How Does Healthcare Credentialing Work?


As soon as a medical practice hires new staff, be it a doctor, nurse, or any other medical care provider, they must go through medical credentialing. You can verify the skills and qualifications with healthcare credentialing to get them listed as an approved practitioner by the insurers you work with! A healthcare provider always has to reapply when working with a new employer despite being approved by the insurer panel in the past. The only problem is that the process of credentialing is expensive as well as time-consuming and may require a lot of resources. This is why numerous medical practices opt for medical credentialing services from medical billing companies! 

What is Medical credentialing?

Credentialing is an essential process that allows a physician to join a facility. Most medical practices tend towards outsourcing medical credentialing services to ensure that the applicant is the person who says they are! These service providers ensure that the applicant’s credentials are legitimate and meet the requirements of the healthcare facility. In the process of medical credentialing, a medical billing company like UControl Billing verifies the following information:

  • Training
  • Licenses
  • Education
  • Residency
  • Qualifications
  • Career history
  • Specialty certificates

To do credentialing of a healthcare facility, the credentialing service providers have to go through primary source verification (PSV). In the process, the medical credentialing service providers reach out to the source to ensure that the data or credentials provided by the applicant are accurate and legit! 

How Does Healthcare Credentialing Work? 

The process of medical credentialing seeks to ensure the standards of services provided by practices to benefit the patients and the medical community. The Joint Commission was established in 1951 to optimize the quality standards of the hospitals. This commission created a manual and required every healthcare facility to create a credentialing committee to ensure that only competent and trained physicians provide the medical services. Instead of forming a committee, many medical practices tend to outsource these services from an experienced medical billing company. 

Although every medical practice has its way of collecting and verifying the practitioners’ data, some get medical credentialing services while others do it themselves. Fortunately for the same credentialing documentation is required. As soon as a physician, new or old, applies for a position in practice, they have to provide the staff with the same documentation that they have to verify using primary sources. The common documentation involved in the process of medical credentialing include the following:

  • State license
  • Surgical logs
  • DEA certificate
  • School diploma
  • Driver’s license
  • Residency diploma
  • Social Security card
  • Immunization records
  • ACLS/BLS certification
  • Professional reference(s)
  • Updated curriculum vitae
  • The 10-year insurance claims report
  • Documentation of hospital privileges
  • Board qualification/certification status

A few more steps are included for physician credentialing, like background checks and sanction checks. To verify other documentation, the service-providing medical billing company may contact the primary sources for double-checking the accuracy of records. 

As soon as the experts providing the credentialing services verify the documents, they send the files of the physician who applied to the executive committee. The committee might meet the applicant and then approve the application and send the information to the Joint Commission. 

Medical Credentialing tools

Many medical billing companies, as well as practices, manually go for the process of credentialing. Manual credentialing is time-consuming as well as prone to human errors. But outsourcing from the best medical billing company will also provide you with the services given by using credentialing software tools. 

When tools do the credentialing, there is a reduction in the errors and redundancies and a more fast credentialing process. In addition, this also helps the organizations to stay compliant to avoid any legal issues. These credentialing tools also enhance visibility into the credentialing process. This implies that it will be more straightforward to examine the progress and spot potential risks that might trouble the physician. 

Who Needs to Receive Their Medical Credentials?

Numerous healthcare providers require medical credentials to provide standard care. These include the following: 

  • Podiatrists
  • Physicians
  • Optometrists
  • Ophthalmologists

Healthcare credentialing is a comprehensive system that includes every aspect of medical care and other clinical services to maintain high standards.  

What Are the Advantages of Medical Credentialing?

Medical credentialing helps in assuring the quality of the medical services provided by medical practices, which benefits both the patients and the facilities. By medical credentialing services, hospitals and other medical facilities can ensure that their staff is eligible for providing the care and services that are up to the mark! To keep the costs down, insurance companies tend to ensure that they partner up with only those practices that have sufficient competence. 

The physicians or the practitioners also benefit from the process of medical credentialing. The reason behind it is that they then are able to get privileges to accept customers from the insurance companies. This helps them to increase the number of patients who might become part of their patient base. Also, patients tend to be credentialed providers as they know that they will get the highest quality of care from eligible and experienced physicians. 

In short, the advantage of outsourcing medical credentialing from the best medical billing company is that you will be able to assure the quality of the services of medical professionals, there will be fewer medical errors, and the costs will also be down. This will make everyone in the system better off. 

Which Healthcare Facilities require Credentialing Services?

The practitioners are not the only ones who require medical credentialing, but other medical facilities are also required to keep up with the standards of care and competence. Here are the healthcare facilities and medical service providers who must acquire and maintain proper credentials in order to act as a healthcare providers: 

  • Dialysis
  • Lithotripsy
  • Ambulances
  • Hospice Care
  • Urgent Care Centers
  • Home Health Services
  • Prosthetics or Orthotics
  • In-Home Care Services
  • IV Home Infusion Therapy
  • Durable Medical Equipment
  • Radiology/Diagnostic Imaging
  • Independent Diagnostic Testing
  • Laboratories and Laboratory Collection Sites

With the medical credentialing of facilities and the practitioners, one can protect the system of patient care even more! 

How Much Does Medical Credentialing Cost?

The costs of medical credentialing services vary from specialty to specialty, from facility to facility, and from service provider to service provider. Ordinarily, there is an application that costs around two or three hundred dollars. Upon completion of successful credentialing, many facilities also repay! The initial credentialing costs much, whereas periodic re-credentialing is done at a discounted rate.

Let’s Wrap It Up!

Healthcare credentialing is an important factor that enables the medical community to maintain high-quality patient care. The downfall is that it is a long and complicated process. This is why this process might cause delays while bringing in new providers. It is a costly process, especially for small practices. If the process is not performed accurately, it might increase the cost and delay rate. Luckily, if your medical billing company is experienced as well as professional, there are high chances of them also providing credentialing help as well. 

If you are looking for the best medical credentialing services, we advise you to check out the UControl Billing website! They provide numerous services, including end-to-end provider credentialing, primary source verification, continuous monitoring, and background checking. With their services and technology, your medical practice can save as well as flourish!