Being credentialed and enrolled may feel like work is done, but that is not true. In reality, it is more of an ongoing process for healthcare providers.
Provider credentialing maintenance is equally essential because credentials, licenses, or any other payer-required information can become obsolete.
For example, if a provider moves their practice, joins another organization, or changes their Taxpayer Identification Number (TIN), the credentialing information must be updated as well.
Provider enrollment maintenance focuses on ensuring that credentials, licenses, and certificates are updated on time for continued enrollment in the payer’s network. Realistically, provider credentialing maintenance issues do not appear until claims errors occur.
They may arise in the form of denied claims, payment blocks, or even termination of payer-provider contracts.
However, claim issues can only be detected through remittance advice. The good thing is that provider credentialing maintenance prevents such issues by ensuring that the billing staff and insurance payer have the latest healthcare provider information.
Still, various deadlines and requirements (depending on each payer and state regulations) may apply.
- Provider Credentialing Maintenance vs. Enrollment Maintenance
- Importance of Provider Credentialing & Enrollment Maintenance
- Which Documents & Information Should Practices Keep Updated?
- Provider Credentialing & Enrollment Maintenance Challenges
- Preventing Provider Credentialing Maintenance Delays
- How Does MediBillMD Help With Provider Credentialing & Enrollment?
Provider Credentialing Maintenance vs. Enrollment Maintenance
Provider credentialing and enrollment are combined into one category even though they address two different issues.
Credentialing is the verification process, which can involve questions such as:
Does this provider have the licenses, credentials, board certifications, and records they claim they have? Provider credentialing maintenance involves regularly re-verifying facts or provider information.
For instance, health plans accredited by the National Committee for Quality Assurance (NCQA) must re-credential their practitioners within a 36-month cycle.
Practitioners are supposed to re-attest their CAQH ProView profiles every 120 days so that the payers can see updated data.
On the other hand, enrollment is the administrative process and covers several concerns. Is this provider enrolled with the payer so that his/her claims can be processed?
Maintaining the enrollment process requires reporting changes and revalidation. Generally, Medicare revalidates providers every five years.
42 CFR 424.516 states that physicians and non-physician practitioners must report relevant information on time. They must report a change in ownership or control, a legal action, or a change in practice location within 30 days.
The credentialing standards also require reporting any other change within 90 days. State Medicaid programs should revalidate enrollment at least every five years to ensure proper provider enrollment maintenance.
The following table covers some of the most essential distinctions between provider credentialing maintenance and enrollment maintenance:
| Category | Provider Credentialing Maintenance | Provider Enrollment Maintenance |
|---|---|---|
| Basic Issue | Is the provider qualified? | Is the provider registered to bill? |
| Common Reasons | License renewal, certification, insurance renewal. | Change in location, group, Tax ID, ownership, or bank details. |
| Where It Is Done | State boards, CAQH ProView. | PECOS, NPPES, Medicaid, payer portals. |
| Frequency | Every 3 years; CAQH every 120 days. | Every 5 years, certain changes within 30 or 90 days. |
| If Not Done | Providers may lose network status. | Claims denied or payments delayed. |
An event can affect provider credentialing maintenance and enrollment. So, both processes should be coordinated. Updating the office, association, and practice ownership can affect the CAQH, NPPES, Medicare, Medicaid, and commercial payers.
Similarly, updating qualifications, such as obtaining a new license or board certifications, can also have an impact.
Note that credentialing and approval statuses are interconnected but not interchangeable. Credentialing does not necessarily mean network participation, and vice versa.
Either one does not necessarily include enrollment status with a billing effective date. Payers may update requirements differently, so it is good to verify those from each payer.
Importance of Provider Credentialing & Enrollment Maintenance
Outdated provider data means that there is a potential billing issue looming. Claims may be denied if the rendering provider is inactive. In other cases, if billing information does not correspond to payer records, the claim will be denied.
With Medicare, failure to respond to a revalidation request can deactivate billing privileges. Reactivation requires resubmission of enrollment information. However, if healthcare providers keep providing patient care, it can lead to unpaid claims.
The administrative cost may not be massive, but it definitely exists. During provider credentialing maintenance, providers spend time chasing payers, resubmitting claims, and fulfilling documentation.
The process is typically scattered because there is no organized file. As far as operations go, scheduling becomes impossible if the provider is no longer within the network. This leads to cancelled visits and out-of-network issues.
Provider credentialing maintenance and accuracy are equally important for patients due to the No Surprises Act.
According to the act, health plans need to validate provider directory information at least every 90 days. Therefore, applicants must ensure all their information is submitted on time.
Why Does Provider Credentialing Maintenance Matter?
If performed effectively, provider credentialing maintenance has consistent returns. It offers improved cash flow, reduced avoidable denials, and decreased payment delays. In addition, applicants can ensure constant network eligibility, avoiding scheduling and referral disruptions.
Applicants also enjoy improved audit results due to having verifications and attestations all documented.
What’s more, practices ensure quick addition of new providers/sites as everything is already verified. Lastly, they also get peace of mind with periodic exclusion screening.
Which Documents & Information Should Practices Keep Updated?
Several documents are required for provider credentialing maintenance. Missing or providing an outdated document can stop healthcare experts from providing services. Since the list is extensive, categorizing everything into three groups helps.
Professional Credentials
State licensing(s), including expirations. The cycle varies from state to state and varies by board. Secondly, DEA registration (which should be renewed every three years), with any State Controlled Substances registration. Next, they must provide a Board Certification, with its maintenance requirements.
Applicants must also provide a current malpractice insurance certificate (including policy expiration dates and amounts). Privileges at hospitals and employment record with no gaps, with continuing education record (as needed for licensure).
Payer Enrollment Records
- CAQH ProView profile, up-to-date, and properly re-attested by the proper payers.
- National Plan and Provider Enumeration System (NPPES) record, which needs updating within 30 days following the changes.
- Medicare enrollment in the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) and Medicaid enrollment information.
- Group NPI, TIN, and locations, which have to match everywhere.
- Billing address, pay-to address, electronic payment and remittance information.
- Information from each payer regarding ID number, the date of effectiveness, and participation status.
- Location, since all the baseline data is accurate.
- Exclusion screening results. The OIG’s List of Excluded Individuals/Entities is updated monthly, which is why many organizations screen monthly.
Internal Tracking Systems
Applicants must also ensure a master provider list containing all expiry and revalidation dates. It should also contain a status log for each payer indicating what was submitted, when it was submitted, the reference number, and the date on which it took effect.
Similarly, submissions, approval letters, and any other correspondence should be documented.
The individual owner for all open items and the action to be taken next must be mentioned. Lastly, the change log should be updated, covering changes made and who did it and when.
Provider Credentialing & Enrollment Maintenance Challenges
Provider credentialing maintenance and enrollment issues are usually not massive. Instead, they arise because of routine operational inefficiency. Here are some common challenges:
Fragmented Records
Scattered records are perhaps the biggest challenge in provider credentialing maintenance.
Imagine records fragmented across different systems. Licenses are in one folder, insurance certifications in one email, and payer ID numbers in one person’s spreadsheet; gathering them is challenging.
When the deadline arrives, finding the most recent record becomes a burden, which can impact credentialing and enrollment.
Inconsistent Provider Information
A suite number listed one way in CAQH and a different way in NPPES or the payer record can result in rejections or delays in updating. These little discrepancies add up across multiple systems.
Payer-Specific Rules
Forms, web portals, processing times, and reportable changes differ among payers. What works with one payer will not work with the next.
Unreceived Notices
Requests for revalidation and payer letters can end up at an old address or email address of a former employee, being ignored.
Poor Hierarchy and Responsibility
Provider credentialing maintenance and enrollment typically involve several offices. Credentialing documents move between front office, billing, and the practice manager during the process.
For this reason, everyone assumes someone else is tracking the dates, which can lead to errors later.
Preventing Provider Credentialing Maintenance Delays
If not addressed, these issues result in administrative rework, delays in enrollment changes, and possible disruptions in claims payments. Multiple practices help to avoid these issues:
Create a Consistent Workflow
Utilize the same checklist for provider onboarding, provider location and group changes, in order to avoid relying on memory.
Use Centralized Documentation
Have a single current and accessible resource for credentials and payers, rather than several incomplete ones.
Assign Task Ownership
Each deadline and open payer request should be assigned to someone on the team to ensure complete ownership and responsibility.
Consistent Reconciliation
Reconcile your internal directory with CAQH, NPPES, PECOS, and payers’ portals regularly. It should be done before payers discover discrepancies themselves.
Change Cascades
Hiring a new physician, letting one go, or changing an address can require updating multiple files all at once. This increases the chance of overlooking one element while completing the first four.
Contact Insurance Credentialing Services
Newer practices are generally at a higher risk of committing provider credentialing maintenance mistakes. A single mistake can jeopardize cash flow and operations, pushing the practice back months.
We suggest connecting with a professional insurance credentialing services provider to avoid such instances and streamline the process.
How Does MediBillMD Help With Provider Credentialing & Enrollment?
It’s easy to procrastinate provider credentialing maintenance since claims will not cease immediately. The effects of poor provider enrollment maintenance generally show up after a deadline passes.
MediBillMD handles that for you through monitoring expiration and revalidation dates, CAQH, and re-attestation. Our professionals update provider and location details. We also follow up with payers until the changes are confirmed.
MediBillMD keeps your information current and your providers’ billing uninterrupted to help you avoid cash flow disruptions.
