Why Medical Credentialing Services are Necessary

Moving upWhat is medical credentialing? Well, medical credentialing is a very important process because it is the process in which the qualifications and experience of doctors and medical practices are validated after evaluation. Usually, the objective evaluation looks at the licensing of the practice, training history, and education. Basically, credentialing is an important part of becoming part of a payor network. Without that medical credentialing, a practice is not able to provide some patients with the care that they need because they may be covered by a specific insurance company.

Without the proper credentialing, an insurance company may choose only to make a partial claim, which means the patient is responsible for any balance that is not paid. This can be a major inconvenience for the patient. But when a physician fulfills a critical payor network requirement, the provider is able to receive better revenue realization. It is a win-win situation for the physician, the insurance company, and the patient.

Payor Enrollment for a Solo or Group Practice

At some point, every practice is a start-up, which means they have to start the medical credentialing process as soon as possible so they are in a good position from the very beginning.

New practice start-up services can include all or some of the following:

•    Fast and accurate completion of all applications for the commercial insurance companies
•    Medicare enrollment for individuals and group practices
•    Medicare EFT enrollment for groups and individuals
•    Weekly or bi-weekly status reports
•    Tracking and confirmation of all insurance contracts, effective dates, and PAR IDs
•    CAQH Credentialing
•    NPI registration – Type 2
•    Prices based on the number of plans and providers
•    Any documents that are requested

The amount of time that this takes can vary on the location of the practice and the plan. However, it can take anywhere from three to four months for the process to be complete. If Medicare needs to backdate, it will only do so for 30 days.

Adding a New Physician to an Existing Practice

There are times when a practice may add a new physician and this means that they will need to have the proper medical credentials in place. The medical credentialing process includes all or part of the following:

•    CAQH Credentialing
•    Weekly or bi-weekly status reports
•    Prices based on number of plans and providers
•    Providing necessary documents
•    Adding the provider to the PECOS system
•    NPI Registration  – Type 1
•    Medicare License Application Processing and Tracking
•    Medicare Enrollment for Individuals & Reassignment to Group
•    Fast and Accurate completion of all applications for the insurance companies

While the process is the same as a start-up in many cases, there are aspects of it that are different and it is a process that has to be carried out carefully.

Maintaining Medical Credentialing

Once medical credentialing is complete, it is important to maintain. A recredentialing service is going to be very useful in this case, just as a medical credentialing service is useful in establishing the credentials in the first place. A recredentialing service is ideal when the practice doesn’t have the expertise or the staff to handle the credentialing aspect of the practice. By selecting a credentialing service that also handles recredentialing, you can ensure that all of your providers are recredentialed the right way and maintained so that you do not have to worry about denied claims. You can also ensure that the payments from providers are received in a timely manner.

If you need help in CAQH credentialing, you can receive the proper assistance there as well. The application can be completed for you after a CAQH ID is acquired, which is an ID that is issued by the participating insurance companies. This ID can usually be acquired in less than one week and the application completed in one month.

When you decide to opt for the help of a medical credentialing service to help you, you are able to focus on the other important operations within your practice rather than the technicalities that can take time away from everything else. That way you have the credentialing you need and you and your patients are not met with any surprises.


Credentialing is something that is necessary to help your bottom line and to also ensure patients get the most out of their insurance companies. For a reliable medical credentialing service, call MD Pro Solutions at 508-946-1665 or fill out our contact form today.