Navigating Closed Panels on the Credentialing Journey

Credentialing – the process of becoming certified to be able to practice medicine and gain reimbursement – is notoriously time consuming. To enroll with payers, physicians will have to provider information detailing their education, certifications, licenses, work history and more. There are loads of paperwork, multiple steps and various deadlines to manage. For specialists like optometrists or behavior health professionals, the process can be even more complicated. And when a new office location is opened or a physician tries to register in a new state, credentials are needed. Circumstances can also cause an influx of applicants to certain areas. Just take a look at effects of the COVID-19 pandemic. In the midst of the pandemic, many people relocated to warm weather climates. As many physicians were changing states, this migration led to a wave of doctors looking to gain enrollment in Florida and the Sunbelt. If all goes as planned, completing enrollments can take anywhere from 90 to 150 days. Any delays could cause setbacks and delays, with simple human error or missing paperwork throwing a wrench in timelines. One missed deadline could delay approvals by weeks or even months. But while timelines are already stressful, what’s even worse is learning that you are denied enrollment.

One of the major pain points that pops up more often than one would assume involves closed panels. When this happens, payers deny enrollment to their networks. Closed panels can occur for a number of reasons. Payers place limits on the amount of new providers joining their plan, and availability is often subject to the number of applicants per geographic area or specialty. Let’s say a provider applies to join Blue Shield of California, one of the 35 subsidiaries of Blue Cross Blue Shield Association (BCBSA), and is denied. If the company has too many providers already, they may close their panels temporarily. Perhaps payers simply can’t keep up with the demand and influx of requests. This may be the case, as recent data shows that closed panels are on the rise.

When a provider has their eyes on joining a large payer in their area and they are denied, it can be frustrating. Even worse, if a provider lacks credentials, they are at risk of losing reimbursement. It’s been said that incomplete payer credentialing can cost a physician up to $6,600 per day. Staying out of network can lead to lost patients and could interrupt cash flow in the short term. Lose a few months of reimbursement and the financial outlook for the entire year could be disrupted.

While closed panels can be a pain, there are best practices to navigate the issue. Although closed, a payer may accept select providers on a case-by-case basis. If a physicians has something unique or different to offer, payers may make an exception. An appeal can be made, usually involving a letter of intent. While not guaranteed, it’s worth the effort to state a case for inclusion.

But dedicating time and resources to each application can add up. Since gaining or maintaining the necessary credentials is a complicated, time-consuming practice, many medical practices and organizations benefit from outsourcing the appeal work to a third party. Outside assistance is often the right option for many practices since it brings additional resources and expertise that are simply not common to find within internal staff. Credentialing experts can help offset the workload that would normally be assigned to in-house staff, allowing employees to focus on other activities. Given the nuances that come with credentialing and appeals, a third-party is often equipped to handle the complications because of the level of experience. Even more, companies devoted to credentialing often have direct relationships with major payers that makes it easy to gain insight and conduct follow up. This efficient, behind-the-scenes assistance can allow a practice to re-focus resources while credentialing needs are taken care of.

A large part of having a solid credentialing strategy is having plans in place and the right partner to navigate the many needs that arise. The credentialing experts at TriZetto Provider Solutions, a Cognizant Company, can assist every step of the way to help gain enrollments quickly and efficiently. Visit trizettoprovider.com/credentialing for more information and request a demo.