Simplifying Medical Credentialing: An Introductory Guide

Imagine a scenario. You hire a new practitioner for your healthcare facility without thoroughly going through his certifications. He prescribes the wrong medicine to one of your patients, resulting in some serious health consequences. The patient has sued your hospital for malpractice. Later on, you discover that the provider was not properly credentialed, and had bogus degrees and certifications. This ignorance exposed your facility to some serious financial repercussions.

Medical credentialing is a crucial process to verify the credibility of healthcare professionals. It is complex, time-consuming, and the healthcare facility must be compliant with the guidelines of regulatory bodies. This blog will provide a comprehensive guide on medical credentialing, including the procedure, importance, common challenges and solutions, reasons to outsource, and how medical credentialing services can help.

Understanding Medical Credentialing

Medical credentialing, healthcare credentialing, and provider credentialing are three different names used for the same process of verifying the credibility of a healthcare professional. It involves the process of evaluating a provider’s educational background, certifications, license, professional references, and clinical experience.

There have been ample cases reported in the past where healthcare professionals, such as doctors, nurses,dentist, allied health professionals, were practicing with fake degrees and certifications. The health of the patients was at stake. So,there was a dire need for a robust system to ensure that patients received the best quality of care. The National Committee for Quality Assurance (NCQA) took some serious measures and published some guidelines to be followed for the credentialing of healthcare providers.

Why is Medical Credentialing Crucial?

Medical credentialing is a very complex process that requires a team of experts who go through all the documentation of the healthcare professionals. There are high risks for healthcare facilities and providers if they haven’t updated themselves on credentialing processes. It is vital for a number of reasons,including:

The safety of the patients

Patients’ health and safety are at great risk if a bogus or unqualified doctor acts as an expert and provides his services. Credentialing the provider’s background enhances the patient’s safety.

Quality care

By confirming the credentials of providers, such as educational background, license, certification, training, and skills, the quality of care is ensured, and patients receive the standard treatment.

Inclusion in Insurance Company’s Circle

In order to receive reimbursement from insurance companies, credentialing is a basic step to take. All insurance companies demand the credibility of the providers before allowing them to start working with their company.

Compliance with regulatory bodies

The credentialing process itself needs to be compliant with the guidelines of insurance companies, governmental agencies, and other regulatory bodies. This helps the healthcare facility to meet the legal requirements.

Reputation and Trust

Patients are likely to trust those healthcare professionals who have passed the verification test of the credentialing team. Thus, it enhances trust and reputation among people.

Reasons to Outsource Medical Credentialing

The following statistical data collected from the collaboration of the American Hospital Association (AHA) with Manatt Health clearly depicts the importance of outsourcing medical credentialing:

  • Around 40% of the credentialing data of healthcare providers is incorrect. This not only wastes time but delays payment as well.
  • Annually, around $39,000,000,000 billion has been spent by healthcare organizations on administrative tasks like credentialing.
  • Healthcare professionals need to spend 17% of their working hours just on credentialing. Less time consumed on credentialing means more time available for patient care.
  • $26 million in Medicare payments has been wasted in connection with the fake credentials of the provider.

Medical Credentialing Process

The medical credentialing process consists of multiple steps to successfully verify the credibility of providers. Healthcare organizations, providers, and regulatory bodies all play an important role in this extensive and hectic process. Here are the key steps involved:

Step 1 Submission of Credentialing Application

The process starts when a healthcare provider submits an application to the facility engaged in credentialing. For individuals, the application typically includes data such as education, experience, license, certification, and professional reference. This task of data collection is time-consuming but requires special attention as inaccurate information can lead to major issues in the credentialing process.

Step 2 Verification of  Education and Training 

After the submission of an application, the next step is to verify the educational background and training specific to the field of healthcare practice. The provider’s educational documents, including his degrees, transcripts, and diplomas, are properly verified. If the provider has gone for some training programs, that too is evaluated based on the guidelines given.

Step 3 Verification of License and Certification

Once the educational background is checked, the process steps ahead, and the license of the provider is verified. Healthcare professionals must have a license to practice. Without a proper license issued by the state medical board, it is considered illegal and unethical for any provider to practice and provide services. Any certification relevant to the provider’s practice is also evaluated.

Step 4 Background check to verify any criminal history

Background checks are mandatory to make sure that the healthcare professional has never indulged in any criminal activity. He must have a clear criminal record and have committed no ethical violations, intentionally or unintentionally. Patient safety is the key responsibility of a credentialing team.

Step 5 Peer References

Healthcare professionals need to provide the credentialing team with some professional references who can justify their credibility. This includes any professor, supervisor,colleague,or mentor. The credentialing team is responsible for contacting these peer references and double-checking the details. This helps to evaluate the provider’s clinical efficiency and competency.

Step 6 Enrollment in Insurance Network

The provider must be enrolled in an insurance company’s network of personal interests if he really wants to work with them. This enrollment process is crucial, and each company has its own set of rules and guidelines to be followed. The credentialing team makes sure that the provider meets all the criteria of the company, and there is no single reason to deny his enrollment.

Step 7 Review from Credentialing Committee

After clearing the initial stage, the provider has to go through another level of screening, i.e., credentialing committee review. This committee has a role assigned to review the collected data and make some recommendations according to their set standards. They check whether the provider fulfills the requirements or not.

Step 8 Decision and Notification

After reviewing the data, the Credentialing Committee takes a decision regarding the credentialing status of the provider. The committee can deny, reject,or approve the application. They have an additional duty to notify the provider about the status of his application.

Step 9 Re-credentialing and ongoing surveillance

Credentialing is an ongoing process. Providers who are credentialed once need to be re-credentialed every two years. This regular interval is necessary as the license and qualification of healthcare professionals demand continuous updating.

Step 10 Appeal the decision

If the provider’s application for credentialing is denied due to any reason, he must have a chance to appeal the decision. The decision can be reversed in favor of the provider if he is successful in providing some data or documentation to support his case.

 Challenges in Medical Credentialing and Solutions

The credentialing process is very complex and requires a team of experts. The intricacy gives birth to some challenges that need serious and timely solutions. Here are some challenges along with potential solutions to address them:

An extensive period of time is required

Challenge: For the process of medical credentialing, an extensive period of time is required. This can extend from a few weeks to a few months. The provider is not permitted to practice for the duration of this time.

Solution:The provider should complete his documentation before the process starts to avoid any delays. They should credential themselves as early as possible.

Margin of Errors in the documents

Challenge: A team from a healthcare facility is not capable enough to find out any minor issues in the documents. Any error in the documentation leads to denial or rejection.

Solution: The provider needs to check twice before submitting the documents for the credentialing process. This can really help reduce the margin of error. He can also hire another person to check the paperwork for him.

Insurance company-specific requirements

Challenge: Every insurance company network has its own unique guidelines and rules to follow. Providers need to be aware of these specific requirements.

Solution: The provider needs to make sure that his application fulfills the criteria of the insurance company he wants to join. He should carefully read all the requirements.

Updates and Renewals

Challenge: All the necessary documents, such as licenses, certifications, and other credentials, demand renewals at regular intervals.

Solution: Credentialing management software can help providers meet the deadlines for renewals.

Selecting the Right Credentialing Partner 

Selecting the right credentialing partner for your facility is the real game changer in the healthcare industry. Medheave has a commendable track record of success. They have both experience and expertise in handling medical credentials. Medheave’s commitment to compliance with the latest guidelines and insurance company regulations is what makes them a trustworthy and reliable asset for providers. Sign up today to get experienced and accurate service for your healthcare facility.


1)  How much does a medical credential service cost?

The annual cost of credentialing services ranges between $2000 and $3000.

2) What factors should I consider while selecting a medical credentialing service provider?

  • Experience
  • Expert team
  • Industry Reputation
  • Compliance with Regulations
  • Cost-effectiveness
  • Use of advanced technology 

3) How much time is required for a medical credentialing process to take place?

It can extend for months, ranging from 90 to 150 days, depending on the responsiveness of the provider.

4) How can the credentialing service help the healthcare facility?

  • Reduces administrative burden
  • Accurate handling of the intricate process
  • Reduces the margin of error. Hence, less denials.
  • Compliance with regulatory bodies

5) How can the credentialing service help the healthcare facility?

The provider’s specification and the insurance company’s standard criteria are what determine the process of medical credentialing.

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