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Medical Credentialing and Revenue Management in healthcare industry- Types and Complexities

Credentialing is one of the essential parts of revenue management for any practice. This is why they always have the chances of delays from payers or patients end. Timely and accurate medical reimbursements paid by insurance companies are integral to running a successful practice. However, the process of credentialing is nerve-wracking and time-consuming and as a medical practice, you can lose hundreds and thousands of dollars if you submit the wrong credentialing claim.

To avoid such delays in the process, it is vital to know how to get your credentialing done the first time accurately and help your practice to save every penny of your revenue through credentialing service

What is a medical credentialing service? 

Medical credentialing is the process of verification of a physician by insurance companies. With the process, the paying parties verify that the provider is eligible to get reimbursed and is sufficiently qualified to be paid for care provided to patients. Once a medical provider is credentialed with an insurance company, they get eligible to bill the company directly and receive their claimed amount in return. 

What type of medical practitioners are subjected to get credentialed? 

Each and every practice that needs to be reimbursed through insurance companies must get credentialed. These practices include physicians, clinics, chiropractors, hospitals, physical therapists, dentists, OTs, behavioral health therapists, social workers, optometrists, etc.

When a provider is credentialed by an insurance company and is eligible to be reimbursed, it is called in-network credentialing. 

Is signing up with a clearing house similar to credentialing? 

Credentialing and clearinghouse registration are two separate things. Once credentialing is performed, practices enroll with a clearinghouse for online insurance claims.

Complexity in credentialing 

Credentialing is not a very difficult task, however, it is time taking and complex to understand for a human being. A single-payer takes more than 20 hours on a single application. Although, there are no fixed times or fixed days for the credentialing purpose. It greatly depends on the field of practice and different requirements for credentialing. Specialists in the field may be required to provide additional documentation other than the usual ones that most hospitals or other physicians would provide.  

For this reason, it is essential to keep a closer eye on the documents that you need to submit for credentialing, otherwise, you may have to wait a long time to be in the queue again for credentialing. 

Once credentialing is performed and the physician has taken on board, other obligations are there as well that can put the physician at a toll. With the massive list of requirements for a potential claim, even the tiniest mistake can be the reason for your claim rejection. In addition, with unique code requirements and the upgraded credentialing system, if a claim does not meet the requirements, it can easily be rejected by the payer, which means a potential delay in the physician’s revenue. 

Plus, if the claim is not submitted timely, the payer might not accept the claim at all. 

Why is there a time frame important in credentialing? 

Based on the payer and the state, physicians have a timeframe of 3 to 90 days to submit the claims once the service is delivered. Once the claims are submitted, payers now have 90-120 days to pay the claim.  

If the claim is rejected or denied, the period of claim resubmission and editing will start all over again. However, the cycle from the payer’s end will not reset, it will resume from the date where the claim was rejected. 

Providers can also face claim filing issues when there’s a delay in credentialing or are not credentialed with the payers properly. Payers will never proceed with reimbursements until the provider is eligible to get payments. In the meantime, if the provider is seeing patients and the designated time passes, they will never be paid for the services they provided. 

Is it enough to be credentialed? 

We can only wish. Credentialing with the insurance companies is not enough. Third-party credentialing services like United Health require credentialing after every 3-5 years. Depending on the type of practice and state, if you bill for multiple payers, they will require you to re-credential yourself by applying to every payer all over again.  

Re-credentialing, however, takes as much time as it took for the first time. The major problem for many practices is that they forget to get re-credentialed and they don’t realize the importance until they start getting denials. By the time they resubmit the claims, it gets too late.

Are there other ways than credentialing errors to lose money for providers?

Major payers like Medicaid and United Health might comprise a percentage of revenue from practices. In case your claims are not reimbursed for three or more three months, you may not be able to keep your doors open. This may be because of a lack of revenue and increasing regular costs.

Also, you may be stopped forcibly to see patients until all the pending claims are resolved. According to an average, a denial from a payer cost a provider up to $10,000 daily. 

How do credentialing hurdles cause clinics to lose patients?

Simply put, suppose you or your clinic staff forgot to re-credential the rejected claims and all the other claims were denied. You have three to four months to apply for re-credentialing or re-certification. In the meantime, you have only two ways to spend these three months. Either you see patients free of cost to retain them after three months. But there will be a huge loss in revenue as there were also your staff and other clinic expenses. 

On the other hand, you can shut the doors until you get certified and eligible to see patients again. This time you will intentionally turn the patient care away and you cannot stop them from going anywhere else for their treatment. And who knows if they return after you open your doors? 


Every practice should learn about credentialing processes and how payers work for accepting applications and reimbursements. Practices can easily lose their revenue when non-compliance occurs on the application or on the claim filing side. It is best to hire credentialing services like Sybrid MD to secure your claims from denials and release the burden of credentialing. 

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