Medical Billing and Credentialing Services

Touseef Riaz

September 14, 2021

medical billing and credentialing

Credentialing is actually an old process that dates back as far as 1000 BC when the Persians came up with a process to officially license the physicians that time. In order for a physician to earn the right to practice medicine, the person was required to successfully treat at least three heretics. If all three patients survived, the physician was then considered fit to practice medicine for the rest of their lives.

Today, even though the process of medical credentialing has evolved greatly, the basic idea is still the same: to govern physicians by putting standards in place to ensure competency. It has become an important part of becoming a trusted and successful healthcare provider by the numerous insurance vendors out there.

In this article, we dive into the credentialing process to illuminate the confusing areas, the importance it has for your medical practice and why you should opt for U Control Billing for all your medical billing and credentialing services.

What is Medical Credentialing?

Medical credentialing, also known as primary source verification, is a thorough process where an insurance vendor conducts an intensive background check on the physician to verify his/her education, competencies and legal authorization to practice medicine.

Physicians and other healthcare practitioners such as a hospital, counseling offices, chiropractors, Dentist, Physical Therapist, Occupational therapists, optometrist offices, Urgent care, Treatment center, Social worker, etc., who wish to bill an insurance company as an in-network provider must undergo the process of credentialing.

Once a healthcare provider is credentialed by an insurance vendor, they can directly bill that vendor. This means that healthcare providers who want to expand their patient base with specialized insurance plans must first meet the requirements set forth by the respective insurance vendors. After going through the application process, the healthcare provider can start receiving insurance reimbursements directly from the insurance vendor for the services they render to patients.

Information Required for Credentialing

Prerequisite information required to process the application for a healthcare provider varies depending on the insurance vendor, but typically includes the following:

–          NPI number


–          License History

–          DEA license

–          Board certification

–          References

–          Work history

–          Insurance Information

The Process of Credentialing

Credentialing in medical billing is a process that requires the involvement of the insurance vendor, healthcare provider and an organization that helps in the overall process. To start off, the organization provides the credentialing application to the healthcare provider looking to get credentialed. The healthcare provider is responsible for filling in the application and attaching any document requested in the application.

After the provider completes the application, they need to submit it back to the organization which then attaches additional documents and information that may be required such as claims history, primary source verification and background screen results.

Next, the completed application along with the documents is submitted to the insurance company. The insurance company reviews the application to determine if the healthcare provider meets the criteria set forth by the insurance company and then approves for credentialing.

Credentialing a Healthcare Provider with Medicare

Healthcare providers that serve Medicare patients are paid off for their services by Medicare, instead of private insurance payers. Medicare reserves the right to approve healthcare providers, hospitals and agencies to provide high-quality care to patients. The process of credentialing is similar to what we saw above, but the standards may vary depending on the type of services that a provider gives.

Here are the general steps to be considered in-network for Medicare patients:

1)      Obtain a National Provider Identifier (NPI) by applying on the National Plan and Provider Enumeration System Website.

2)      Complete and submit the enrollment application through the Provider Enrollment, Chain and Ownership System (PCOS).

3)      Select a specialty, when applicable.

4)      After submitting the paperwork, the reviewing takes around three months to be either accepted or refused. Once your application is approved, you will be able to bill retroactively for all services provided during the waiting period.

The Significance of Medical Credentialing

Medical credentialing is crucial in determining if a healthcare provider and the support staff are capable and credible in performing their duties when it comes to healthcare. Other benefits of credentialing include:

Establishes your Professionalism

It’s in your best interest to demonstrate your professionalism in a healthcare setting, with irrefutable documentation. Taking the time to fill out the paperwork required to show your credentials is a small price to pay for being able to assure patients of your bona fides.

Instills Confidence in Patients

It is important for your patients to trust you, which plays a big role in the healing process. Also, patients who have more confidence in their doctors are less likely to leave for another healthcare provider. Having a fully credentialed medical staff will make your practice more appealing to patients and encourages a sense of trustworthiness in your services. 

Required for Compensation

You’ll need to be medically credentialed, as this is required for reimbursement from insurance companies. Getting the documentation finished promptly ensures that a new nurse or doctor you’ve hired can actually begin providing services on hiring day.

Why Choose a Credentialing Service?

The process of credentialing in medical billing and medical staff credentialing can be time-consuming and tedious given the sheer number of insurance providers. Outsourcing credentialing to a professional services provider who is knowledgeable in the process can help you a long way. The reasons or advantages of why medical practices should outsource credentialing services are:

Cost Effective

Almost every medical practice has to face budget constraints and is trying to limit administration costs, that is only possible when all processes are streamlined. When it comes to credentialing, outsourcing the process means that there are fewer chances of errors or getting rejected, which means that you can take on more patients and improve your revenues. The medical practice can also save millions of dollars on litigation and malpractice cases, ensuring that all the healthcare providers working in their facility are qualified, and their credentials are verified

Error Free

Many professional credentialing service providers use automated software in credentialing that has a huge plus over traditional manual processes. According to research, it was noted that healthcare centers using software solutions saw a reduction in complaints, complications, and cost. Moreover, outsourcing the process allows healthcare providers to focus on their patients without being biased.

More Efficiency

In many medical practices, the existing process of credentialing incorporates multiple documents, spreadsheets and checklists that the administration uses and updates frequently. By outsourcing the process, it means that there is less paperwork for you, hence improving overall efficiency. 

The Best Billing and Credentialing Services

The increasing challenges in the medical sector as well as the growing number of patients due to the pandemic make it difficult for healthcare providers to get medical credentialing. The solution, therefore, is to seek out a prominent and established medical company such as U Control Billing for your medical billing and credentialing services.

Outsourcing the credentialing process does not mean that the administration is replaced but leaves them more time to focus on other challenges and crucial issues. At U Control Billing, we make sure that the credentialing is done quickly so that doctors and supporting staff can take on more patients and provide them with healthcare.

You May Also Like…


Submit a Comment

Your email address will not be published. Required fields are marked *

Ready To Get Started?

Pin It on Pinterest