Insurance Recredentialing Issues – Beware!

Requests for recredentialing with insurance companies is not something new however you will probably notice more requests coming your way. As part of some of the new healthcare changes, requests will be coming more regularly and we strongly advise you give your office staff a heads up to watch for these. Recredentialing requests are not tied to negotiations or changes in fee schedules, they are information requests to keep your current contract in good standing. Contracted doctors MUST return these or you can/will get bumped out of network. If you get bumped out of network, getting back in isn’t as easy as just responding later, you may have to start all over getting recredentialed and it can take months to get pulled back in-network.

We have had some recent major issues with doctors returning recredentialing information, having proof that they returned it, and still getting moved out of network. Do not just return recredentialing paperwork by mail and check it off your list. Get confirmation in writing that it was received, either by email confirmation or by certified mail where someone from the insurance company must sign for it. Keep a copy of the signed receipt in case it’s needed later.

Also note that if you are in a state where you participate with Delta Premier and that state no longer allows for new contracts to be Premier only it is especially important you return and verify recredentialing information. If you get bumped out of the Premier network and new contracts are requiring PPO participation you will no longer be able to get your Premier status back once lost. In states where this applies it’s about a $100,000 mistake for most offices so do not allow this to be overlooked by your front office staff.

If you are contracted with a third party administrator (Connection Dental, DenteMax, etc.) you could have dozens of companies being pulled in-network through that single contract. If you get bumped out of network with that third party administrator you then find yourself out of network with all of the companies falling under their umbrella. Connection Dental, for example, is taking 4-5 months to process effective dates with applications in many areas right now so getting back in-network can be a lengthy process. If you get termed from a third party administrator like Connection Dental, even if you sent the paperwork back in time, if they make an error and term you it may not keep you from having a gap in participation with any carrier you are in network with. We’ve recently seen several real world examples of this and it’s impacted critical carriers for those doctors. In case of an error, just because the third party contract itself gets resolved doesn’t mean all the individual carriers get resolved at the same time. If claims were processed incorrectly due to a lapse in participation from a third party error there is no guarantee the individual carriers will reprocess the claims.

Also note that recredentialing requests do not necessarily coincide with dates of when you signed your most contract. Let’s say, for example, that you have a relatively new practice that just opened 6 months ago and you recently signed a new contract to participate with an insurance company. You may receive a notice for recredentialing that indicates every 3 years they need to recredential doctors and you are due. You may assume it is in error because you know your contract is only 6 months old. Keep in mind that you may have been showing up in-network as an associate or at another location prior to the new contract you signed for your new office. Your initial full credentialing may have been tied to another office with a previous date so the clock for recredentialing may not have started with your new office’s contract. This could make you due for recredentialing even though your current contract has been in place for a short time.

In short, when your office gets a notice to recredential do not ignore it! Regardless of if you think you are due or not, you must return it or you should plan on being moved out of network. And always get verification in writing that it has been received!