What Happens When Provider Credentials Expire?
Posted on Monday, April 5, 2021
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.
Expired Provider Credentials Can Result In:
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).
CredentialingOne can build a custom credentialing maintenance and monitoring program that works with your credentialing policies. We offer a robust software solution for credentialing management and a team of experienced credentialing professionals to handle the work for you.
- Our real-time messaging alert system, which sends email and text reminders to the provider when documents are nearing expiration (starting at 120 days prior to expiring).
- A master report for the practice indicating providers with expiring documents at 120, 90, 60, and 30 days out.
- CAQH quarterly attestations (we re-attest the provider every 120 days and upload new documents as they are set to expire).
- Re-credentialing for commercial payers and re-validation for government payers (e.g., Medicare, Medicaid, TriCare).
- Demographic updates, such as address/phone/name change.
- Directory updates; Medicare payers in particular request providers to verify their demographic information every 6 to 12 months.
- NPDB (National Practitioner Data Bank) queries
- SAM and OIG queries
- Primary source verification
- 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
CredentialingOne’s expert staff and technology are dedicated to keeping providers compliant and making sure they do not miss credentialing deadlines that are vital to the health of their practice and careers. Contact us to learn more about our credentialing maintenance and monitoring services, health plan audits, and how we can help you avoid the dire consequences that can occur when provider credentials expire.
By Stephanie Salmich