1. Introduction

Credentialing in medical billing is mandatory, and insurers require health practitioners. It is so that health providers can serve insurers’ customers after verifying themselves.  

Credentialing in medical billing is the process that all healthcare service providers perform to become enlisted with insurance companies. Only trusted, vetted, and verified insurance companies include healthcare providers to serve their customers.  

Upon successful credentialing in medical billing, the healthcare provider is part of an insurer’s network of hospitals, care providers, health centres, clinics, or medical centres. After successfully applying and receiving the credential as a listed service provider, a healthcare operator can receive reimbursements. The reimbursements are received from the insurer.  

The insurer pays the healthcare operator for the services rendered to their customers by the healthcare operator. The agreement terms between the insurer and healthcare service provider are a contracting or credentialing agreement.  

Introduction to Credentialing in medical billing

Credentialing in medical billing turnaround times varies because there are several factors involved. Government programs such as Medicare have their provider enrollment, chain, and ownership system (PECOS). The approval of provider enrolment and provider credentialing in medical billing is faster than commercial insurance providers, and Medicare has an average approval time of 41 days. On the other hand, commercial insurance carriers can take anywhere from 60 to 180 days. Therefore, this is a game of waiting, hurrying, and waiting again.  

Insurance companies have varying standards and policies for enlisting healthcare service providers. When the government and international regulatory policy changes come into effect, there could be a modification in the credentialing in medical billing requirements. This could warrant another cycle of credentialing by the healthcare service provider.  

Healthcare service providers are willing to re-credential after initial credentialing in medical billing exercise to access a wider pool of patients. Given the penetration of insurance providers into the market, most people will be covered very shortly under insurance policies. But re-credentialing without using automation can be expensive considering that healthcare service providers already have administrative overheads.  

Introduction to Credentialing in medical billing

Some insurance companies treat credentialing quality in medical billing efforts as a precursor to providing contracts. The level of contract, the facilities offered within, and the scope of operational flexibility for the healthcare provider are determined by the process of medical credentialing. Credentialing is an active and trusted source of verification for patients. Many patients do not consult physicians or visit hospitals, not in their insurer’s network.  

Healthcare providers always want to expand their reach and be enlisted by several insurance providers. But meeting the insurers’ rigorous set of rubric requirements can be overwhelming. The amount of paperwork involved in credentialing in medical billing is substantial. 

For credentialing in medical billing, healthcare operators sometimes need to work with CAQH solutions and PECOS for this purpose. It could involve some training, and some costs could arise associated with it. Therefore the need of the hour is a credentialing in medical billing solution that provides intelligent healthcare automation. The level of automation applied in the solution can streamline the application process.  

A credentialing in the medical billing system that is agile and adaptable can complete the application process, reduce errors, suggest improvements, and expedite the process. This will allow the healthcare service provider to become a contractor in the quickest time possible. They can start receiving insurance money or benefits for the services rendered to the insurer’s customers.  

2. Why is Credentialing Important in Medical Billing?

In this section, we will establish the importance of credentialing in medical billing. How credentialing develops trust among patients for health care providers, prevents loss of revenue, and provides a source of reference for patients and their insurers will be discussed among other things.

Given below are some of the reasons why credentialing in medical billing is important:    

1. Instills Confidence

Instills Confidence

Credentialing elevates the level of confidence in a healthcare delivery process. Patients are sure of the outcomes and become cooperative. One of the aspects of a physician’s healthcare delivery is medical billing. The other important one is credentialing. Medical billing along with credentialing are both tied to each other. Therefore, it is ideal for credentialing in medical billing software that provides physicians and medical practitioners credentialing services.  

Patients rely on credentials, and it instills confidence in them. Some insurance providers have a reputation for very high credentialing standards. So any healthcare practitioner enrolled with such insurance companies is easily trusted by patients. Credentialing has to be done with utmost attention and detail. And here is where credentialing in medical billing software can help.  

2. Patient Trust

Patient Trust

As credentialing is stringent, a healthcare provider is trusted. Their qualifications and credentials become valid, and patients can trust the services of these providers. In a world of healthcare scams, under-experienced doctors, and medical facilities providing the wrong diagnoses, it is up to the insurance companies to keep the best and discard the rest. Patients require that their insurance companies have stringent vetting requirements so that only the best healthcare practitioners, nursing homes, clinics, and hospitals are enlisted by them. They rely on the insurance company’s internal processes and fully trust enlisted medical practitioners. A credentialing in the medical billing system can automate the patient trust process.  

Physicians can cater to such patients that such insurance companies cover, expanding physicians’ scope of services and activities. Credentialing with these insurance companies is the best option. But there could be situations where re-credentialing would be required. It is also not convenient to do tons of paperwork. Therefore, using automation in healthcare in such cases yields a world of benefits.  

3. Prevents Loss of Revenue

Prevents Loss of Revenue

Credentialing promptly and ahead of time allows continuity of services, and it does not disrupt services to patients. Thus, there is no loss of opportunity and revenue. Medical offices must have a partnership with insurance carriers. Insurance companies may require periodic records of verifications from healthcare professionals to keep the partnership active. The verification list could change from time to time, and it might require a different set of documentation to be furnished by the medical practitioners.  

Failing to provide adequate documentation signals a lack of organization in the medical office. Insurance companies may not have tolerance thresholds for such a lack of compliance. In an outright fashion, they may reject the medical practitioner’s office application. Failure to provide credentialing information could result in the insurance company withholding the funds to be disbursed to the medical office, which could lead to revenue loss.  

4. Hiring Process Efficiency

Hiring Process Efficiency

Recruitment agencies and healthcare chains recruiting medical practitioners can use credentialing as an efficient and effective hiring tool. Medical professional credentialing can also be proof of qualification. The credentialing process verifies the medical practitioner’s qualifications, certifications, licenses, and experiences. After successfully determining the validity and integrity of such data, the medical practitioner will be given a contract from the insurance company.  

Medical offices, hospitals, government health centers, and other such medical establishments can use this data to hire medical practitioners. Instead of doing all of the vetting and verification processes, they can simply reuse this data. They can use medical billing credentialing software to perform basic verification and hire a medical practitioner. A credentialing check completes verification of a medical practitioner’s residential history, work experience, license, and educational background. Checking through this data is time-consuming, and it is better to reuse verification processes. So therefore, using medical credentialing software is the best way to achieve this.  

5. Improves Reputation

 Improves Reputation

Credentialing improves the reputation of a healthcare center and its medical practitioners, and it provides a source of reference for patients and their insurers. Patients have access to information, and they are researching healthcare providers. Patients are becoming watchful because of the number of bad diagnoses and poor treatment quality instances across healthcare departments. That is why credentialing is an important tool to win their trust and confidence. Not only that, credentialing improves and elevates a healthcare provider’s reputation.  

Medical professionals, therefore, take time and effort to credential themselves with insurance companies. They can manage their online reputation and build effective long-standing relationships with their clients by doing this. Once an insurance company gives a medical practitioner the go-ahead, this professional can treat patients. There is no limit to the number of patients treated and the number of insurance providers covered.  

6. Cost Saving

Cost Saving

Credentialing in medical billing is cost-saving. If done ahead of time and using automation, there are no risks involved. Healthcare organizations are finding ways to automate and streamline their processes. With increased competition between hospitals and private medical practitioners, they face several constraints. They have to provide quality service at an ideal price point, substantiate the cost of services, constantly innovate to provide quality healthcare and retain their customers.  

Doing paperwork and manual data entry is considered wastage in such a scenario. It is better to use automated healthcare solutions instead, and one that takes away all the manual aspects and makes it completely automated. So that medical practitioners and their staff can focus only on non-mundane non-repetitive innovative, and forward-moving tasks.  

7. Increase in Third-Party Reimbursements

Increase in Third-Party Reimbursements

Credentialing with multiple insurers increases a medical practitioner’s scope of business. They stand to gain revenue streams from multiple insurers. By credentialing with multiple insurers, a medical practitioner can serve customers of all these insurers. Considering that some insurers have a massive customer base, having a contract with them is worthy. So it is not a surprise that many multi-insurer credentialed medical practitioners transitioned their private service to full-fledged multi-specialty multi-bed clinics to serve the humungous numbers of patients.  

Given this potential that credentialing can provide, it is good to use medical billing credentialing software to automate credentialing. Using a suite of solutions from a healthcare services software vendor, a medical practitioner can benefit from the complete ecosystem. The credentialing software component will be part of the whole and provide integrations to several other data sets, all of which can be leveraged in a customized way.  

8. Establishes Professionalism

Establishes Professionalism

Credentialing is a way to announce professionalism in service. A credentialed service provider is viewed as professional and therefore trusted. The healthcare sector thrives on professionalism. Healthcare practitioners are required to exercise all levels of professionalism. There have been cases where experienced medical practitioners became complacent and thereby unprofessional, and their callous attitude cost patients their health and the medical offices their reputation and revenue.  

Medical billing and credentialing software can assist healthcare delivery chains to credential doctors, verify their licenses, set alerts if there are upcoming license re-certification exams, and use tools to scrutinize educational claims. This type of automation is better than traditional credential methods. Additionally, using cloud computing in healthcare and clinical data analysis, the process of medical credentialing can be automated, and a standardized workflow can be set into motion. Medical Credentialing solutions can also come under the wide umbrella of healthcare automation, consisting of several services.  

9. Compensation Prerequisite

Compensation Prerequisite

Credentialing in medical billing is a process that is mandatory for being compensated. Without credentialing, medical billing is withheld, and sometimes the withheld amount is released much later. Medical billing and credentialing are mandatory processes in almost all countries, and all payments are made through insurance service providers. So, medical practitioners and health facilities have to undergo the medical credentialing process as a requirement to be compensated.  

Customized healthcare solutions can be implemented to provide prompt services to healthcare organizations. Such a level of automation will reduce delays in physician credentialing. Healthcare analytics solutions can be used to understand the variances in credentialing requirements. It will provide an insight into specific regulatory, compliance, and credentialing-related laws of a particular jurisdiction. Credentialing and medical billing can be streamlined, customized, and tailored to an organization’s specific needs using customized custom healthcare solutions, healthcare analytics solutions, and integrated health solutions.  

10. Reduces Errors

Reduces Errors

Credentialing reduces errors if it is done using an automated solution. The solution applies on-the-fly verification and auto-population of data as some of the mechanisms to reduce errors.  

A startling statistic shows that medical errors have caused close to 100,000 deaths in the US. Healthcare service providers have a huge responsibility on their hands. One of the first steps to ensure zero data errors is to undergo credentialing. A credentialing process validates the certifications and qualifications of a medical practitioner and determines the safety of the medical practice.  

A credential management system can be custom-built for an organization, and it can serve as an automated system to resolve all credentialing requirements. This system can be interoperable with many other systems, and it can integrate other credentialing systems and the healthcare center’s various ERP systems. A credential management system such as this will use data from various sources. One of the benefits of such an approach is that it eliminates data ambiguity and duplicity. The fact that there are multiple channels of verification, and multiple dimensions of the same data, can give rise to recording the true nature of data. This type of automation in healthcare can reduce errors and improve the overall quality of healthcare delivery.  

11. Ensures Adequacy

Ensures Adequacy

Credentialing ensures that hospitals and medical centers can get their staff credentialed, and it can be done using an automated solution. Healthcare organizations may have not hundreds but thousands of staff. Managing their credentialing is a humungous task, especially if manual intervention and manual data entry are involved. It is not a scalable model too. So a medical billing and credentialing system can automate credentialing of hospital staff, allowing the medical organization to increase its capacity.  

Healthcare organizations can use advanced medical credentialing and billing software for this. An integrated approach involving health interoperability principles and clinical informatics systems can provide enough data for automation. Medical credentialing can then be done on thousands of hospital staff in a systemized manner.  

12. Competitive Advantage

Competitive Advantage

Credentialing in time using an automated solution helps medical practices to be competitive. They can get more patients and serve more patient cases. After researching it, patients who seek healthcare at quality health organizations are also the ones who chose the health organization. Patients are demanding and critical of healthcare delivery and expect nothing but the best. In this situation, even a small lapse can spurn a patient. The patient may verbally advertise the shortcomings of the hospital. Soon this unverified rumor could spread and cause loss of reputation.  

One of the ways to tackle this is through credentialing. As the first line of defence, a medical facility can only hire qualified and thoroughly verified healthcare practitioners through credentialing. By doing this, almost all quality issues that could arise in healthcare delivery are nullified simply because the medical establishment is using an automated credentialing solution to hire and onboard medical practitioners.  

3. Credentialing Mistakes to Avoid

Credentialing mistakes slow the credentialing process. This section will talk about common credentialing mistakes that can make a provider risk reputation.

Listed below are some of the common credentialing in medical billing mistakes can be avoided through automation.  

A. What Are Mistakes In Credentialing?

What Are Mistakes In Credentialing?

Like every industry has its challenges and demands, the healthcare sector also faces its own. Healthcare industry practitioners have to ensure high fidelity data quality and precision. Quality healthcare that is delivered consistently is the bare minimum prerequisite. There is zero room for errors in diagnosis or treatment, and there are no provisions for increased healthcare costs without proper rationale. Given the stringent requirements, credentialing is one of the ways to ensure quality healthcare delivery.  

Patients treat credentialed healthcare providers as trustworthy, and they have the assurance that expert hands are treating them. Medical facilities can be confident that their medical facility staff can provide world-class healthcare. Medical practitioners and hospital chains can serve a wider customer base of patients from multiple networks.  

Medical centers do not have to worry about lawsuits or malpractice investigations. Insurance companies with competent medical practitioners can ensure standardized healthcare for their patients. Insurers can also guarantee their customers the quality of healthcare and treatment costs. Accordingly, the insurer can price an insurance policy.  

Medical centers have to credential whether they offer invasive procedures or non-invasive treatment options. Both treatments have varying credentialing requirements depending on the type of procedure, its criticality, the number of people involved, the knowledge involved, and several other factors. All medical practitioners involved in the healthcare delivery lifecycle must be credentialed with an insurance provider. Physical therapists, chiropractors, mental health providers, behavioral health providers, physician assistants, optometrists, dentists, nurses, podiatrists, doctors, etc., are all required to go credentialing.  

What Are Mistakes In Credentialing?

All medical facilities such as sleep study clinical centers, radiology centers, labs, diagnostic centers, ambulance services, clinics, hospitals, and surgery centers must do a contract or credential with an insurer or insurers. Given the extent and scale of this process, there are chances that mistakes could occur. The following are some of the common credentialing mistakes.  

B. Planning and Timing Mistakes

Planning and Timing Mistakes

Credentialing delay can cause stalling of operations. So it is important to credential and re-credential much ahead of the due date.  

Credentialing is a time-consuming process involving processing and verifying large amounts of data. Depending on the complexity of the healthcare delivery, the process could take 3 to 4 months or more, and there could be more data and information needed. Multinational healthcare delivery chains involving multiple countries and healthcare delivery laws would warrant a different set of credentialing requirements.  

Collection of data and preparation of the same is a time-consuming affair. Getting the required documents ready for the application may require multiple to-and-fro communication. The timeline for credentialing is therefore always under flux. Especially if it is a manual credentialing process, if the healthcare service provider is not using healthcare automation, it could result in tons of paperwork. The processing of this paperwork could present unique challenges. Some of them, namely qualified resources, to pre-verify the paperwork. Signatories to relevant documents. Verification stamps and seals from relevant medical regulatory authorities etc.  

A common mistake that most medical facilities or medical staff make does not time their credentialing, and they do not properly estimate the time required for credentialing. Re-credentialing may not take time if there have been no changes to the medical care practice. But if there are changes to the medical practice, such as a new healthcare treatment introduced, re-credentialing might take time.  

A simple change of surgical equipment, upgrade to a newer medical platform, a change of skillset of a medical practitioner – all of this could trigger a credentialing requirement. Because of the high level of interconnectedness of all these services, credentialing could become complex.  

An operation theatre that uses multiple lab equipment, medical instrumentation, surgical materials for specific types of operations might need a level of skill and knowledge in operating and using them. Medical practitioners such as surgeons, anesthesiologists, duty doctors, lab technicians, duty nurses, and even lab attendants might need to be credentialed.  

The expansive nature of healthcare delivery, the constant innovations, and the evolving expertise areas of medical practitioners create newer forms of credentialing. Without credentialing, a medical practitioner may not practice until being credentialed. This loss of time could affect this professional and all the patients dependent on this professional.  

C. Mistakes in Data Entry

Mistakes in Data Entry

Credentialing data entry mistakes such as accuracy and incorrect data could make insurers reject the provider. Such mistakes can be avoided through automation.  

Data accuracy is paramount when applying, and failure to provide details when required could lead the application to be rejected. When the application is rejected, initiating a credentialing request might involve more documentation. The denial by the credentialing authority could result in delays for the medical practitioner to resume services. Some of the common data entry mistakes when making a credentialing application are:  

  • Type errors:  
Type errors

Simple mistakes can result in expenses and costs. Interchanged information, wrong information, misspelled names, wrong addresses, and incorrect credentials are type errors. A simple check for such errors after entering them is all that is required. But medical facilities may not do it. Either because it is manual or they are not experienced in credentialing, or they have not provided proper training to their medical staff on the process of credentialing.  

  • Missing information:  
Missing information

Credentialing may not be a straightforward process, and there could be several twists and turns in the process. Because of the complexity involved, there could be strong chances of missing critical information. This information could be required by the credentialing authorities to make a decision. The act of missing out on information could be due to lack of information, negligence, overlooking important aspects, lack of expertise in filling out the application, and lack of healthcare automation.  

  • Improper documentation:  
Improper documentation

Credentialing involves more than just filling up application forms, and it might require supporting documentation. In a manual process involving paper documents, the chances of missing documents are more. Worse, the chances of providing improper documentation are real. Paper-based manual processes have the propensity to generate many errors. It is not easy to keep a tab on this paperwork, especially if thousands of medical staff.  

Improper documentation could also mean ambiguous information. The matter is that most healthcare organizations, how much ever they profess to be automated, have a large portion of their processes being done manually. They resort to old-fashioned and error-prone processes because they do not have holistic, automated healthcare solutions. Lack of perspective on technology’s nature, scale, and benefits and unwillingness for change causes this.  

Healthcare providers can use a holistic solution comprising many modules to manage their processes. The benefit of such an approach is that not only will the credentialing process be automated, several other processes will be automated too. Healthcare ERP records, patient information systems, practitioner files, prescription information, medical health records, visitation documentation, healthcare travel documents, medicine files, doctor license audit trail, etc. These datasets could be resident in various other systems.  

Only if the accuracy of these systems is improved will the accuracy of the credentialing process touch 100%. A credentialing process is highly dependent on the data received from these systems. A credentialing system cannot support verification and validation of datasets that have never been validated and verified at the front-line when inducted into the healthcare provider’s ERP.  

Improper documentation can have far-reaching consequences. It could lead to the contract cancelation between the insurer and healthcare provider. If the insurer is a big company with a large and diverse customer case, this could seriously jeopardize the healthcare provider’s business prospects.  

Insurers are becoming more skeptical of healthcare quality, given the stiff competition in the insurance market. They have automated their decision-making process. And if healthcare providers make low-tolerance mistakes, then the healthcare provider is delisted unceremoniously. To avoid such potential situations, proper documentation should be provided. Using an automation solution is one of the ways to ensure proper documentation preparation and uploading.  

D. Application Process Mistakes

Application Process Mistakes

Critical errors in the credentialing application process could put the medical organization’s reputational and transactional risk. Seemingly innocuous mistakes can spiral into large problems. Medical errors can cause serious issues to patient safety. Ensuring the safety of healthcare delivery has been a constant challenge. The healthcare industry has woken up to this reality. Hospital chains are using automated solutions to streamline their processes. They are partnering with healthcare solutions providers for this. They are using cloud-based solutions, mobile applications, desktop applications, and web applications. They are relying on machine learning and artificial intelligence-backed solutions.  

One of the grave mistakes that a healthcare service provider could make is omitting, misrepresenting, or unknowingly entering incorrect information. As the application process is the most important component of a credentialing process, it would outright reject it. But the rejection could have long-lasting effects. The insurer could flatly refuse to work with this healthcare provider in the future. And even if there is an agreement or contracting term in the future, it would come with many stringent requirements.  

The insurer would classify the error as malpractice for a seemingly innocuous error. Once it comes under this category, no explanation may lift this status. Then a whole new stream of activity could be required to lift this status. This could involve providing more documentation, supporting evidence, legal documents, etc. The delay would prolong, making the medical practitioner run in circles.  

Insurers may also classify the mistake as being negligent credentialing. Insurers have various mechanisms to classify credentialing errors, and these are more for internal benchmarking purposes. The extent to which the insurer uses these classifications to allow or deny a medical practice depends on the insurer, the country of operation, the medical practice type, etc. Whatever the case, providers have to be wary of not entering into any classifications of insurers.  

So now the question arises about how to make the application process tight and error-free. One way is to verify the credentialing information before committing to it being part of the application. But this process is cumbersome, time-consuming, and wasteful. It requires a lot of resources, and unnecessary time is wasted on this process. The result is that it induces unnecessary administrative overheads.  

So the best approach to it is to automate the application process. Data in the application can be pre-populated based on artificial intelligence and machine learning. Customized solutions can be built for this. The tailored solutions can be applied to solve the discrete use-cases of healthcare organizations, their specific departments, and specific medical practitioner practices.  

E. Compliance Errors

Compliance errors in credentialing put the medical facility at risk for negligence and lack of professionalism. Such errors can be avoided through the use of automation. There are various types of compliance errors. The following are some of them:  

  • Not Knowing the Candidate  
Not Knowing the Candidate

Before starting a medical practice, a medical practitioner undergoes an initial screening at a medical facility. Then the medical facility proceeds to align the medical practitioner with a contract. The contract or credentialing agreement with the insurance company will allow the medical practitioner to start treating patients.  

But the medical health center has to have complete information on the medical practitioner they are trying to credential. Not knowing the candidate puts the medical facility at risk. Transactional risk, reputational risk, operational risk, and compliance risk. So before eliciting documentation from the medical practitioner, the medical healthcare center’s credentialing department must obtain complete information on the candidate.  

It is also important for the candidates to know what the credentialing department expects. The necessary checks and verifications that will happen must be pre-known, and it will prepare the medical practitioner for what to expect. The medical practitioner can also prepare the required documentation and personal information for verification.  

  • Furnishing Documents That Are Already Given  
Furnishing Documents That Are Already Given

A lack of systemization and robustness in the credentialing process leads to this. When work practices and workflows are inefficient, such situations could arise. Furnishing documents already provided or asking for documents already collected could lead to delay. Medical health professionals could lose trust in the medical establishment’s credentialing processes. Candidates might look at other avenues because they have low confidence in the recruitment agency’s methodologies.  

The best way to overcome this is to keep a tab of all documents collected, disbursed, and verified. All of this can be done with intelligent automation. But the problem is that even some sub-standard healthcare automation solutions are making things difficult. Healthcare providers and recruitment agencies are using such solutions. The issue will be resolved only if such a solution is purchased or subscribed from a quality healthcare solutions provider.  

  • Unclear Documentation Requirements 
Unclear Documentation Requirements

There are many regulated healthcare practitioners in a healthcare organization. They have their standardized methodology of healthcare delivery, and they have their levels of competence and policies for conduct. So, when the credentialing or re-credentialing process arrives, the documentation requirements could become overwhelming. A manual credentialing department might find handling all of this data difficult.  

Under many statutory regulations for the healthcare sector, about thirty-two healthcare professions come under the ambit of regulators. Under this ambit, the common healthcare professions are nurses, doctors, pharmacists, dentists, osteopaths, and opticians. These healthcare professionals need to constantly validate their credentials periodically or based on a new skill or specialization they have learned and want to apply.  

Organizations such as the NHS, which are healthcare regulators, have their employment checking standards and framework regulations. These standards and regulations come with their own set of stringent requirements. So, the issue here is that there are too many regulators, too many standards to comply with, and too many documentation requirements. Without automation, the potential for errors is immense.  

Even if compliance managers understand regulatory obligations, frameworks, and the latest standards, the number of documentation requirements to keep a tab of is overwhelming. And because the documentation requirements could change, manually tracking them is not a scalable approach.  

  • Documents Expiring  
Documents Expiring

Once the candidate or the medical practitioner starts their duty after credentialing, the compliance department can still lie. It is because documents provided as part of a credentialing agreement or verification have expiry dates, and keeping track of these expiry dates manually is not scalable. Many healthcare organizations’ compliance and credentialing departments do poorly track the follow-up compliance processes after the initial compliance process.  

Examples of documents to keep track of for their expiry dates are DBS, visa, and mandatory training requisites documents. Failure to renew these documents could cause the medical practitioner or candidate, affect patient care continuity, and put many people at risk. It could also create administrative overheads associated with offering rationales, explanations, supporting documentation to establish the true cause of document expiry.  

One workaround for this is to train compliance and credentialing departments. But ongoing training is not enough. An automated solution that can reduce human intervention to zero is needed. An integrated healthcare system that checks for document expiry dates sends reminders, follow-up with the required practitioners can prove highly efficient. This type of automation will ensure the smooth functioning of the healthcare value chain.  

F. Enrolling Process Mistakes

Enrolling Process Mistakes

Enrolment and credentialing are related processes. Before credentialing, there is an enrolment process. Mistakes have to be avoided in this process for a successful transition to the credentialing stage. Often there is a lack of clarity between payer enrolment and medical credentialing. They are not the same, and the differences are subtle. Mostly, they are done together, and one process logically follows the other. Payer enrolment is when a provider requests enrolment with an insurer, and this process requires a separate application process.  

Once the enrollment application is submitted, the next process is to submit the medical credentialing documents. The credentials are then verified. Upon successful verification, the practice is considered valid and accepted. Subsequently, a contract is created. Enrolled providers are considered to be in the network of insurance service providers. Becoming a listed provider is useful because patients do not use the co-pay option that prominently. Patients are always trying to curb out-of-pocket costs, and therefore, patients keep away from non-participating healthcare service providers.  

When payers or insurers delay payments or flatly refuse payments to medical practitioners because of enrolling process mistakes, it could impact their financials. For example, if the affiliations information is incorrect during the provider enrolment and credentialing process, the payer could delay credentialing. Suppose the medical provider has not provided complete information on any adverse medical or clinical occurrences from their medical practice. In that case, this could lead to a delay or flat refusal of payment from the provider.  

Therefore, an automated enrolment process is required. It could be required when a medical practitioner starts a new practice or joins one. It is required when a medical practitioner switches from one practice group to a different one. When a medical practitioner joins new practices, groups, or affiliations, it is required. Medical officers might enlist new payers or insurers, requiring a credentialing process with them.  

G. Issues With Lack of Automation

Issues With Lack of Automation

Healthcare organizations that still use outdated manual processes for data collection risk a lack of automation. The chances of anomalies are more here. A typical credentialing process involves collecting documents and data required for completing credentialing application forms by the medical practitioners. The documents required are stored somewhere. If it is an automated system, it is stored in a central database; it is stored as physical documents. If a medical practitioner has not been enrolled, there is a process that selects top insurers. These payers are to which the provider sends regular claims. Contact is initiated with the payers.  

An audit is done in which the insurer and payer-specific formats are applied to the application. Then the application status is tracked regularly with the payer. The payer gives the enrolment number to the medical provider upon successful completion of the enrolment. The document library is updated, and then the credential process is initiated.  

H. Unaware of State-Specific Credentialing Requirements

Unaware of State-Specific Credentialing Requirements

Credentialing varies by state, medical practice, practitioner, and other factors. Automation can help medical centers avoid mistakes in credentialing because of these unknowns. Medical credentialing is state-specific. Certain states have the reciprocity law. This law allows healthcare providers to practice in multiple states, and the provider need not relicense in the other state or undergo any formal education again. States that have reciprocity laws have their specific credentialing requirements.  

Some of the reciprocity laws are that chiropractors must have passed NBCE exams in all states and have a D.C. (Doctor of Chiropractic) accreditation. While this law is applicable for all states, professionals such as naturopathy physicians might not have all-state-specific laws.  

Only a handful of states might license such professionals. An accredited 4-year degree will be required from a naturopathic medical school for naturopathic physicians, and they may also be required to clear certain postdoctoral board assessments.  

The credentialing requirements may not be the same for all medical practices. For example, in the case of massage therapists, the credentialing requirements have a lot of variances. Requirements for registration, certification or license could vary by state. Even standard requirements could vary as well as the advanced requirements. Some states could require a minimum of 500 hours of clinical practice, and some states may have a higher requirement.  

Given that every practice has its own set of evolving credentialing requirements, including the educational details and exams to pass, it is difficult to track all these requirements without automation. Although there are interstate medical agreements to create transferable medical licenses, these details are largely unknown. Such details can be formally used only via a customized and automated solution that integrates with the required external system.  

I. How to Troubleshoot Credentialing Mistakes?

 How to Troubleshoot Credentialing Mistakes?

Troubleshooting credentialing mistakes is a costly affair. The best form of troubleshooting is to prevent it, and using automation is one of the ways to do it. Prevention is the best cure in credentialing. Many of the mistakes that can arise in credentialing can be avoided. A seemingly innocuous mistake such as outdated contact information can make an entire credentialing process stunted. Outdated contact data is responsible for more than 85% of rejected applications. The missing or incorrect contact information may not be considered a serious mistake. Yet, it will lead to application rejection.  

One of the ways medical offices troubleshoot credentialing mistakes is to retrain their staff. They add members to their medical staff, and the members are trained to rectify the mistakes. The troubleshooting is done despite the time and labor involved. The resources ensure accuracy, patience, and attention to detail when troubleshooting. All parties in the credentialing process, namely, therapists, nurses, physicians assistants, and doctors, participate.  

Reactive troubleshooting is the process of re-verifying all records. The intent this time is to ensure that there is no scope for being pulled up for negligence. Yet, again, this type of troubleshooting is highly laborious. It is reactive and not proactive, and it is not automated and therefore has room for creating manual errors. The troubleshooting effort retrains staff on critical knowledge aspects such as differences in state compliance policies.  

The best way to troubleshoot credentialing mistakes is to prevent them. And the way to prevent them is through the use of automation. Using an automated platform, such manual errors will never arise. A medical billing and credentialing software will offer on-the-fly verification, suggestions, and auto-fills. If it is an integrated solution, then data from other systems can be reused. Such a facility allows the credentialing application to save on time and be on time.  

4. Advantages of Automated Credentialing in Medical Billing

In this section, we will discuss the benefits that automation gives for credentialing. Automated credentialing helps create workflows, reduce staff, ensure transparency and reduce errors.

i. Streamlined Process

Streamlined Process

Automation helps create workflows in the credentialing process. Workflows cut out the risk of errors in human judgment and labor-intensive tasks. Without credentialing in medical billing, most processes are manual. These processes are error-prone. When there are errors, there are costs associated with rectification. Along with rectification, there is a danger of reputational risk. Insurers could categorize the provider into a particular bracket, and to come out of that bracket may require further compliance processes. Therefore, all of these situations can be avoided by using the automated credentialing solution.  

ii. Reduced Staff Cost

Reduced Staff Cost

Automation helps reduce staff to operate and maintain a credentialing process. Only technical configuration and a few implementation personnel would be needed. Automation reduces the requirement of staff to zero. There is no requirement for implementation specialists or dedicated operators to operate the credentialing in the medical billing system. The customizations can be done based on a needs-based approach. Whenever there is an organizational change or a change in the workflow, the system could be customized to align with this change. Reduced cost for staffing increases return on investment and decreases the cost of ownership. It helps the healthcare organization to realize favorable costs over benefits over the long term.  

iii. Increased Transparency

Increased Transparency

Automation allows all stakeholders of the healthcare organization to get full visibility into the credentialing process. No part of the credentialing process is opaque. The virtue of being an automated solution allows for all processes to be transparent. No process or workflow operates behind opaque doors, and all workflows and transactions are logged. This level of transparency ensures that all stakeholders have equal knowledge of the process proceeds. There are no siloes in an automated system; the workload can be shared, distributed, and collaborated upon.  

iv. Reduced Errors

Reduced Errors

Automation reduces errors because there is no manual intervention. All aspects of the credentialing in the billing process are automated, requiring no manual entry. As total automation reduces manual intervention, there are no errors. If any errors exist, they are logical errors – created by the configuration personnel when defining workflows. These errors can be easily remediated, and the seriousness of these errors is not prominent. An automated system has done its job as long as there is no error in data and the integrity of data is holy.  

5. How Can Credentialing Software Help?

A credentialing software system performs basic to advanced credentialing functions. The software system offers a suite of features that allows providers to perform credentialing and re-credentialing without manual intervention.

A credentialing software system can store and process information, irrespective of the quantity and type of data. If it is a cloud-based system, voluminous data can be housed in a secure, searchable, and centralized data store. There is no paperwork involved in electronic format, and a paperless environment ensures data accuracy and low or no labor cost.  

A credentialing system can quickly assess and validate credentials and qualifications. If there are gaps or anomalies in the data, the automated system can arrange virtual meetings. The virtual meetings will allow the medical practitioner to explain a credential or license to a compliance officer. A credentialing system will continuously track renewal requirements, application filing deadlines, and documentation requirements. All documentation such as licenses, medical requirements, and certificates will be continuously tracked. If expiry dates are nearing, the internal workflows could initiate a renewal using auto-populated data or send reminders to the concerned parties.  

How Can Credentialing Software Help?

Although simplistic from the outside, Credentialing in medical billing has many intricate internal processes. The credentialing process could vary by country, medical practice, and medical practitioner requirements. All of these internal processes are complex or simple, depending on the nature of operations of the healthcare organization. A customized credentialing in medical billing solution can enable the complete automation of these intricate processes. It can be through workflow automation, dynamic workflow creation, machine-learning, AI-induced workflow adaptations, and dynamic data leveraging.  

Good credentialing in medical billing software systems should be modular. It should provide the facility to deploy the solution in various environments, including on-premises, on-cloud, and hybrid environments. It is helpful if there are equivalent mobile apps, too, since most transactions are done via smartphones.  

6. What to Look for in Credentialing Software?

This section will discuss the features to look for in credentialing software. Why should a credentialing system be integration-friendly and possess an evolved document management and electronic forms systems? Let us find.

1. Integration and Migration Simplicity

Integration and Migration Simplicity

A credentialing system must be integration-friendly and also allow the migration of data. The system should operate standalone and also amidst a software suite. A credentialing software system might be a standalone system. But it cannot function autonomously unless it has integrations, which ensures the system’s interoperability. Without integration, the onus of feeding data is with the system’s operator, which is not a scalable approach.  

As much as integrations are required, credentialing in the medical billing system’s ability to migrate data. The system’s internal processes to refine, format, and ready the data are critical. This data can then be used in other systems. This should be achieved with minimal configuration and without the need for dedicated specialists for implementation.  

2. Cloud-based


Credentialing solutions should be standalone as well cloud-based. This flexibility allows for a modular and scalable approach to cater to all business cases. A cloud-based solution for credentialing in medical billing provides a lot of advantages. The number one advantage is scalability. Unlike a desktop-based system, a cloud-based system can scale infinitely, and it also has access to cloud-based resources. All computations are cloud-based, and so is the storage. This creates a potent system for scalable automation that can handle multi-site credentialing requirements.  

A cloud-based enterprise credentialing system can function coherently and cohesively with a suite of applications. It can easily integrate as well as migrate data simultaneously. It will allow hospitals and medical health centers to scale their credentialing in medical billing processes. As the system automates this workflow, they can add as many staff and branches and not worry about credentialing.  

3. Document Management

Document Management

A credentialing system should have a robust and evolved document management system, and the system should have flexible document storage and retrieval structure. A simple document management system would not suffice for a complex healthcare process such as credentialing in medical billing. Given this process’s dynamic nature and its variances across geographies, a dynamic document management system is required. Such a system can be cloud-based or on-premises, or a mix of both. Security and privacy rules can be applied to control access and classify data into various categories.  

A customized document management system can be built, and a healthcare solutions provider can build this. This system will be specific to the organization’s current and proposed future needs. Such credentialing in the medical billing document system will have multiple layers to normalize the data from proprietary formats for external consumption and analysis.  

4. Electronic Form

Electronic Form

A credentialing system should have electronic forms systems to automate form filling. There should be little or no manual entry. A medical billing software system credentialing should have electronic forms that pre-populate information. The system should be capable of populating data from various provider profiles. Depending on the medical practice and practitioner, the system should populate the data.  

Electronic forms can be used at all stages of credentialing. They can be configurable too, and drag and drop functionality can allow providers with little technical knowledge to create workflows. Just like pre-populating data is useful, so too is pre-populating signatures. A digital application that can be signed online needs no downloading and printing. The entire process becomes automated and paperless.  

5. Workflow Systems

 Workflow Systems

Good and flexible workflow systems allow a credentialing process to be fully automated. The credentialing process can also be tailored periodically to suit complex use cases. Credentialing in medical billing is a complex process. Workflows for credentialing differ and are subject to change. Customized development of these workflows is possible, but a better idea is to allow users to define their workflows. This can be achieved using a declarative user interface. By way of this user interface, workflows can be stringed together declaratively. The process would require no coding from the users’ part. Workflow systems can be template systems as well. They can be standard workflows to include dynamic data from an external system, and such an approach allows one workflow to cater to various types of data sets.  

6. Peer Review

Peer Review

A peer-review process in a credentialing system allows providers to gain peer reviews on their applications and elicit instantaneous feedback. Rubrics and emails are used for peer review. But the need of the hour is to use a HIPAA compliant system for this. By doing this, the provider ensures that their data is private. There is no worry about accidentally disclosing or sharing data with the wrong entity, and there is no issue of letting out protected information such as patient records.  

All peer review is done from one single platform. Any outside intervention is only via automation, and it is tracked and logged. Even external interfaces can be controlled by using standardized and structured mechanisms.  

7. CAQH Integration

CAQH Integration

Credentialing systems should have integration with CAQH. This ensures that the credentialing systems access accurate insurer and provider community information. CAQH solutions for provider data management helps healthcare businesses streamline their processes. A non-profit alliance, CAQH develops solutions for healthcare providers for their many day-to-day use cases.  

CAQH Core, for example, is a body that creates electronic transaction rules. The operating rules and technical standards have to be complied with for healthcare interoperability. CAQH Pro View is a web-based solution used for self-reporting, and it supports more than 1.6 million providers and counting. Therefore, the system should have CAQH integration. It is a highly necessary feature. Not just integration, but the system should be capable of utilizing the facilities offered by CAQH intelligently.  

8. CME Tracking

CME Tracking

A credentialing system should allow medical professionals to track their continuous medical education requirements, and it will help them plan their credentialing activities accordingly.  Continuing medical education is a basic requirement for medical professionals, and they have to constantly keep themselves updated on the latest and greatest developments in the medical world. A credentialing and medical billing system can have a CME (continuous medical education) module that tracks CME hours.  

The hours required to earn a license, credential, affiliation, or certification can be compared with the cost of the credential. This data can be reported to understand the cost and labor involved in CME, and it can serve as a benchmark for new medical practitioners who want to obtain credentials for a prospective new practice.  

9. Short Implementation

Short Implementation

A credentialing system should have low or no implementation overheads. It can be provisioned in multiple ways, including virtual machines and containers. A platform such as a credentialing system should have low implementation and training overheads, and the platform should have self-explanatory workflows. People of all skill levels should use it, and basic computer knowledge should be required to use it.  

Many people can easily use such a system. When many people use it, the quality of data improves. There is a reduction in manual intervention. More people are onboarded online, and there is more online interaction, and more online data is generated. It can help healthcare solutions provider customization teams to build customized workflows faster. Such a system will have short enhancement implementations.  

10. User-friendly


A credentialing system should have a self-explanatory and intuitive user interface, and it should help users of all levels of computer knowledge use the system. Context-based user interfaces, customized logins, customized screens, auto-prompts, and several such user-friendly features make using complex software simple. A uniform interface that is similar in appearance usage and has recognizable workflows is one aspect of user-friendly software.  

Instead of limited people being able to use it, the credentialing in medical billing can be used by many people. And the prolonged and consistent usage of the system generates a better return on investment. A complex process such as credentialing and medical billing needs user interfaces that are highly usable, self-explanatory, and guided. Good UI helps train staff faster, reducing costs related to retraining. An ADA-compliant site can also become useful for people with special abilities. Clear, concise, and uncluttered user interfaces with organized dashboards, readable text, and navigable user interface elements can make anyone use the credentialing in the medical billing software system without trying to understand how to use it.  

11. Customer Support

Customer Support

Customer support such as email, chat, or phone is required for users to get assistance at any time of the hour. A credentialing in medical billing system should have good customer support. There could be live chat, email, and calling features. Customer support should provide a good help system for customers to use. There should be training and learning material. There should be online videos to help users leverage the system’s functionality.  

The customer support should also extend into how well the vendor can understand customization requirements for the credentialing in the medical billing process. Sometimes customer support can be required constantly to support an evolving system that may require frequent customizations. A good healthcare solutions vendor should address such growing concerns for healthcare organizations that are undergoing a digital transformation.  

7. How to Choose a Credentialing Software Vendor?

What are the parameters that one can use to choose a credentialing in medical billing software solutions vendor? Let us learn.

A credentialing software vendor must have a consulting department, a suite of healthcare solutions, and a framework for customizations. Check if the software vendor provides a solution that can be deployed on-premises, in the cloud and in a hybrid environment. The software vendor should have a customization and personalization practice that allows providers to implement frequent customizations whenever there is a valid business case.  

The credentialing in medical billing software vendor should ideally be a healthcare solutions provider with a suite of healthcare applications. The credentialing software system could be part of the suite or a standalone module built on a common framework, allowing for easy integration with the other software in the suite if required. The credentialing in medical billing software should have all the mandatory features of a credentialing software system. The one very important feature is CAQH integration. Although credentialing systems may have this integration, it is rarely done right. The Council for Affordable Quality Healthcare or CAQH, in short, has multiple health insurers under its ambit. CAQH has a dynamic and updated repository of credentialing information that providers can use.  

The medical billing software vendor credentialing should know credentialing requirements from various government and national agencies. For example, there could be specific requirements from the National Committee on Quality Assurance. Without knowledge of their requirements, it is difficult to build workflows. So it is desirable that the credentialing software vendor also has a consulting practice.  

How to Choose a Credentialing Software Vendor?

The consulting practice or services from a credentialing medical billing software vendor has far-reaching impacts. For one, it reduces the burden on providers and insurers to use their research departments or rely on external agencies to collect their credentialing requirements. The credentialing software vendor takes ownership of this process. The consulting services department consults on the healthcare provider’s internal organizational matrix. The data is assimilated, credentialing requirements are generated, and an appropriate solution is conceptualized and implemented.  

Another important aspect to check with the credentialing in medical billing software vendors is their security knowledge. A weak credentialing system could break the healthcare delivery supply chain’s digital landscape, which is as strong as its weakest link. Therefore, the credentialing software solution should have higher security standards than a healthcare organization’s prevailing security standards of IT assets.  


Credentialing is a mandatory process, and it has to be done right the first time. The only way to achieve this is to automate all its aspects. Credentialing in medical billing is a critical process for a healthcare service provider. Although there are several commercial-off-the-shelf credentialing software products, they barely fill the complex needs of most healthcare organizations. They do not support customizations and are often based on proprietary technologies and frameworks.  

This causes vendor lock-ins, and it could be several millions of dollars to transition to a truly open-source free-technology-based system. Instead of investing in such software, it is better to work with healthcare provider solutions is better. Such a solutions provider will build custom solutions that can scale, have no vendor-lock in probabilities, are modular, and extendable.  

Given the nature of credentialing in medical billing and its proximity to medical billing, both of these systems can be made to co-operate. Credentialing requirements specific to medical practices, departments, processes, techniques, methodologies, practitioners, geographies, and medical centers-all of them can be automated. Without such a granular level of automation, it is difficult to build a truly universal credentialing system that caters to all types of credentialing use cases.  

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