Top Reasons Credentialing Applications Get Denied

Credentialing is a complex process that requires extensive documentation, involving numerous details in the credentialing application, which makes mistakes and errors almost inevitable. A small error can turn into an application rejection. Healthcare providers, practice administrators, and all other physicians can avoid unnecessary delays and financial losses by understanding the reasons behind these denials.

You can deal with and finally settle most credentialing denials if you understand the top reasons for credentialing denials. In this article, we’ll look at the Top Reasons Credentialing Applications Get Denied so you can avoid them and achieve faster credentialing.

Top Reasons Credentialing Applications Get Denied

If you do not submit a proper credentialing application with complete details, it will negatively impact your practice. If you detect the error before rejection and resubmit the correct application, it also wastes a lot of providers’ time and effort. These denials and delays can affect the revenue cycle due to delayed reimbursements. This could put your patients’ health and safety in danger. To avoid problems with your credentialing process, be aware of these provider credentialing mistakes and try to avoid them.

The following are the top reasons for credentialing denials.

Incomplete or Inaccurate Applications

Most of the time, credentialing applications are denied because they lack complete information. Payers need to know all about your education, career history, and personal life. One of the most common credentialing application errors people make when applying for credentials is submitting incomplete or inaccurate information. If your application contains missing signatures, inaccurate dates, or incomplete fields, it will be turned down immediately. Payers need accurate information to confirm credentials, so even minor errors can create significant delays.

Missing Documentation

Insurance companies require extensive paperwork to verify that you are who you claim to be. Not having the correct documentation is a key factor for denials. You have to provide each payer with the documentation they require because they all have different demands.

Some crucial papers are

• Medical school certificates
• Certificates showing that you have finished your residency
• Board license
• State healthcare provider licensure
• Proof of malpractice insurance
• Paperwork for hospital rights
• Professional references

Before you start the application, make sure you have all of your documentation in one place. Make copies and keep the originals safe. Some payers will take digital copies, but others want the originals. Read the standards for each application very carefully.

Discrepancies in Work/License History

One of the primary reasons for credentialing denials is that the provider or their administrator sends in an application with expired medical licenses or certifications. Providers must first check that their medical licence, DEA registration, board certification, and malpractice insurance are all current.

Payers pay serious attention to your employment history and license information. Every gap or divergence is a warning sign. You need to provide the correct times and explanations for any breaks in work or practice.

Here are some frequent historical problems:

• Unidentified gaps in work
• Conflicting dates between documents
• Missing the location of your previous practices
• Incomplete residency information
• Unlisted licenses

Write down every element of your job schedule. If you see any gaps, be honest about them. Let others know if you take time off for personal reasons, to care for family, or to receive further training—credentialing committees value providers who are honest and transparent.

Expired or Incorrect Licenses/Certifications

To get credentials, you need to have licenses that are current and legal. If your licence is out of date, you will be denied right away. Your board credentials also need to be current and relevant to your business.

• Licensing issues include when the following licenses have expired:
• State-specific licenses
• DEA licenses
• Board licenses  
• Incorrect license numbers
• Specialty certifications

Make sure to check the expiration dates on all of your licenses. Set reminders for a long period before the date when the renewal is due. You should have both digital and print copies of all of your licenses. You should instantly add a certification to your CAQH profile after you renew it.

Insurance Payer Requirements Not Met

Every insurance business has its own rules for credentials. What one payer requires may differ from another. Denial happens when specific standards set by the payer are not met.

Problems that are specific to the payer are

• Inadequate malpractice coverage limits.
• Incorrect insurance panel selections
• Missing payer-specific form
• Insufficient practice location details

CAQH Profile Errors

The CAQH profile (Council for Affordable Quality Healthcare) is where most payers review provider information. One of the main reasons for credentialing denials is that CCAQH records are often inaccurate or outdated. Providers need to keep their CAQH up to date to ensure it is accurate and avoid rejection.

Here are some frequent CAQH credentialing application errors

• Outdated contact information
• Missing or expired documents
• Incorrect practice details
• Wrong specialty designations
• Incomplete education history

Check that your CAQH information is correct and up to date. You need to upload updated documents promptly if your licenses or certificates change.

Failure to Respond to Requests for Information

Sometimes, credentialing processors may need extra information or proof. If providers or administrators don’t respond in time, the application may be denied. Credentialing groups often seek additional information during the review process. If you don’t answer right away, you will get a denial. Payers have rigid timeframes for acquiring what they require.

Not responding includes

• Not fulfilling deadlines
• Incomplete or wrong information
• Not responding to follow-up requests
• Communication that takes too long

How to Avoid Denials – Best Practices

To avoid credentialing rejections, you need to pay close attention to details and be well-organized. Here are some things you can do to increase your chances of getting approved:

• Create a credentialing checklist: It’s crucial to make a list of all the papers and information you need for each application. Cross things off your list as you finish them.
• Maintain current documentation: Make sure your records are always up to date. Check that all of your licenses, certificates, and insurance plans are current—store copies in a well-organized filing cabinet.
• Review application carefully: Go over finished applications more than once. Have someone else check them for faults that you might not see.
• Start early: Begin credentialing well before you need payer approval. Allow 90 to 120 days to finish.
• Track deadlines: Use a calendar to keep track of when your applications are due and when your renewals are due. Set reminders for weeks ahead of time.
• Communicate proactively: If you have questions concerning standards, talk to payers. Respond quickly to any requests for more information.
• Keep detailed records: Keep detailed records: Document all communications with payers.
• Use professional help: Get help from someone who knows what they’re doing. You might engage a credentialing specialist or business to handle the process for you.

Conclusion

If a credentialing application is denied, it might hurt the practice’s revenues and patient care. Similarly, it can also take longer for payers to enroll. Providers can prevent problems and get approved faster by learning what provider credentialing mistakes can lead to rejections and following best practices.

Missing documentation, incomplete applications, or licenses that have expired are also common grounds for refusal. Paying great attention to the specifics and closely following payer requirements will make it less likely that you will get denied. 

To speed up the process and cut down on rejections, you can take help from a professional credentialing company like Credex Healthcare. Our expert ensures that your application is always complete, accurate, and sent in the appropriate method to get approved on the first submission.

FAQs

Q: Why do credentialing applications get denied?

A: Applications that aren’t complete, missing papers, licenses that have expired, or CAQH problems are the most common grounds for refusal.

Q: How long does it take to resubmit after a denial?

A: It can take anywhere from 30 to 90 days, or even more in some situations, to resubmit.

Q: Can denied applications affect my practice revenue?

A: Yes. When insurance companies deny a claim, it takes them longer to pay, which directly affects your practice’s cash flow.

Q: How can I reduce errors in credentialing applications?

A: You can avoid provider credentialing mistakes and reduce the chances of denials by working with credentialing professionals, keeping your papers up to date, and making sure your CAQH profiles are accurate.