Credentialing in medical billing is the verification process of a provider’s qualifications with payers before claims submission begins. At the present time, this process is essential for revenue generation and legal compliance in the healthcare space.
What Is Credentialing in Medical Billing?
Credentialing refers to the verification of a provider’s license, education, training, and work history to participate in payer networks. In this situation, credentialing is not just an onboarding step—it’s required to legally bill insurance.
According to the Council for Affordable Quality Healthcare (CAQH), credentialing errors contribute to 20% of claim denials, and delayed credentialing leads to $8,000–$10,000 in monthly revenue loss per provider.
To explore credentialing workflows in-depth, check out our comprehensive credentialing in medical billing guide.
Why Is Credentialing Important for Medical Practices?
Credentialing is important because it connects providers with insurance panels. Without it, reimbursements are delayed or denied. Not only that, but credentialing also ensures the provider’s compliance with payer requirements and supports public trust.
You can also learn how credentialing services help prevent revenue delays in our detailed blog.
What Happens If a Provider Isn’t Credentialed?
Credentialing delays can leave providers legally unable to bill for services rendered. For example, if claims are submitted prior to payer approval, denials are inevitable. As a result, practices may lose thousands in unpaid services.
Moreover, according to CMS guidelines on enrollment, providers must be fully enrolled before claims are processed.
How Long Does Credentialing Take for New Providers?
Credentialing usually takes 60 to 120 days, depending on the payer and location. On average, Medicare credentialing is quicker than commercial plans. To speed up approvals, documents like CAQH profiles must be up-to-date beforehand.
For help navigating payer delays, read our blog on overcoming credentialing challenges in healthcare.
What Are the Top Credentialing Challenges in 2025?
In 2025 still presents common roadblocks, such as:
Payer-specific variations in forms
Long response times from payers
Manual paperwork and lost documents
Inaccurate or expired credential details
All things considered, many practices now outsource credentialing to reduce processing errors and save administrative time.
How Much Revenue Is Lost Due to Credentialing Delays?
Credentialing delays lead to missed claims and revenue loss. According to the American Medical Association (AMA), provider onboarding delays can cost a practice $30,000–$40,000 during the first few months. That is to say, delays in credentialing can make or break a practice’s launch.
Is CAQH Required for Credentialing?
Credentialing often requires a complete CAQH profile. In most cases, commercial payers use CAQH ProView as a central repository for provider data. Accordingly, missing or outdated CAQH profiles can stall the entire credentialing timeline.
What Are the Steps in the Credentialing Process?
Credentialing involves several important steps:
Gather required documents (licenses, NPI, CAQH, etc.)
Choose insurance panels and complete applications
Submit applications and track status
Respond to any follow-up or corrections
Receive payer approval before seeing patients
To get expert assistance, visit our provider credentialing services page.
Can Credentialing Be Outsourced?
It can absolutely be outsourced. In fact, over 50% of independent practices rely on credentialing services to manage applications. These services handle documentation, payer communications, and re-attestation.
How Often Does Re-Credentialing Occur?
Credentialing renewals occur every 24–36 months, depending on the payer. If re-attestation is missed, the provider may be removed from payer panels. Hence, practices must maintain strict credentialing calendars or partner with services that automate alerts.
Does Credentialing Affect Patient Volume?
Yes. it affects patient access, as many only visit providers in-network with their plans. In this case, being credentialed increases the likelihood of appointment bookings and higher retention rates.
Is There a Difference Between Enrollment and Credentialing?
Often confused with enrollment. While credentialing verifies a provider’s qualifications, enrollment officially links that provider to a payer for billing. Both steps must be completed before submitting claims.
Which Payers Require Credentialing?
Credentialing is required by all major payers, including:
Medicare and Medicaid
Blue Cross Blue Shield
Aetna, Cigna, and UnitedHealthcare
TRICARE and state-specific plans
Evidently, missing payer-specific credentialing rules often leads to application rejection or delays.
What Makes Credentialing in 2025 Different?
Credentialing today is more digital than ever. Specifically, e-signatures, centralized credentialing portals, and AI-based verifications are reducing the burden of paperwork.
What Happens During a Credentialing Audit?
Audits in Credentialing may occur if errors or inconsistencies are detected. These audits review submitted credentials, malpractice history, and payer communications.
Should Small Practices Use Credentialing Services?
Credentialing services offer value to small practices that lack dedicated admin teams. In contrast to hiring full-time staff, outsourcing is often more affordable. Most services cost $150–$300 per provider per application, depending on the payer and state.
Conclusion
Credentialing is one of the most critical processes in medical billing that directly affects when—and how—you get paid. With rising patient expectations and payer complexity, having accurate, timely, and ongoing credentialing is no longer optional.
To summarize, whether you’re a new practice or expanding your provider team, outsourcing credentialing ensures a smoother onboarding and billing experience.
Need help getting credentialed? Talk to our team today and avoid reimbursement delays.
