CASE STUDY
How Inactive Provider Listings Led to Payor Rejections and Revenue Loss at a Maine Hospital
Overview
When a hospital in Maine faced persistent rejections of new provider applications with commercial payers, Cred2Bill helped with a comprehensive fact-finding initiative revealing the root cause.
The Challenge
Despite stable market conditions and consistent patient numbers, revenue was declining. The number of providers remained constant, and operational efficiency was maintained.
New hires were encountering rejections as payer panels reached full capacity.
The Solution
Cred2Bill was brought in to identify root causes and build a system that worked across the entire provider lifecycle.
The audit included:
- Verifying payer rosters against active Medical Staff members.
- Identification of new providers hired in the past 3 months.
- Documentation of rejected payer applications linked to recent hires.
- Requesting rosters/provider lists from all payers.
- Cross-referencing the rosters with the current Medical staff provider list.
The Results
Provider audits uncovered a crucial gap: inactive providers were not being communicated to payers for removal. This discrepancy led to an imbalance in provider availability versus patient needs.
- Discovered 226 inactive providers still listed on payer rosters.
- Confirmed no termination requests had been made in the last 3 years.
This case study emphasizes the importance of aligning provider data with payer records to optimize healthcare delivery and financial sustainability.
Why It Matters
Administrative oversights such as failing to update payer rosters can have far-reaching consequences for healthcare operations, patient access, and financial performance. Despite steady demand and staffing, the hospital experienced revenue loss and delays in patient care simply because outdated information led payers to mistakenly believe their provider networks were full. It underscores the critical need for accurate, proactive data management and communication between providers and payers to ensure that qualified practitioners can deliver care, especially in environments with limited network capacity. Ultimately, it’s a reminder that operational details, if neglected, can directly impact both the bottom line and patient outcomes.
If you’re experiencing similar issues-lost revenue, communication gaps, delayed onboarding—you don’t have to settle for the status quo.
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