Credentialing in 2020?

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CredentialingOne Blog

Why Outsource Credentialing in 2020?

Posted on Monday, January 6, 2020

There are many reasons to outsource credentialing this year. Below are just a few of the benefits of choosing a credentialing services provider to manage the process for you.

Outsource Credentialing to Ensure Credentialing Compliance

Credentialing can become “out of sight, out of mind” following completion of the initial credentialing process.

However, the credentialing life cycle of a practice includes maintenance of provider credentials. Monitoring CE credits, expiring certifications, licenses, and insurance is a detailed task and without a dedicated credentialing team of experts, opportunities for human error are significant.

Re-credentialing or re-validation with commercial and government payors is also a part of the credentialing life cycle. Payors will re-credential or re-validate a provider every 2 to 3 years. Failure to complete re-credentialing or re-validation will result in claim denials and lost revenue.

Outsource Credentialing to Prevent Claim Denials

Credentialing directly affects the cash flow of a practice. Yet, many practices do not think about credentialing until something triggers there is a credentialing-related issue.

A BIG trigger occurs when a claim is denied or reimbursement is lower than anticipated. If the issue is not due to how the claim was filed, then the reason may be related to provider credentialing.

For example, a provider may not have completed re-credentialing or may not be participating in the plan in which the patient is enrolled. Non-credentialed or non-paneled providers do not receive any reimbursement for their services from plans with no out-of-network benefits (e.g. HMO plans).

Lower-than-expected claim reimbursement can also be attributed to the out-of-network benefits the patient’s plan offers. PPO plans, for instance, have out-of-network benefits with higher deductibles, co-pays, and lower co-insurance levels.

Every practice needs an experienced team solely committed to credentialing maintenance so that nothing slips through the cracks. Outsourcing with the CredentialingOne team yields the additional advantage of innovative technology that monitors credentialing compliance and automatically alerts you to pending expirations.

Outsource Credentialing to Save Time & Resources

A provider may see 25 to 35 patients (or more, depending on the practice) on an average day. Providing medical treatment is a full-time job; but making sure the practice is profitable is also both essential and time-consuming. This is the main reason practices outsource services to experts in various industries.

CredentialingOne’s expert staff and technology complete all credentialing documentation, track applications through fulfillment, and follow up when necessary. With CredentialingOne you can maximize cash flow by preventing claim denials and other credentialing issues and do so without sacrificing time and attention away from patient care.

Outsource credentialing with CredentialingOne in 2020.

CredentialingOne: Your external credentialing solution. Outsource credentialing with us in 2020.


Providers are in the business of healing – providing comfort and compassion to patients and their family and friends. Most chose this profession for their passion for helping others, not for the extensive administrative work and time that the credentialing process requires.

Connect with CredentialingOne in 2020 – outsource credentialing this year and let us take the burden off your hands!


By CredentialingOne

An annual health plan audit is performed.

Why an Annual Health Plan Audit is Critical to Your Success

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CredentialingOne Blog

Why an Annual Health Plan Audit is Critical to Your Success

Posted on Tuesday, December 3, 2019

Conducting an annual health plan audit is critical to the success of your practice. Over the life of a practice, providers and staff come and go and insurance companies add and terminate health plans. Keeping track of these changes is key to protecting your practice from legal issues and ensuring adequate cash flow.

Protecting Your Practice

When a new provider joins a practice, they must of course become credentialed and linked to the practice’s payor contracts in order to be considered “in-network.” However, most practices forget that they must notify their payors when a provider leaves their practice as well.

Payor contracts include language requiring a practice to send notification within a specific time frame when a provider terminates. Not only does notification of the termination date keep the practice compliant with these contracts, but it also protects the practice if the provider experiences malpractice issues or sanctions after leaving the practice.

Performing a health plan audit can ensure all payors are up to date on the providers currently associated with your practice.

Improving Front Desk Collections

A health plan audit is also crucial for front desk collections.

Turnover of front desk staff is not uncommon for any practice. It is vital that both your new and experienced staff members know the plans in which each provider participates. They also must be knowledgeable about the payors with whom your practice holds contracts.

Without a current roster of plan participation, the front desk will not know the appropriate co-pay or deductible to collect and your cash flow will bear the consequences.

An annual health plan audit is performed.

An annual health plan audit helps your practice maintain compliance and improves cash flow.


CredentialingOne’s maintenance and compliance services include an annual health plan audit. We can also provide health plan audit services on a standalone basis for clients.

The health plan audit process usually takes fewer than 30 days to complete.

Contact us today to learn more about how an annual health plan audit can protect both your practice’s liability and cash flow.


By CredentialingOne