Credentialing Gaps Killing Claims

Provider not par issues occur when a healthcare provider is not contracted with a payer, resulting in claims denials. For example, if a provider is not par with a particular insurance company, any claims submitted for services rendered to patients with that insurance will be denied. This can lead to significant revenue losses for the practice. In one instance, a practice lost over $10,000 in a single month due to provider not par issues. To avoid this, practices should regularly review their provider contracts and ensure they are up-to-date with all payers.

To identify provider not par issues, practices can use the CO-22 CARC code, which indicates that another payer is primary under COB. By monitoring this code, practices can quickly identify when a provider is not par with a payer and take corrective action. Additionally, practices can use automated credentialing software to streamline the credentialing process and reduce the risk of provider not par issues.

An expired CAQH (Council for Affordable Quality Healthcare) can cause significant delays in the credentialing process, leading to claims denials and revenue losses. CAQH is a universal credentialing dataset that allows healthcare providers to self-report their professional and practice information. When a CAQH expires, it can no longer be used to verify a provider's credentials, resulting in delays and denials. For instance, a practice with an expired CAQH may experience delays in processing claims, leading to an increase in accounts receivable days.

To avoid expired CAQH issues, practices should regularly review and update their CAQH information. This can be done through the CAQH website or through automated credentialing software. By keeping CAQH information up-to-date, practices can ensure that their providers' credentials are always verified and reduce the risk of claims denials.

Wrong billing NPI (National Provider Identifier) issues occur when a practice uses an incorrect NPI number when submitting claims. This can result in claims denials and revenue losses. For example, if a practice uses an incorrect NPI number for a particular provider, any claims submitted for that provider will be denied. In one case, a practice lost over $5,000 in a single month due to wrong billing NPI issues.

To avoid wrong billing NPI issues, practices should regularly review and update their NPI information. This can be done through the CMS website or through automated credentialing software. By keeping NPI information up-to-date, practices can ensure that their claims are always submitted with the correct NPI number and reduce the risk of denials.