How to Avoid the Top 5 Mistakes in Contracting and Credentialing

Proper contracting and credentialing in urgent care is not easy, especially for clinics who don’t have an expert working with them. Yet without it, you risk not getting paid, payers revoking contracts, payers asking for reimbursement on paid claims, and even some legal issues over non-compliance.

To help you stay compliant and profitable, we collected five of the most common C&C mistakes from Experity’s Senior Contracting and Credentialing Manager, Marley Page, along with what steps you can take to avoid them.

1.    Providers Not Properly Credentialed and Linked to Payer Contracts

This is the largest mistake clinics make. And we know it’s often because the clinic owner simply does not realize that they are not credentialed properly.  If you have a non-credentialed provider seeing patients, not only might they not get paid, but also, all that RCM work that you do on those claims is null and void because you didn’t have that provider credentialed and linked to your payer contracts.

Prevention Steps:

• Ensure you understand and follow the credentialing criteria for each payer. Document these criteria and keep them updated
• Regularly check and update the credentialing status of all providers to ensure compliance. Set a schedule and be consistent
• Track the effective dates of credentialing and ensure all paperwork is submitted on time

If your schedule does not allow you to properly keep up on this, it would be wise to either appoint someone else at your clinic to own these tasks, or to work with a third party. You don’t want to take chances when it comes to compliance.

2.    Not Following State and Federal Regulations

Even though your state regulations may say one thing, your payer contract can say something completely different as long as they’re following state guidelines at a minimum. It’s critical to understand both. For example, if you have a supervising physician that is supposed to be on site at all times by your payer contract and that payer comes in and audits the clinic, and that physician is not there, you risk losing your payer contract or revocation of that physician’s credentialing requirements.

Prevention Steps:

• Be aware of your state and federal regulations and ensure your payer contracts meet these requirements
• Ensure that supervising physicians are present as required by payer contracts
• Conduct regular audits to ensure compliance with oversight requirements

It’s very important that you know where your payers stand — whether they follow state minimums or whether they have stricter guidelines. And that typically is outlined in your provider credentialing criteria.

3. Misunderstanding Locum Tenens

Locums is commonly misunderstood. A locum cannot be an advanced practice provider (APP.)  A true locum is defined by the CMS federal guidelines as a physician filling in for another physician. And just like the risks already mentioned, if you are misusing a locum, an audit of claims could result in a recoupment of any reimbursement a payer has given you, or revocation of a contract.

Prevention Steps:

• Ensure that locum tenens are used correctly according to CMS guidelines
• Educate your staff on these guidelines to avoid misunderstandings
• Regularly monitor the use of locum tenens to ensure compliance

Again, locum cannot be an APP filling in for another APP or an APP filling in for another physician. A locum is a physician equals a physician.

4. Outdated Payer Contracts

A common mistake we see clinics make is — for example — they opened five years ago, got their first payer contract effective, they’ve been credentialing their providers, and then now they’ve added another level of service to their patients, and they didn’t update their payer contract. Their payer contract type isn’t correct based on the level of services they’re providing now.

That ultimately equates to giving services away for free.

Prevention Steps:

• Regularly review and update your payer contracts to ensure they cover all services you provide
• Understand the termination clauses in your contracts and negotiate changes if needed
• Reach out to payers to ensure your contracts are current and comprehensive

In short, it’s critical that you understand your payer contract setup, that you ensure that your payer contract type is correct, and that it encompasses all the services that you want to provide in your clinic.

5. Not Updating Contact Information with Payers

Even though you go through credentialing, get your effective date, and you’re following those guidelines, every payer has its own set of re-credentialing time frames and processes for providers and your group. If you miss those notices and miss that deadline, you run the risk of that provider or your group suddenly being totally out of network.

Prevention Steps:

• Regularly update your contact information with payers to ensure you receive recredentialing notices
• Stay on top of payer newsletters and other physical or electronic mail for any changes in credentialing requirements
• Document all credentialing requirements and implement processes to ensure compliance

Even though you’ve already gone through the process once, if you don’t answer those recredentialing notices, you risk of being out of network. So check your mail and stay on top of those payer newsletters.

Get More Help With Your RCM — for Free

Much like your annual physical exam, it’s good to check the health of your RCM. And Experity offers a free RCM Performance Assessment that is not a sales pitch, but a comparison of your clinic against industry KPIs. You can use this data to understand your compliance status and any opportunities to improve. Request a health check by clicking the button below. You can also complete a self-evaluation to see where you are compared to industry norms >>

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