If you are also wondering about what is credentialing in medical billing, this guide is for you.

Credentialing in medical billing is the process by which insurance companies check the credentials of service providers. What does it mean? It means that they check the qualifications, license, and training of healthcare providers.  It also checks that are they meet the requirements or not. This process is essential for service providers to receive their service charges. 

Credentialing confirms that the providers are authorised to provide you with healthcare services. This will save them from claim denials and provide a smooth revenue cycle. Trust is more important than anything in this world. When they win the trust of patients, it means their chance of progress increases automatically. And their patients know very well that these providers provide quality services. 

This blog is basically about “What is credentialing in medical billing?”. In this blog, you will learn completely about this. If you are a service provider, then it will be very informative for you as you will be able to understand the importance of credentialing in medical billing. Let’s start from the beginning. What does it mean? 

What is Credentialing in Medical Billing?

In simple terms, credentialling is basically checking the qualifications of providers. Its qualifications include its degree, license for work, and training. It’s how hospitals make sure the doctors on staff are properly certified to practice medicine.

When a doctor or service provider wants to be credentialed, their a few important things that are checked. These include their license, education, or any training they have done. They also check whether they have any work experience or not, and also their NPI (National Provider Identifier). This process is helpful for insurance companies. 

Most people are confused about credentialing and the enrollment process. They think that they are the same or different. The main difference between them is that Credentialing means checking the qualification of a provider, and enrollment means signing them up with an insurance company. Both steps are important and must be done before billing insurance.

Why is Credentialing Important for Medical Providers?

The question arises, why is it essential for medical providers? Then the answer is that when a service provider is not credentialed and is not qualified, then the insurance companies will not pay for their services. To receive their service fee, they must have to be verified.
Doctors or any service provider need credentialing to join insurance networks. Without it, they can’t treat patients who have those insurance plans. It also helps patients feel safe, knowing their doctor is fully qualified and approved by law.

How Does the Credentialing Process Work?

The credentialing process involves the following steps. These are given below. 

Step 1: Collect provider documents

First of all, collect the provider documents. These documents may include their personal documents, education documents, license, and training proof. 

Step 2: Create/update CAQH profile

After collecting the documents from a service provider, create their CAQH profile. CAQH (Council for Affordable Quality Health) is an online database of healthcare providers.

Step 3: Apply to insurance companies

After creating a CAQH profile, apply to insurance companies for claims. 

Step 4: Wait for verification and approval

After applying to the insurance company, it’s time to wait for verification and approval.

Step 5: Re-credential every 2–3 years or when info changes

Doctors have to do credentialing again every 2 to 3 years to stay approved. If anything changes, like their license or workplace, they need to update that too.

Common Problems and Delays in Credentialing

Some common mistakes cause problems and delays in credentialing. You should avoid them. These are as follows. 

• When your documents are Incomplete or outdated, they cause delays in credentialing. 
• During your application process, minor mistakes or incorrect data can cause rejection of your credentials.
• Sometimes insurance companies or licensing boards take a long time to check the documents.
•  If you forget to renew your credentialing on time, it can stop you from getting paid.
  

Tips to Make Credentialing Faster and Easier

There are some tips you should follow to make it faster and easier. 

• Save all your necessary documents in one place. You can find them easily whenever you need.
• Start the process early to avoid delays and rejection.
• Get help if you are not sure what to do.

Conclusion

In conclusion, credentialing is the process of checking the qualifications of a service provider.  They need to get paid for their services. If they are not credentialed, they are not able to collect their service fee. It is the first step to getting paid for services. If you are a service provider, you should be credentialed first. For the solution of this problem, MedICD is providing such credentialing services reliably and at affordable costs. Don’t wait more to be credentialed yourself; otherwise, you will be late. 

FAQs

1. What is credentialing in medical billing?

In simple terms, credentialing is the process of checking the qualifications of a doctor or any service provider. After verification, they can work with insurance companies. 

2. Why is credentialing needed for billing?

Credentialling is needed for medical billing because if they are not credentialed, insurance companies will not pay for their services. They consider them illegal. 

3. How long does the credentialing process take?

It usually takes 60 to 90 days. But it can be delayed if anything is missing or incorrect.

4. Can I bill insurance before I’m credentialed?

No. You usually have to wait for full approval before billing. Some payers may allow backdated billing, but most don’t.