Stay on Top of Provider Credentialing and Revalidation

It happens all of the time.  You are sorting through all of the mail that arrives and you come across a letter from one of your major payers stating that this is the third letter they've sent and you have only 30 days to get Dr. Smith credentialed.  Your heart stops a beat and you think, "Did I really ignore previous attempts of contact from the payer?!  Am I forgetting something so important?!"  Relax, you're not forgetting and you're not ignoring.  This happens to practice administrators everywhere, every day.  Don't waste your energy arguing with the insurance company, just reach out to the practitioner needing credentialing updated or revalidating and get their up-to-date information that is required.  The most common pieces of information are :

• Copy of practicing license (easy to find online)

• Copy of current CV

• Copy of current malpractice/liability insurance

• Copy of payer's application form

• Copy of NPI (easy to find online)

If you're going to fax these documents to the number provided, remember to obtain a proof of sent form that your fax machine spits out.  It's nice to have if something goes "wrong" with the payer receiving your application.  Another smart move is to call five working days after you've faxed the information, and ask if they have received the required documentation.  If they have not, ask for a different fax number and include the original proof of sent sheet.  Wait another five working days and call again.  This time, try to reach a supervisor.  Be sure you are getting reference numbers and representative names for these conversations.

Another tip I would give is to have a master credentialing spreadsheet or document with your physician names down the left side and any pertinent information.  I would suggest the following:

• Hire date

• License expiration date

• Date Medicare certified

• Date certified with any insurance network you are contracted with

• Date certified with the major payers (Blues, Optum, etc.)

Keeping this document current can alert you in advance if there might be a problem looming on the horizon.  With turnover in the healthcare field, it's rather important to have this type of document shared with a few key people in the event you lose an employee that monitors this information.  Oftentimes people say, "Oh, I have it all up here" (tapping their head).  Something happens and the employee does not return to work, and "all up here" does your practice no good and sets you up to fail.

Last tip I can share with you is to occasionally log into the Provider Enrollment, Chain and Ownership System (PECOS) and check to make sure Medicare hasn't suddenly dropped one of your providers out of their system.  This also happens more often than we'd like.  If this has happened in your practice you know the potential for thousands of dollars of lost income. It can be devastating to a smaller group.

Overall, try to be one step ahead of your insurance companies by monitoring your contracts, and healthcare practitioners credentialing dates.  It can save you headache, heartache, and hostile interactions with the insurance company.