9 Tips on Medical Credentialing to Boost Revenues

physician burnout

Is your medical practice experiencing an increasing number of out-of-network claims? Do you see a reduction in benefits because your providers are non-participating? Both these are signs that your practice has medical credentialing issues. Whether you are an established medical practice or in the process of launching one, you need to understand the credentialing process to minimize claim denials and boost practice revenues. Lapses in medical credentialing will reduce your cash flows, lead to wasted efforts in communicating with payers, create difficulties in appointment scheduling, and impact the patient experience with your medical practice. 

Tips on Improving Medical Credentialing for Existing Providers

To improve credentialing processes for existing providers at your medical practice, follow these steps:       

  1. Analyze claim denial reports 

Sometimes your billing staff may not notice that denials are happening due to credential issues. You must analyze claim denial reports regularly and ensure that the denial codes are captured accurately.

  1. Compare provider records with the information available with the payers.

Consolidate the following information on your contracts and providers:

  • List of payers, networks, and insurance products.
  • Details of each provider containing name, date of birth, national provider identifier, and Social Security number.
  • Provider’s start date, transaction access numbers, CAQH ProView logins, and previous employments.

Contact each network to ensure that providers are credentialed with each; if not, find out what can be done to fix the problem.

  1. Track Medicare revalidation dates

You must proactively monitor the Medicare revalidation dates. If you have more than ten providers at your medical practice, you may want to invest in technology to streamline the process. A medical credentialing software will help you track expiration dates, set revalidation reminders, and maintain a comprehensive database of credentialing documents.

  1. Outsource credentialing

Just like medical coding and billing, credentialing also can be effectively outsourced. When you outsource medical credentialing, your credentialing work will be handled by a team of experts who will track revisions in Medicare regulations and have access to the best credentialing software.

  1. Check credentialing status before appointment booking.

From a patient perspective, if a provider is non-participating with a payer or product, ensure that your front office does not schedule patient appointments for that payer or product until the physician’s credentialing issue is resolved. ( For out-of-network patients, ensure that you inform them of the cost of medical service and collect payment prior to the appointment.)

Tips on Improving Medical Credentialing for New Providers

When applying for new provider medical credentialing, ensure that every aspect of the application is supported by documents. Download this list of documents and information required from a provider for credentialing

The main reasons for new provider credentialing to fail are as follows:

  • Incomplete work history.
  • Failure to explain time-lapses of more than 30 days.
  • Proof of start of practice is missing.
  • Less than three references are provided, or the references are unavailable.
  • Uncovered hospital privileges.

Medical credentialing for a new provider can take up to 120 days, so some medical practices give a joining date that is four months from the date of submission of credentialing paperwork. 

Here are some additional tips on securing medical credentialing for new providers:

  1. If three references are required, submit at least five references.
  2. Payors receive an influx of credentialing requests in the months following graduation. So don’t wait until the summer months to apply as you will probably experience delays.
  3. Check the progress of your application at least once a week to resolve deficiencies as soon as they are highlighted.
  4. Be aware of the reciprocity guidelines. For instance, if a provider is credentialed with a payor in one state, the payor may be able to fast-track the credentialing for the same provider in another state.

Understanding how medical credentialing works can make a significant difference to the revenues of your medical practice. An inefficient credentialing system can impact your cash flow and prove expensive in the long run. Outsourcing medical credentialing will ensure that your provider credentialing remains up to date and you can attend to your patients without worrying about claim denials.

Contact us to know more about medical credentialing.


Parul Garg, CEO and co-founder of PracticeForces, has significantly contributed to the growth of over 1,000 U.S. medical practices through her expertise in medical billing and coding since the company’s inception in 2003. With a background in Computer Science and an MBA in Human Resources, her leadership and AAPC-certified coding skills have been pivotal in managing the company’s operations effectively.

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