Credentialing 'unknown-unknowns'

Verifying the credentials of and enrolling new providers in health plans requires collecting extensive information from them and the efficiency (or inefficiency) of the process can make or break the provider’s first impression of the organization. Beyond annoying the new provider an organization worked so hard to recruit, fragmented credentialing, privileging and enrollment processes also create compliance risks, barriers to care, and claim denials.

Former U.S. Secretary of Defense Donald Rumsfeld famously mused, “There are known knowns. These are things we know that we know. There are known unknowns. That is to say, there are things that we know we don't know. But there are also unknown unknowns. There are things we don't know we don't know.” Through our work as both a consulting firm and a certified Credentials Verification Organization (CVO) providing services for all types of healthcare organizations, including physician groups, hospitals, systems, and health plans, VantagePoint HealthCare Advisors has encountered clients generally experiencing one or more ‘unknown-unknowns’ in the realm of credentialing or enrollment prior to engaging us.


Are your organization’s providers moonlighting somewhere or even moonlighting within your organization? The Cambridge English Dictionary defines moonlighting as additional paid work, “especially without telling your employer”. For operational efficiency and to provide comprehensive care, many specialties and types of facilities may elect to employ providers for just a few hours each month. Urgent Care Centers, Federally Qualified Health Centers, Walk-in Centers, and Substance Abuse Treatment clinics frequently employ moonlighters. Organizations that are unaware of their providers side-gigs face an increased risk a moonlighting provider may have an “issue” at his or her other job, leading the moonlight employer to experience compliance exposure due to malpractice claims, license or DEA lapses, or exclusion from a government payer. The risks associated with the moonlighting ‘unknown’ can include loss of accreditation or even recoupment of all government payments for all services provided.

Moonlighting within the same organization is an ‘unknown’ risk for health systems and provider groups with locations in several states or multiple locations in the same state with different tax identification numbers (TINs), particularly if credentialing and enrollment process are not centralized or coordinated. For example, while it may seem like a quick fix to employ a physician from another hospital or provider group (different TIN) within the same system to cover clinical shifts on weekends, unless the moonlighting provider is enrolled with health plans at that location and under the TIN of the moonlight employer, any claims with the moonlighting provider as rendering may deny. The multi-state issue comes into play in respect to DEA licenses and State medical licensing. Even if a provider from within the same organization is covering another location across State lines for just one shift a month and he or she happens to have a valid license to practice in that State, he or she may only have a DEA license tied to the full-time practice State and not the ‘moonlighting’ State and the Federal DEA may also only be for the full-time State address.

More commonly, providers moonlight for another organization or provider group. Sometimes the provider shares this information with the full-time employer, but not always, making this a perennial unknown. While each organization employing the same provider must follow their own policies and procedures for privileging, the moonlighting employer may be able to preempt a full credentialing with health plans if the moonlighting provider is already participating with their full-time employer. Unfortunately, much effort and time can be wasted when all that needed to happen was ‘linking’ the moonlighter to the roster of participating providers. Another ‘unknown’ risk of moonlighting lies with maintaining CAQH profiles. If more than one CVO or employer is changing or updating information in the provider’s CAQH profile, conflicts and employment information discrepancies can result.


Are your organization’s newly credentialed providers prescribing for patients before their payer enrollments are confirmed? Organizations and physician groups are understandably eager to onboard newly contracted providers as soon as possible to fill urgent clinical coverage needs. While the credentialing and privileging process can be expedited and condensed to a few weeks in an urgent situation, the Medicare and Medicaid enrollment timeline is fixed at 30-45 days and the commercial health plan enrollment process can stretch to 90 days or more for newly licensed providers or those transferring from another State. Payers may agree to backdate enrollment effective dates for the purpose of claim payment, but the courtesy doesn’t apply to ordering, prescribing, or referring.

A license to prescribe meets the requirements of State law; however, unless the provider is fully enrolled with the payer, the payer is not obligated to reimburse for any care or referrals, including therapy, pharmaceuticals, or durable medical equipment (DME), that the provider prescribed for the beneficiary or plan member prior to a confirmed enrollment. The burden of appealing the denial falls to the patient in these cases, which isn’t an ideal outcome if patient satisfaction is a priority.

Claim Denials

‘Provider Not Enrolled’-type claim denials come in many flavors and most aren’t really about enrollment. Managing denials usually falls to billing staff, but how much do they know about the organization’s credentialing and enrollment processes? Are denials worked in a silo? Clues that enrollment processes are siloed or communication with the billing office may be broken include 'non-credentialed' staff or similar being a common denial reason for newly on-boarded and payer approved providers. Or worse yet, one claim is denied as “provider not enrolled” for a patient that has been seeing the provider (who has been with the group for five years) every three months for the last year.

 Denial codes aren’t universal, nor always appropriately applied by the payer. Different denial reason descriptions from the same payer can seem to communicate the same idea but aren’t enrollment related at all. For example, ‘Provider not active for plan on DOS’ and ‘Provider not eligible to be paid for this procedure/service on this DOS’ may sound like the same issue, but revenue cycle staff shouldn’t assume the root cause is the same. The first could be enrollment related while the second may indicate that the service was inclusive within another procedure.

Hybrid or Paper-based Processes

Credentialing and enrollment processes require providers submit documentation containing personal information that if exposed could lead to identity theft of the clinician. Who is making sure the information stored in multiple places and mediums (paper, spreadsheets on desktops, network wide applications) is protected while still being accessible? Beyond paper being cumbersome to manage and a potential security concern, hybrid processes involving various methods create compliance risks in respect to lack of audit trails, timely recredentialing or revalidations, ensuring the facility has current licensure for each clinician, as well as that there have been no changes to malpractice claims nor OIG exclusions.

Electronic systems have a distinct advantage over paper or spreadsheet tracking methods in respect to keeping up with revalidation for PECOS and Medicaid. The five-year revalidation timeline isn’t necessarily five years to the day of initial enrollment. At VantagePoint, we’ve observed an organization can enroll three new providers simultaneously and the revalidations will be due on different dates. Provider recredentialing for commercial payers runs on a three-year cycle but doesn’t necessarily coincide with the date a provider is first enrolled with an organization if that provider has been previously linked to another organization’s contract (or is moonlighting!). VantagePoint’s credentialing specialists have noted from experience that it’s entirely possible to enroll a ‘new’ provider to an organization and then recredentialing for that same provider must be completed just a few months later. For larger organizations with frequent turnover or dozens to hundreds of providers, hybrid or paper processes are too cumbersome to efficiently manage and comply with the timeliness required for the recredentialing and revalidation cycle.         

Eliminating Unknowns

Size and type of organization influences the complexity and work effort associated with maintaining effective credentialing and enrollment processes. Moonlighting, prescribing prior to enrollment, claim denials, and paper-based/hybrid processes are potential ‘unknowns’ representing a veritable kitchen sink full of compliance risks, barriers to care, and claim denials.  With industry changes such as narrowing networks, mergers, and other disruptions it is important to not only keep up with the changes but anticipate enhanced scrutiny and mitigate it. VantagePoint’s experience partnering with all types of healthcare organizations, including physician groups, hospitals, systems, and health plans confirms that the strategy of deploying a comprehensive credentialing program that includes primary source verification can improve patient satisfaction, reduce unnecessary expenses related to legal issues, ensure best practice revenue cycle management, support compliance efforts, and most importantly, eliminate ‘unknowns’.