Once your healthcare agency is credentialed with Medicare, Medicaid, or private insurers, your work doesn’t stop there. Credentialing isn’t a one-time task; it’s an ongoing process that requires you to stay on top of re-credentialing, documentation updates, and regulatory changes to ensure your agency remains in compliance. Failure to maintain credentialing can result in losing your in-network status, causing disruptions in reimbursements and access to patients. Here are steps to stay on top of re-credentialing cycles:

1. Track Re-Credentialing Cycles 

Most insurers require healthcare providers and agencies to go through re-credentialing every 1 to 3 years to ensure that your qualifications, licenses, and other documentation are still valid. Re-credentialing typically involves submitting updated documents and undergoing a new verification process. 

How to Stay on Top of Re-Credentialing: 

Know Your Deadlines: Each insurance company may have a different re-credentialing cycle. Keep track of these deadlines in a calendar or credentialing management system to ensure you never miss a re-credentialing date. 

Start Early: Begin the re-credentialing process several months before the deadline. This gives you time to gather updated documents and resolve any issues before the submission deadline. 

Update CAQH Regularly: If your agency uses CAQH ProView for credentialing with private insurers, make sure your profile is up to date. CAQH will notify you when it’s time to re-credential with participating payers. 

Tip: Assign a staff member to manage credentialing deadlines and notify you when it’s time to start the re-credentialing process for each payer. 

2. Keep Licenses and Certifications Current 

One of the most common reasons for re-credentialing delays is expired licenses or certifications. Insurance companies will not renew your credentials if they find that any staff member’s license or certification has lapsed. 

Tip: Develop a central file or database where you store copies of licenses and certifications for each staff member. This makes it easy to update and submit documents during re-credentialing. 

3. Maintain Up-to-Date Insurance Policies 

Insurance companies require healthcare agencies to maintain valid and adequate insurance coverage, including malpractice insurance, general liability insurance, and workers’ compensation. Your credentialing status can be affected if your insurance policies lapse or don’t meet the minimum coverage requirements. 

How to Stay Insured: 

Review Policies Annually: At least once a year, review your agency’s insurance policies to ensure they meet the requirements set by each insurer. This includes checking coverage limits and policy expiration dates. 

Renew Insurance Early: Start the renewal process for your insurance policies well before they expire to avoid coverage lapses. Send updated proof of insurance to payers as soon as renewals are completed. 

Add New Services or Locations: If your agency expands its services or opens a new location, ensure that your insurance policies are updated to reflect these changes. Notify insurers of any updates to your coverage. 

Tip: Contact your insurance provider a few months before renewal dates to confirm that your policy meets current requirements for all payers. 

4. Submit Updated Business and Ownership Information 

If your agency undergoes any changes in ownership, management, or business structure, insurers will need to be notified. Failing to update them on these changes can cause compliance issues or even disrupt your reimbursement. 

What You Should Update: 

Ownership Changes: If there are changes in ownership, such as new partners or shareholders, inform insurers immediately. You may be required to submit new documentation and go through additional verification processes. 

Business Structure Updates: Changes in your agency’s legal structure (e.g., from an LLC to a corporation) or business name should also be communicated to insurers. Provide updated business registration documents as necessary. 

New Services or Locations: If your agency offers new services or opens additional locations, update your credentialing information to reflect these changes. 

Tip: Notify insurers in writing of any changes to your agency’s business structure, ownership, or services as soon as the changes occur. 

5. Follow Insurance Contract Terms 

Insurance contracts outline specific terms for how your agency will provide services and how you’ll be reimbursed. It’s important to stay compliant with the terms of your contracts, as violating them can lead to penalties or even termination of your in-network status. 

How to Stay in Compliance: 

Understand Contract Terms: Carefully review your provider agreements with each insurance company. Pay close attention to reimbursement rates, claim submission deadlines, and any specific compliance requirements. 

Submit Claims Accurately and On Time: Follow the billing guidelines outlined in your contracts, including using the correct codes for services provided. Late or incorrect claims can cause delays in payment and raise red flags with insurers. 

Meet Quality Standards: Some contracts include performance benchmarks or quality standards that your agency must meet. Make sure your agency maintains high standards of care and tracks any quality metrics required by insurers. 

Tip: Conduct regular internal audits to ensure that your agency’s billing practices and care quality meet the terms of your contracts with insurers. 

6. Regularly Update NPI and CAQH Profiles 

Both your agency and individual providers within it need to keep their National Provider Identifier (NPI) and CAQH ProView profiles up to date. These profiles are essential for credentialing and billing, and failure to maintain them can lead to credentialing delays. 

How to Stay Compliant: 

Update NPI Profiles: Ensure that both your agency’s NPI and the NPIs of individual providers are current. Update addresses, specialties, and any other relevant information as needed. 

Keep CAQH ProView Updated: For private insurance credentialing, make sure your CAQH ProView profile is updated at least once every quarter. Payers access this information to verify your credentials during re-credentialing and claims processing. 

Tip: Set reminders to review and update your NPI and CAQH profiles on a regular basis, especially before starting any re-credentialing process. 

7. Conduct Regular Internal Audits 

Regular internal audits can help you catch any potential compliance issues before they become major problems. By reviewing your agency’s credentialing status and documentation on a periodic basis, you can ensure everything stays up to date. 

What to Audit: 

License and Certification Status: Review all staff licenses and certifications to ensure they’re current and meet state and payer requirements. 

Insurance Policies: Confirm that your malpractice, general liability, and workers’ compensation insurance policies are valid and have adequate coverage. 

Contract Compliance: Check that your agency is following all the terms in its contracts with insurers, including billing practices and quality benchmarks. 

Tip: Conduct audits at least once a year, and more frequently if your agency is growing or undergoing significant changes. 

8. Stay Informed About Changes in Regulations 

Insurance requirements and healthcare regulations can change, and staying informed is critical to maintaining compliance. Make sure your agency keeps up with any changes in state or federal laws, as well as updates to payer requirements. 

How to Stay Informed: 

Subscribe to Industry News: Stay connected to industry news sources, regulatory updates, and insurance bulletins to stay aware of any changes that could affect your agency. 

Attend Training and Webinars: Many healthcare associations and insurers offer training sessions, webinars, and workshops on regulatory updates and best practices for maintaining compliance. 

Consult with Legal Experts: If you’re unsure about a regulatory change or how it impacts your agency, consider consulting a healthcare attorney or compliance expert to help you navigate any new requirements. 

Tip: Designate a compliance officer or team member to stay informed about regulatory changes and communicate any updates to the rest of your team.