You'll almost probably need to have physician credentialing services with insurers whether you're starting a new practice or getting your start in the industry. The first step in a collaboration with any insurer is credentialing. It's a technique to protect important revenue sources. Additionally, it's a means to guarantee the caliber of all the new doctors you hire.

Insurance and medical billing companies may grant credentials to practices and hospitals. Individual doctors can also. Strong practices are accredited at both levels. This article will describe how medical credentialing functions in both circumstances.

What is Medical Credentialing?

Being publicly acknowledged by both public and commercial medical insurance is the process of credentialing. A practice needs to be credentialed by the insurer in order to join its network and provide its members "in-network" rates. The same is true for doctors.

Let's contrast medical credentialing with other related terminology to help explain what it is.

Credentialing vs. Contracting

An insurance provider's contract with your practice is a legally binding commercial arrangement. You must obtain their accreditation before you or your practice may negotiate that deal with an insurer.

Credentialing may not be necessary in order to contract for medical staff members who are not doctors (such as physical therapists). Depending on the state, insurance provider, and specialty.

Credentialing vs. Privileging

Individual members of the medical team are granted privileges in order to provide specialized care. The specialties of gastroenterology, cancer, and pulmonary medicine are three instances that need for prioritization.

Hospitals and medical offices grant privileges. Within the network of an insurer, a physician may practice medicine without priority. However, they must request the right to do so if they're interested in carrying out specific procedures like surgery.

Benefits of Medical Credentialing

Without credentials, it's challenging for a medical practice to succeed because credentials give medical practitioners access to many opportunities.

Increasing Patient Base

One of the most fundamental truths about health insurance is that insured individuals are encouraged to use in-network healthcare providers. Patients frequently save a lot of money by choosing in-network providers, and insurer listings make it simpler to find one.

Your potential clientele will be larger the more certifications you have with (public and private) insurers. Avoiding credentials will prevent you from earning a lot of money.

Improved Revenue Cycle

Which is simpler: collecting money from a few insurance companies or hundreds of individual patients? You may collect payment gradually, effectively, and more frequently when you have credentials and are engaged.

Of course, even if you're out of network, insurance companies may still reimburse you on occasion. The procedure is more difficult, though, and payment is less certain. 

Minimal legal obligations

A practice must take into account all relevant licensing and credentials as part of the credentialing process. Individual physician certification involves checking job history and professional references.

A practice can thoroughly examine each member of the medical team by going through this process. Discrepant job histories are revealed. Examining unqualified candidates is simple. Getting rid of unqualified employees early on is a good strategy to guard against malpractice later on.

Recognized Reputation

Credentialing may be seen as a wise marketing strategy in addition to safety, quality control, and financial security. It is a recommendation from professionals in the medical field. Prospective patients gain confidence in the reliability of your practice when they learn that reputable medical insurers trust you.

Things to understand regarding the certification procedure

When it comes to earning credentials, each state has slightly different standards. So what should medical professionals understand before starting this process?

Who verifies professional information?

Several organizations are in charge of handling this step in the procedure for primary credentialing. Each program will be divided into numerous stages because each state will run its own licensing scheme. Information is provided by organizations like the National Student Clearinghouse to get past the first hurdle.

How does the normal credentialing procedure work?

The credentialing procedure normally consists of three stages

  1. Credentialing - The credentials and training of a physician are confirmed. A different name for this procedure is primary source verification.
  2. Privilege - Permission is granted for a doctor to carry out particular services at an institution (based on confirmed credentials)
  3. Enrollment - A doctor can then sign up for payment and submit a service invoice. Frequently, this entails collaborating with insurance firms (see next section). 

After the process, what happens?

A provider signs a contract with an insurance company after receiving credentials. By virtue of their inclusion as in-network providers, practices are permitted to bill and get paid for the services they render thanks to this contract. Healthcare providers are unable to provide service without the necessary certifications and get payment from insurance companies.


Recredentialing, also known as re-enrollment, occurs occasionally. The same procedure must be repeated by practitioners and providers to guarantee that they have the most recent knowledge in the rapidly evolving medical field. Your credentials certainly have a shelf life, but how long depends on the industry you work in.

Everybody with credentials will get a paper letter when they need to go through the procedure once more. A deadline will be provided. Providers may carry on with regular practice until the deadline if chosen for recredentialing. To avoid suspension, healthcare professionals should start the recredentialing procedure as soon as they receive this letter.