From Enrollment to Revalidation: The Ongoing Cost of Credentialing

Just because a payer has approved enrollment can you say provider credentialing has ended? 

Maybe, it’s not as simple as it looks. Providers need to keep their enrollment information current and complete revalidation requirements on time. The schedule depends on the payer and program. For Medicare, most providers and suppliers generally revalidate every five years, while DMEPOS suppliers generally revalidate every three years. CMS can also request revalidation outside the regular cycle. 

For a practice, that creates ongoing work. Someone needs to know what is due, keep provider information current, respond to requests, and confirm that each requirement has been completed. When that process falls behind, the billing team bears the brunt. 

Provider Revalidation Creates Recurring Work

Revalidation confirms that the information a payer has for a provider is up to date. That may involve reviewing enrollment information and updating changes related to practice locations, licenses, supporting documents, or other provider details depending on the payer. These requirements do not necessarily follow one schedule.

A practice working with several payers and multiple providers may therefore have many dates and requirements to track. As the practice adds providers or locations, the administrative workload can increase as well.

CAQH Attestation Is Another Date to Track

CAQH adds another recurring requirement for many providers. It requires providers to review and re-attest their information every 120 days, with a different interval for providers practicing in Illinois. If the re-attestation is not completed by the due date, the CAQH profile moves to an expired status. That does not mean an expired CAQH profile automatically removes a provider from every payer network. Each payer manages its own credentialing requirements and status.

However, what it does mean is that practices need a process for keeping CAQH information and supporting documents current. CAQH itself advises providers to check with individual organizations to determine their credentialing status.

Who Is Tracking Your Provider Revalidation Deadlines?

Revalidation responsibilities can easily become divided across the practice. A biller may manage certain payers, while an office manager or provider receives notices and CAQH reminders. Without a centralized process, deadlines can be missed or followed up inconsistently.

Practices should clearly define who owns revalidation, where due dates are tracked, who monitors payer notices, and who confirms that applications and attestations are completed. Clear responsibility helps reduce the risk of credentialing issues affecting provider enrollment and claims.

When Provider Revalidation Problems Reach Claims

A missed revalidation can affect a provider's ability to bill a payer. For example, Medicare states that failure to revalidate on time can lead to a hold on reimbursement or deactivation of billing privileges. If billing privileges are deactivated, Medicare will not reimburse services provided during the period of deactivation. 

For an eye care practice, that could affect claims associated with a provider who continues seeing patients while an enrollment issue is unresolved. The billing team may then need to identify affected claims, verify the provider's enrollment status, correct the underlying issue, and determine which claims require follow-up.

Patterns in denials can help identify where billing work is repeatedly being created. If recurring billing issues are adding work to your team, the EVAA Billing Assistant ROI Calculator can help estimate the operational impact.

The Cost Continues After a Deadline Is Missed

Revalidation requires staff time throughout the process. Before a deadline, the team may need to review provider records, update information, gather documentation, submit applications, and monitor their status. If an enrollment issue begins affecting claims, the workload can increase as staff contact payers, review affected claims, make corrections, and manage follow-up.

A consistent process can reduce this administrative burden. Practices should assign clear responsibility, track deadlines in one place, keep provider information current, and review unexpected denial patterns for possible enrollment issues. This helps make revalidation a manageable part of the revenue cycle and keeps provider enrollment current.

See what recurring billing work may be costing your practice with the EVAA Billing Assistant ROI Calculator.