Maintaining the highest quality of care for all patients in the United States requires many facets and attention to detail. One of the most important of all these quality care standards is medical credentialing.

It plays a role not just in making sure that patients are seeing the best possible provider for their condition. It also is crucial in claim submission, determining reimbursement rates, and ensuring that you or your practice is adequately compensated by various medical insurance providers.

The Importance of Medical Credentialing

The medical credentialing process requires in-depth verification of the prospective provider’s educational qualifications, as well as their experience, their current state of licensure, all the specialist training they may have received, as well as a bevy of other important background details.

Of course, accurate medical credentialing is required before any prospective provider can join on-ground procedures within any established healthcare facility. It is also a critical step any time your practice adopts a new insurance provider to the qualified network.

The Different Facets of Medical Credentialing

Unfortunately, even for the well-initiated, the medical credentialing process can seem a bit arcane. Yet even the slightest error can lead to massive delays, or even an insurance provider refusing to accept you in their reimbursement schedule or claim processing procedures.

Ideally, the medical credentialing process will include the following facets such as:

  • Verifying qualifications
  • Verifying career background
  • Verifying practicing licenses
  • Privileging with sanctions to perform specific treatments
  • Privileging to perform specialist procedures

Once these critical facets have been verified, the provider can start the enrollment process. This includes submitting verified credentials to all the insurance companies in the practice’s network to enlist in their panel.

The insurance providers will then respond. Assuming that all verifications are accepted they will then commence with contract negotiations to enable reimbursements and payments for approved claims.

What Medical Providers Need To Be Credentialed?

The medical, dental, and mental healthcare industries have implemented stricter standards, and the insurance industry has matched their rigorous requirements. This means that medical credentials are necessary for:

  • Primary Care Physicians
  • General Practice Doctors
  • Nurses
  • Dentists
  • Chiropractors
  • Physical Therapists
  • Podiatrists
  • Optometrists
  • Physician Assistants
  • Mental & Behavioral Health Practitioners
  • Hospice Care Attendants
  • Hospital Workers
  • Clinics
  • Surgery centers
  • Diagnostic centers
  • Medical Labs
  • Ambulance Services
  • Certified Sleep Research Clinics

Common Medical Credential Errors

Even the smallest error in the medical credentialing process can lead to massive delays and problems. Though some of the following are common errors and/or red flags found throughout the process in the healthcare and insurance industries.

Timing & Planning Error

There is a staggering amount of data involved in the medical credentialing process. It typically takes around three to four months for an individual provider to complete the process. During this prolonged delay, you cannot treat patients.

During the entire process, you will have to wait for approval before you can even start consulting patients or rendering services. Insurance companies will not reimburse new providers without approved credentials. If you attempt to shortcut this process, it can lead to even greater delays.

Data Entry Errors

Even the slightest error or incongruity in your application can lead to delays or outright denial. Some insurance companies will even require you to start the process again if there are significant errors or missing information that cannot be quickly corrected.

So, it’s of vital importance that you recheck the data entries to avoid things like:

  • Misspelled titles
  • Incorrect email addresses
  • Inaccurate postal addresses
  • Wrong NPI numbers
  • Incorrect identification numbers
  • Incorrect license numbers
  • Missing information
  • Empty data fields
  • Disorganized Documentation

Improper or disorganized document handling is also a common medical credentialing mistake that can lead to massive delays in the process. Unfortunately, this level of confusion might even necessitate total resubmission.

State Compliance Errors

Every state has its own credentialing requirements. Providers, technicians, and assistance staff members also need to comply with these state compliance requirements in order for a new insurance provider to accept the clinic or practice.

Failure to Document Specialty Specifics

Specialist providers and diagnosticians are subject to even greater scrutiny in the credentialing and privileging process. This often requires an even greater amount of specific documentation demonstrating proficiency.

Unawareness of Legal Implications

The clinical staff assigned to the credentialing process may be unaware of the legal ramifications of the current application. Although a layman’s limited understanding of legal language is understandable, the practice may be subject to legal liability if things are not in order.

Enrollment Errors After Medical Credential Approval

Even after a provider’s medical credentials are approved there is still an enrollment process that must be handled. Without it, claims cannot be approved and reimbursement cannot be issued. Any faults in this area could affect how the healthcare revenue cycle management is handled.

Failure to Adhere to Insurance Carrier Guidelines

Each insurance carrier has its own unique set of guidelines for how they handle a new provider and how they add them to their panel. This can include:

  • Deadlines for enrollment
  • Procedural requirements
  • Carrier specific rules

Failure to satisfy the provider requirements is an error that frequently happens in medical credentialing.

Lack of Adequate Administrative Staff

Insurance carriers typically have a variety of questions, and various clarifications, and often require primary source verifications as part of the enrollment process. If your facility doesn’t have sufficient personnel to answer these inquiries promptly, it can lead to massive delays in the credentialing process.

Specialists without Expert Support

Specialists often need expert support and/or staff that are trained to handle the specialty. This means a clinic that offers specialist services needs to have nurses, technicians, and administrative support staff that are credentialed as being capable of assisting in all manners of care.


There are a lot of things that can go wrong in the medical credentialing process. Especially if you are new to the process or you are trying to handle the entire process internally at your practice. Requiring personnel to deal with time-consuming paperwork can rob them and their prospective patients of the valuable time meant for direct care.

This is why there are specialists in the medical billing industry who can help guide providers and practices through the medical credentialing process to eliminate timely errors