Provider Credentialing is Critical to Revenue Cycle and Practice Management – Here’s What You Need to Know

By Heather N. Gibson, Senior Consultant
Healthcare Division, RS&F

Medical credentialing, also called insurance credentialing and provider enrollment is how medical organizations and insurance companies verify that a provider is certified to practice medicine in a particular state. It is the process of becoming affiliated with insurance companies to ensure healthcare providers are eligible for in-network reimbursement for services rendered. It may not be a sexy topic, but it’s one of the most important aspects of medical practice. Without proper credentialing, a physician or provider cannot legally practice medicine or submit claims through insurance carriers. Healthcare providers must be credentialed to obtain the best reimbursement rates and maximum revenue from the payors.

A successful credentialing process demands strategy and planning. Requiring extensive paperwork and documentation, the credentialing process can take anywhere from 90 to 120 days. For new practices or new medical professionals entering an existing practice or healthcare system, it is imperative that credentialing is initiated well before the date that the provider will see patients. If a new provider is not credentialed by their official contractual start date, they may not be able to provide services and submit claims for services rendered to patients, resulting in lost revenue.


From a patient’s perspective, being credentialed helps to build trust as patients can view a provider’s medical background and certifications, as well as verify that the provider is in their insurance network.


A Three-Step Process

At RS&F, our medical credentialing specialists work with the payors through each of the three-step credentialing processes:

  1. The Initial request to payor and review. Each insurance provider will review the request and determine their provider network need for the specialty in a particular geographic area.
  2. The insurance company verifies the provider’s credentials and if they meet the requirements for participating in the payor network. This includes a thorough review of supporting documents such as licensing and board certifications.
  3. This final phase is where the provider contract is drafted and sent for signatures. Each insurance company issues an agreement that defines the terms for receiving in-network reimbursement for claims.

Remember, these three steps can take anywhere from 30 to 45 days, which is why it is so important to start early.

Providers: Do Your Due Diligence

All healthcare providers need to be part of the Council for Affordable Quality Healthcare (CAQH), a national database that houses a provider’s essential information in an online portal.  About 95 percent of all U.S. health insurance companies use the CAQH which is a prerequisite for the enrollment process in most states. Providers must attest that their information is up-to-date every 120 days as insurance companies can deny a provider if the information is outdated.

In addition to maintaining their profiles, providers must also:

  • Know what the required documents are for each insurance carrier, which can vary for each insurance company.
  • Know the demographics of the area and the most utilized insurance companies. Providers want to ensure they are part of the region’s largest networks to maximize in-network benefits.
  • Ensure that all information is updated and accurate before submitting the credentialing application.
  • Follow up with insurance companies consistently to establish relationships and stay on top of the process. Things do fall through the cracks so talking to the insurance representatives regularly is important.

Consequences of an incomplete credentialing application:

  • Lost revenue. Being properly credentialed and contracted with the big insurance carriers in a specific region ensures that a provider is in-network and capable of seeing the vast majority of patients.
  • Being out-of-network. Most consumers will not choose a practitioner who is not in-network because of significantly higher out-of-pocket costs.
  • Losing out on insurance directory listings. In-network providers are included in the insurance directories for each carrier. These directories are essentially free marketing provided by each insurance company as a benefit to their subscribers. If you’re not listed, patients aren’t booking appointments with you and are finding other medical professionals who are credentialed with their carrier instead.

Reduce the Credentialing Burden

Credentialing is certainly time-consuming, which is why most practices and healthcare organizations either have credentialing specialists on staff or work with advisors like RS&F.

Our credentialing specialists navigate clients through this entire process. We work with large hospital systems and small practices alike. The process is the same whether you have one provider or 1,000. It’s important to note that credentialing is not something a practice does just once. From the initial review and collection of documentation to continual updates and ongoing follow-up with insurance carriers, the work is ongoing. Our team streamlines the process, taking the burden off of healthcare practices to free up time to focus on revenue cycle, practice management, and patient care.

Our team also trains and educates existing staff on the procedures, providing the tools needed to perform the duties internally. We provide clients with the contacts and credentialing representatives at each insurance company and ensure the practice and its healthcare professionals are set up in every applicable insurance carrier’s provider portal. We provide credentialing policies and procedures for staff, so that they understand the terminology and how-to of credentialing. It’s an ongoing partnership that results in medical staff that are ready to provide patient care on day one  – a win-win for the providers, the practices, and the patients.  Get in touch with a credentialing specialist at RS&F to learn how we partner with our clients every step of the way.

Posted in |