How Medical Credentialing Services Can Benefit Your Practice

by | May 20, 2022 | Blog | 0 comments

Medical insurance credentialing is a necessary part of every medical practice. A medical degree may qualify a doctor to practice medicine, but without insurance credentialing, they can’t be paid for their services.

The process of being credentialed by an insurance company is a mammoth task. It requires a great deal of documentation and exact adherence to the guidelines. To make it even more difficult, each insurance company sets its own credentialing regulations and guidelines, so the journey to becoming credentialed may be different with each payer.

In many practices, the process is nearly continuous, as each medical professional is required to recertify every 1 to 3 years, depending on the insurance company’s regulations. Soon after the practice finishes the first round of credentials, it is time to begin the process of re-credentialing.

The tedious and constant work required to receive and maintain credentialing is why many medical practices choose to use professional medical credentialing services to take care of the process for them.

What is Medical Credentialing for Insurance Companies?

Credentialing is the verification process that every medical professional must go through before they can bill that insurance company for their services. The medical practitioner must go through the credentialing process separately for each insurance company they want to receive payment from. If a practice intends to accept insurance coverage from 15 different insurance companies, then the medical providers who work there must go through the credentialing process 15 different times.

Regardless of the exact guidelines set by the individual insurance companies, though, there are some universal things that they will all want medical practitioners to document for verification. These include:

  • Identity and citizenship status
  • Any and all relevant training
  • Any licenses they have been issued
  • Whatever registration or certification they have to practice in their specific health care field
  • Academic history, including schools attended, certain test scores, and degrees received
  • Any and all relevant dates for all of the above-listed criteria.

In addition to all of those details (which must be completely accurate, or the process will be delayed), every insurance company may ask for more information about things like the doctor’s work history, prior results, and medical ethics.

Those are the requirements to receive credentialing for private insurers. If a medical professional is trying to receive credentialing from Medicaid or Medicare, which almost all do, the list of the necessary information to be presented for verification is even more substantial.

As if all of this wasn’t enough to keep on top of, the guidelines and regulations set up by any individual insurer may change from one credentialing period to the next. This means that before starting the re-credentialing process, a doctor or practice must take the time to research any changes that have been made by the insurance company during those years.

For Medicaid and Medicare, the changes happen more frequently, and insurers may ask a doctor to show verification of adherence to these changes even before it is time to become re-credentialed.

Keeping up with the credentialing process for even one doctor can take up a great deal of time but with a larger practice of 5 or 10 physicians it could almost be a dedicated full-time job to keep them all current on every detail and regulation change for all of their payers. Moreover, since the process is never-ending, no one can relax just because an insurance company has credentialed them once.

The Difference Between Credentialing and Re-Credentialing


Insurance company credentialing is a detailed process during which the medical professional seeking credentials must present documentation on everything from their identity to their educational background and their certifications to their work history.

Every detail of this information must be accurate and up-to-date, or the paperwork will be kicked back for corrections. This can delay the process by weeks. Any delay in the credentialing process is a delay in payment for services, or even a fully idle employee, so it is vital that the paperwork be done right the first time and turned in by the requested due date.


Re-credentialing does not usually require the doctor or practice to resubmit all of the documents submitted the first time around, but it comes with its own share of headaches.

As technology and the practice of medicine continues to evolve, re-credentialing may require that the medical professional offer documentation of their efforts to stay on top of the new trends and best practices in healthcare. This new information changes frequently, and it is the responsibility of the petitioner to know precisely what information is required to meet new guidelines or regulations.

In addition, re-credentialing must be accomplished before the original credentials expire, and the practice might not receive notification about the upcoming expiration of credentials until it has already happened. In this case, there may be a notice sent out that the credential expired some weeks ago and no payment will be made on any services rendered after that date. This can lead to a substantial loss in payment for services that have already been done and the cancellation of procedures and appointments until the credentials have been reacquired. That kind of inconvenience could have an even larger ripple effect down the road in terms of patient loyalty.

If credentials are allowed to expire, the process must begin all over again from the beginning. This creates a long period during which the doctor will not receive any payments from the insurance company.

Sometimes, “Free” Help Isn’t Worth the Price

Given how complicated and vital the medical insurance credentialing process is, it is no wonder that many practices seek out help to get it done. Some may turn to their local physicians’ organizations for advice and help. These organizations often offer “free” credentialing help for members. The problem with this is that the memberships themselves can be costly, with their prices jacked up to cover the salaries of those who offer credentialing help.

Even if a practice believes that the membership costs are worth the help they are being given with the credentialing process, there still may be problems with using these organizations to get credentialing done. First, these organizations are often not designed to offer individualized advice and help to their members. What they offer is cookie-cutter services that may work well for most, but not all practices.

As part of this one-size-fits-all approach, physicians’ organizations only offer to help their members get credentialed with a limited number of insurance companies. If a practice is looking to become, or stay, credentialed with an insurance company that the organization does not deal with, then the practice is back to accomplishing the task on its own.

Let TRIARQ Health Help You With All of Your Credentialing Needs

The process of obtaining and maintaining insurance company credentials is time-consuming and never-ending. Keeping up with all of the requirements requires a great deal of time and money. Not keeping up with all of the requirements is even more costly, as denied or expired credentials will mean that the medical professional will not receive payment for services until the situation is rectified.

TRIARQ Health’s Payer Credentialing can take all of the stress and hassle of keeping your practice credentialed with any insurance company, including Medicaid and Medicare, off of your hands. This team has the experience and skills to keep you and your practice seamlessly credentialed, so there will be no delays in payment or loss of income.