Cred Hawk
All in One Software you Need
How Medical Credentialing Influences Healthcare Revenue
Why Medical Credentialing Is the Most Underestimated Revenue Driver in Healthcare
In most cases, the credentialing of health care providers is viewed as merely an administrative exercise. Providers are hired, paperwork is completed, and before it’s very long, the patients start seeing providers. But what happens in the middle, along with how much that costs, tends to be totally forgotten about.
Provider enrollment and credentialling services are important because this isn’t just an administrative process but a financial one. In 2026, commercial payer enrollment takes up to 90-120 days, and during this period, the hired physicians cannot submit any in-network claims. No, this isn’t just a small period of time; clinics miss out on $1,000 to $5,000 worth of patient revenue per day per provider.
Since the average collection per day for a full-time specialist is $1,200, the total exposure can amount to hundreds of thousands of dollars.
What Is Medical Credentialing and Why Does It Matter?
Medical credentialing is the process of evaluation and verification of the credentials, education, licensure, and background of the physician according to criteria set by the insurance company. It is the condition that precludes a physician’s ability to be paid through insurance billing.
Without credentialing, the provider could be clinically qualified but financially invisible. The provider is able to provide care, but unable to get paid for it. Without credentialing, there would be no ability to use the insurance company network, to be reimbursed from Medicare or Medicaid, or to submit claims for processing.
What Are the Most Common Credentialing Mistakes That Cost Practices Money?
Incomplete application forms, failure to check expiration dates, incomplete documentation and problems with the submission of applications are the most common errors in credentialing, and each will only serve to delay the process and widen the revenue deficit.
The mistakes that cost the most money:
- Incomplete or inaccurate applications: More than 85% of credentialing applications are wrong. Every mistake generates a need for more information, prolonging an already long process.
- Missing reappointment deadlines: Provider credentials like licenses, DEA registration, and board certification expire. So, missing the deadline means lapsing the credentials and suspending billing privileges during operations.
- Failure to link mid-level providers: A nurse practitioner and/or physician assistant must be linked to a credentialed supervising physician. Wrong linking leads to immediate claim denials from commercial payers and Medicaid managed care.
- Lack of real-time monitoring: Credentialing involves continuous verification against the OIG exclusion list and the National Practitioner Data Bank. Any provider that appears on these lists cannot submit claims. And practices that do not monitor it find out too late.
- Treating credentialing as a one-time onboarding process: Payer panels change; cycle times of revalidation differ. Inactive credentialing process leads to interruptions of revenue without notice.
Why Is Credentialing in Medical Billing So Critical to Get Right?
Credentialing in medical billing is what provides the basis of each medical reimbursement; otherwise, a physician without credentials would not be reimbursed regardless of whether his claims are coded properly and have all necessary documentation.
The risks connected with improper credentialing of physicians in medical billing are very serious; they are ongoing, cumulative, and concealed until they grow to an extent impossible to ignore.
With specialty-specific provider enrollment and credentialing services offered by Altermed RCM, you can easily avoid credentialing pitfalls and make sure that all providers in your organization are enrolled and ready to generate income from day one.
Contact us now and learn where your credentialing process is threatening your income!
Frequently Asked Questions
Medical credentialing is the procedure of validating the credentials of a provider and forming a provider's payer relationships, which would allow him/her to bill in-network and get paid. Absence of completed credentialing means inability to file a claim; in-network discounts are out of reach for providers, and the provider can't receive any payment for the delivered services from Medicare, Medicaid or commercial payers no matter what.
The time required for commercial payer credentialing is about 90-120 days starting from the date of filing. The Medicare/Medicaid government payer credentialing will require 60-90 days. Time frames may differ from one payer, type of the provider, the completeness of the application, and other factors. Over 85% of the applications include mistakes or missing information; thus, extending the time needed for enrollment. It makes the correctness of the application the only controllable variable in the process.
Providing services prior to completion of credentialing will not allow for reimbursement at in-network rates. Some payers allow retroactive billing with proper pre-authorization in a specified window, which may be as short as 90 days. Anything beyond that window is considered a revenue loss. The cost of being uncredentialed can range anywhere from $1,000 to $5,000 per provider per day.
Yes. All provider credentials, including license, DEA, board certification, and payers' enrollment have expiration dates and require periodic revalidation. For instance, Medicare requires a revalidation cycle every five years, whereas state licenses are valid for 2-3 years. Missing an important revalidation date may render you unable to bill. It is important to monitor the expiration of these credentials.
Credentialing is the process of verifying the qualifications of a provider based on education, training, licensure and work history. Provider enrollment is the process of proving the inclusion of a particular provider into the network of a particular payer, which allows him or her to submit claims to this payer for reimbursement. The two processes go sequentially one after another, where credentialing determines eligibility and provider enrollment makes the payment possible.
Credentialing outsourcing to the specialist company means the absence of such problems as application mistakes, deadlines misses and all those other aspects of the problem which lead to financial losses because of improper credentialing. Specialized team of specialists submits applications timely and properly; monitors their expiration dates; manages payer requirements for several payers at once and deals with recredentialing periods without even thinking about it. In addition, all of this leads to the faster transition of a new provider from being hired to becoming a part of the billing cycle.
Still have questions?
Contact Us
