Medical Credentialing Companies: What Services Do They Really Offer?

The most common question healthcare professionals, clinic owners, and billing agencies that are new to credentialing services ask: What do medical credentialing companies do? The answer is not always immediately clear.

There is no need to panic or fear; we will explain it to you in simple terms.

Understanding the Role of Credentialing in Healthcare

Healthcare centers around credentialing. It determines how providers are paid, how they gain trust, and how they stay compliant. However, it can be time-consuming and confusing. This is why many practitioners seek help from credentialing specialists. Credentialing is the process of verifying a healthcare provider’s qualifications and eligibility. 

It is designed to help doctors, nurses, therapists, and other professionals meet the requirements set by insurance companies, government payers, and hospital networks. RoC achieves this by verifying qualifications such as education and training, issuing state licenses, board certifications, employment history, malpractice insurance, and other essential identifications like NPI and DEA. Once eligibility is verified, providers can apply to join insurance panels through a process known as payer enrollment.

What Do Medical Credentialing Companies Actually Do?

Medical credentialing businesses are also known as healthcare credentialing agencies or medical enrollment firms. To handle this complex process, they manage the medical credentialing procedure on your behalf. They organize paperwork, complete applications, contact payers, and monitor various enrollment statuses. Their services cover the entire process, ensuring nothing is overlooked and that your application remains on track.

Key Services Provided by Medical Credentialing Companies

Payer Enrollment

Payer enrollment is one of the most important services credentialing companies provide. This involves contracting providers with insurance companies such as Aetna, Blue Cross Blue Shield, UnitedHealthcare, Medicare, and Medicaid. Credentialing professionals gather all necessary documentation, complete payer-specific applications, submit them, and continue following up with the payers to track approvals and denials. Proper enrollment is crucial for billing insurance, and without it, no payment can be made for your services.

CAQH Registration and Management

CAQH registration and management is another essential service. Council for Affordable Quality Healthcare operates an online database that most insurance companies use to verify provider information. Credentialing firms assist you in completing your CAQH profile, ensuring it is accurately maintained and re-attested every 120 days. This is vital because outdated or incorrect CAQH data can be costly to process and may even halt your credentialing progress.

License and Certification Verification

Credentialing firms also handle verification of licenses and certifications. Your state licenses, DEA registrations, and board certifications must be verified directly with the issuing sources, although this does not always happen. These companies also request verification from licensing boards, obtain confirmation from certifying organizations, and ensure all credentials are current and active. This step not only meets the requirements of payers but also enhances patient safety.

Ongoing Compliance Monitoring

Credentialing is not a one-time process. Insurance payers require periodic re-credentialing and ongoing compliance. This is where continuous compliance monitoring becomes essential. Credentialing firms will keep track of license expiration dates, re-attestation dates at CAQH, document expiration dates, and changes in practice information. They maintain a digital record that is kept current to ensure your practice remains compliant at all times.

Re-Credentialing

Most insurance companies require re-credentialing, which occurs every two to three years. This involves recertification of the credentialing steps required to remain in-network. Credentialing agencies also monitor these renewal dates, collect the necessary documents, update profiles as needed, and communicate directly with insurance companies, thereby preventing service interruptions. Missing these deadlines may result in deactivation, delayed payments, or termination from the network.

Medicare and Medicaid Enrollment

Enrollment with Medicare and Medicaid involves a specialized process with its procedures and rules. Credentialing companies are experienced in handling such processes. They operate on PECOS (Medicare’s online system) and navigate the state Medicaid portals, ensuring that applications are submitted correctly and promptly. Since these applications can be time-consuming and prone to errors, it is essential to have an expert assist in ensuring they are completed accurately.

Multi-Provider and Facility Support

Credentialing companies handle not only individual providers but also groups, clinics, and other healthcare facilities. Their services include group NPI registration, facility licensing, enrolling multiple providers, and managing multi-specialty rosters. These services are very beneficial for growing practices or large clinics that are continuously hiring more providers.

Credentialing Audits and Clean-Up

In some cases, the issues may already exist by the time they reach the credentialing companies. There might be missing information, application delays, or outright refusals. Credentialing companies that provide audit and clean-up services handle such cases. They review your files, correct any errors or outdated data, reprepare the necessary documents, and resubmit the applications with the amendments. This type of clean-up can help a struggling provider get back on track.

Benefits of Outsourcing Credentialing

The question you might ask yourself is whether you can handle all this alone. Technically, yes. However, credentialing is a demanding, labor-intensive process that requires precision, commitment, and knowledge of the payer’s regulatory requirements. Any error can lead to significant delays or even lost revenue. This is why it is usually wiser to outsource to the professionals.

Outsourcing credentialing offers clear benefits. Firstly, it speeds up the enrollment process. Credentialing firms have experience with how payer systems operate and can anticipate potential pitfalls. They also significantly reduce errors, as trained professionals carefully review each submission. Outsourcing saves both time and money, allowing you and your staff to focus more on patient care. It also simplifies compliance, as someone ensures deadlines are met and updates are made on time. Most importantly, it provides peace of mind, knowing that your practice’s revenue won’t suffer due to minor paperwork mistakes or missed steps.

How Credentialing Impacts Revenue and Cash Flow

Credentialing delays will directly impact revenue. For example, A provider might see 30 patients a week, but if not credentialed, those visits may not be reimbursed. Not all insurers reimburse retrospectively; they do not pay for services already performed without prior credentialing. These delays can also lead to claim rejections, extended resubmissions, and hinder cash flow. Using credentialing companies helps prevent application issues from the outset and acts as a form of risk management, providing significant benefits.

Final Thoughts: A Long-Term Partner for Practice Success

The role of medical credentialing companies is much more than just submitting applications. They are long-term partners that help healthcare providers stay compliant, organized, and profitable. It doesn’t matter whether you are registering a solo practice, enrolling a team of practitioners, or managing a larger facility; these professionals streamline the process. They protect your bottom line, whether it involves setting up CAQH, enrolling in Medicare, or ongoing re-credentialing.

Whether you are opening a new clinic, adding several new providers, or dislike doing the credentialing work, you might want to outsource the role to a credentialing company. With the right help, you will avoid losing time and money and stay focused on delivering excellent care to your patients.

FAQs

1. Are the services of all credentialing companies alike?

No, these are different. Some specialise in individual providers, while others focus on hospitals, group practices, or billing companies. Never hesitate to request a comprehensive list of the services you will receive.

2. Does CAQH fall under credentialing services?

Yes, setting up your CAQH profile, managing it on an ongoing basis, and re-attesting are part of the standard services offered by most credentialing companies.

3. What is re-credentialing?

Re-credentialing is the process of renewing your credentials every few years to stay in-network with insurance payers. It involves updating and resubmitting documents.

4. What is the normal length of credentialing?

Credentialing generally takes 90-120 days for some insurance companies, and for Medicare, it can take 45-60 days, and for Medicaid takes 60-120days. Starting the process early can significantly speed things up.

5. Can credentialing firms handle Medicare and Medicaid enrollment?

Yes, most well-established credentialing companies possess the management skills to handle PECOS and state Medicaid enrollments.