or healthcare providers and practice managers, credentialing is a critical, yet tedious, step. Consequently, even minor errors can cause major setbacks. Understanding the most common credentialing red flags helps you avoid rejection and costly delays in provider onboarding and revenue generation.
Top 5 Red Flags That Trigger Denial
Five key issues frequently lead to immediate application rejection:
- Missing or Mismatched Information: Errors in license numbers, misspelled names, or incomplete fields raise immediate red flags with payers and credentialing bodies. Always check for perfect consistency.
- Expired Documentation: Submitting expired state licenses, DEA certificates, board certifications, or malpractice insurance will almost always result in automatic denial. Therefore, track expiry dates proactively.
- Employment Gaps or Frequent Job Changes: Unexplained gaps or too many job transitions suggest instability. You must provide clear, concise explanations for any irregularities in your work history.
- Malpractice Claims or Board Actions: Any prior claims, settlements, or board investigations must be fully disclosed. You must support this disclosure with documentation showing resolution. Transparency is mandatory.
- CAQH Profile Discrepancies: Inconsistencies between your CAQH profile and submitted documents raise compliance concerns. This often triggers immediate red flags. Regularly attest your profile to confirm accuracy.
Critical Administrative Errors to Avoid
Administrative failings also cause significant delays or rejection:
- Ignoring Requests: Delays or lack of response to follow-up questions from credentialing teams indicate unreliability and often lead to rejection.
- Unresponsive References: If your listed references do not respond, your application may be delayed or rejected. Always alert your references in advance.
- Verification Problems: Any difficulty verifying a provider’s education, training, or licensure will slow or stop the process.
Conclusion
Mastering the credentialing red flags protects your practice’s revenue cycle. In summary, be transparent, check for accuracy, and respond promptly. This diligence ensures uninterrupted provider eligibility.