Keep credentials with payers up to date or you could find yourself out of network
Susan J.Kressly, M.D., FAAP
Private Payer Advocacy
The AAP Payer Advocacy Advisory Committee has heard from several members that they
had been “dropped” from payers’ participating panels for no apparent reason.
Investigations showed that in some cases, there simply was a computer error. Other
cases, however, provide examples of pitfalls to avoid and how pediatricians can protect
their credentialing status.
Many pediatricians have someone in their practice or organization handle credentialing
with insurance carriers. They may assume that once they become a participating provider
with an insurance carrier, there is nothing further to be done. In reality, the credentialing
process has become more complex due to automation, involvement of third parties and
its relation to payment.
Payer credentialing requires periodic updates of information including but not limited
to the following: state licensing, Drug Enforcement Administration licensing, malpractice
information with adequate coverage, demographic information, disclosures and attestation,
and provider affirmation of what information payers are permitted to access. In addition,
copies of documents supporting the above should be kept.
One AAP member reported that he attested that everything was current and a few weeks
later his state license needed to be renewed. The credentialing review was “out of
sync” with the licensure renewal cycle.
In another case, the office staff member who updated credentials for all of the providers
in a practice had a medical emergency. No one else had credentialing on their radar,
and emails that came to the staff member who handled credentialing went ignored. The
oversight finally was noticed when a patient had to pay a bill because the provider
was “out of network.”
So how can pediatricians protect themselves?
If you delegate credentialing to someone in your office, continue to receive email
notifications. You can follow up with office team members to make sure they are updating
credentials as promptly as they should be.
When you renew your licenses and malpractice, automatically update this information
with any credentialing third party or directly with payers, if necessary. Don’t wait
until your “credentialing update” is due.
If you use a third party or automated platform, ask for credentials to log in and
monitor the information periodically. Maintain awareness of who is requesting your
information, while ensuring only the payers you are contracted with or seeking to
contract with have access to it.
Most payers will require that you regularly attest that the information in your credentialing
file is correct. Your staff may not be aware of information such as new malpractice
claims, changes in hospital privileges or medical board sanctions. Therefore, you
should perform the attestation yourself.
Ask your payers who they notify and how if there is a problem with your active credentials.
Make sure you receive notifications so that you can act on them promptly.
Credentialing seems like an inconvenience, but don’t be caught off guard. You don’t
want to find out you are no longer in-network from a patient who gets stuck with an
And while you’re at it, make sure you practice high-quality, evidence-based medicine
and consider total cost of care when you order medications, tests and referrals. Some
practices are reporting being dropped from networks as the payer narrows the network
to what it considers “high value” providers.
Dr. Kressly is chair of the AAP Payer Advocacy Advisory Committee.