Delayed credentialing is one of the most underestimated revenue risks in the US healthcare system. It does not generally appear as a separate line item in financial statements, but rather, it silently takes away money, increases refusals of claims, interrupts the flow of money, and annoys both the doctors and the patients.

The physician credentialing procedure for medical clinics, hospitals, and laboratories directly dictates when the billing and reimbursement of the services can take place. In the case of slow credentialing, even having a high number of patients cannot guarantee revenue protection.

In this paper, the hospital credentialing delays' impact on the business, the reasons for their occurrence and the role of professional medical credentialing services in the financial health of the healthcare organizations are addressed.

What Is Medical Credentialing and Why Does It Matter

Medical credentialing is the process by which a healthcare provider’s qualifications are authenticated and the provider is registered with insurance companies for the purpose of claims submission and payment.

Credentialing of Healthcare Providers usually involves:

• Verification of educational background, licenses, and certifications

• Review of professional experience and malpractice history

• Enrollment and credentialing with insurance providers

• Signing contracts with the government and private payers

Providers will not be allowed to submit claims to payers, and claims may even be outright denied until the credentialing process is complete.

Medical billing and credentialing have a close relationship. A delay in one area affects revenue in the other area.

The Real Financial Impact of Credentialing Delays

Credentialing delays are not merely a sluggish procedure of onboarding. They influence the earnings of the company straight away.

Revenue loss due to services that cannot be billed

It happens that providers get authorized to see the patients even though the process of credentialing has not been finished yet. However, the services provided during the latter period cannot be billed to the patients after the period has passed.

A short delay could lead to revenue loss of up to a hundred thousand dollars or even more.

Higher claim denial rates

Submitting claims without an active enrollment status usually leads to denial of the claims. It is really hard to recover such denials, and they often end up as write-offs.

Cash flow disruption

Delayed payments from the health insurance company will cause cash flow gaps, making it more difficult to pay for payroll, supplies, and other operating expenses.

Costs of administrative rework

Employees have to spend time fixing enrollment mistakes, resubmitting claims, and calling the payers for updates.

Real Healthcare Billing Scenario

A multi-specialty clinic recruits two newly qualified providers and starts patient appointments just a few weeks later. The credentialing process, however, with the major commercial payers turns out to be quite long due to incomplete documents and slow follow-up.

During a period of three months:

• Hundreds of medical encounters have been created, but no money has been received for them

• Claims have been submitted and are denied because of the doctor's inactive enrollment

• The billing staff has to spend a lot of time fixing the claims

• The cash flow situation gets very unpredictable

This situation is often encountered, and in addition, it is preventable by using proper credentialing and enrollment solutions.

Common Causes of Hospital Credentialing Delays

Comprehending the root causes is the key to not having the same troubles.

Incomplete or inaccurate provider data

Unlicensed providers, outdated CAQH profiles, or false work history are the reasons behind slow payer reviews.

Manual Tracking and following up 

Payer follow-ups are not well organized, and delays are not seen if there are no structured workflows.

Not enough payer-specific expertise

Requirements differ for each payer. Treating the credentialing process as a universal one increases the chance of rejection.

Poor coordination between credentialing and billing

Claims are sent out too early when the medical billing and credentialing teams work independently.

Why This Matters More Now Than Ever

The situation with credentialing timelines is such that they are getting longer instead of shorter.

Here is a list of the reasons behind this trend:

• Provider turnover has increased

• Payer requirements have become more complex

• More value-based contracts are being used

• Audit scrutiny has increased

Today's healthcare organizations that do not improve their healthcare provider credentialing process are risking a larger financial loss.

The Role of Professional Medical Credentialing Services

Medical credentialing services introduce order, responsibility, and knowledge to a complicated procedure.

The efficient credentialing and enrollment methods offer:

• Specialists with exclusive credentialing knowledge

• Knowledge of specific payers and follow-up

• Management and verification of documents

• Tracking of status in real-time

• Connecting with billing departments

This results in less risk and faster readiness for revenue.

How to Evaluate Medical Credentialing Services

Prior to selecting a partner, decision-makers must pose these questions:

• Do they have expertise in healthcare provider credentialing?

• What system do they use to keep track of payer follow-ups?

• What is the procedure for consultation with billing departments?

• What are the measures adopted for compliance?

• Can they expand their services in line with the growth of the organization?

Unambiguous answers denote advanced and trustworthy processes.

Why Outsourcing Credentialing Is a Strategic Decision

Even though outsourcing medical credentialing services is often thought of as giving up control, it actually means acquiring knowledge, standardization, and observability.

Outsourcing organizations frequently realize:

• Quicker provider enrollment

• Decreased denial rates

• More reliable cash inflow

• Less administrative load

All of these results are closely related to the financial performance of the organization.

Why Dilijent Systems is One of The Best Medical Credentialing Service Providers in the USA

Dilijent Systems is the best medical credentialing service provider in the USA. The reason is that we are bringing not only real but also vast industry experience in handling the burden of credentialing healthcare providers. 

The whole process of credentialing and payer enrollment is taken care of by us, starting from the very beginning when the documents are being collected, and provider information is being verified through enrollment with insurance companies, and finally, maintaining an active status.

The work we do not only helps the providers to get credentialed correctly and on time with commercial payers and others like Medicare and Medicaid, but also lets them start billing faster and avoid unnecessary claim denials. The main contributor to our success is, however, the focus on compliance, rigorous and consistent follow-ups, together with the knowledge of the payer rules and regulations.

We continuously monitor the status of the credentialing applications and, at the same time, manage the recredentialing before the deadlines, thus preventing the practitioners from experiencing any payment delays or interruptions in patient care. Our close association with billing workflows results in a decrease in the denials related to enrollment and an increase in the first pass claim acceptance.

Moreover, we combine credentialing with revenue cycle management services so as to cut down on the administrative workload and bring operational costs under control. The structured processes, the adoption of technology, and the focus on measurable results help not only to improve the cash flow but also to build up the confidence of healthcare organizations to support their long-term growth.

Conclusion

The process of credentialing getting delayed incurs unnoticeable expenses that are indirectly related to revenue, approval of claims, cash inflow, and satisfaction of patients. However, these losses can be avoided if appropriate measures are taken to support.

Mediсal credentialing services not only offer the much-needed structure, but also the specialized knowledge and decisiveness that together shield the revenue from the very beginning.

In case your institution is facing issues of being delayed in enrollment, increased denials, or cash flow difficulties, then it is the right moment to check the credentialing processes in your organization.

Get a consultation scheduled to analyze the present credentialing system.

Demand an audit of the eligibility verification for spotting the risks related to enrollment.

Consult our billing specialists for synchronizing the processes of credentialing and billing, which will facilitate achieving better financial results.