Provider Credentialing: The Smarter Way to Get Paid

Provider Credentialing: The Smarter Way to Get Paid

A small medical practice—perhaps one that specializes in podiatry or audiology—is a precious gift to the people who are fortunate to work there. A small practice is more nimble, and the doctors and staff who run it are more in control of their day-to-day life. Reaching the point where such a practice becomes revenue-positive is an exciting milestone and cause for celebration!

A new practice is excited to help new patients, establish itself in the community, and deliver quality care, but they often don’t realize they’re leaving money on the table when it comes to dealing with insurance companies. Even a more established practice may never have created an effective system for credentialing—the process by which providers’ credentials are confirmed and contracts are established with commercial insurance networks.

Out-of-Network Reimbursements

It’s easy to get used to receiving out-of-network reimbursements, especially when the process of enrollment is so labor-intensive. But when a practice enrolls its physicians and other providers in contracts with insurance companies, it brings visibility to the practice while ensuring higher rates of reimbursement at the same time!

Billing out-of-network companies can result in claims never being paid at all. Claims may be denied with a note that the provider was unauthorized to provide one or more services. Your staff may not realize that this authorization was required because the provider giving care was considered out of network.

It is possible for office staff to work to gain authorization for each service provided, but this is time-consuming and fails to address the root issue: the lack of credentialing and contracting. An effective plan for contracting and credentialing will save time per individual patient visits, while also bringing higher reimbursement for the same services.


Once your providers are contracted and credentialed with the appropriate insurance networks, your practice brings in more revenue per visit, and potential patients will see your providers as “in-network,” making them more likely to seek you out in the first place. The value this brings to your practice is hard to overestimate!

But every three to five years, your providers will need to re-credential and your contracts may need to be renegotiated. These will likely not happen at the same time. It happens all the time: a notice comes from the insurance company saying that it’s time to re-credential, it gets put in a stack of papers, lost in the shuffle, and the contract expires. Now an application must be resubmitted for the provider to re-enroll in a plan they were already included in!

Professional Mobility and Credentialing

Providers may move between private practice and larger hospital networks. At a private practice, it is a privilege and a responsibility to negotiate one’s own contracts with insurance payers. However, in a hospital network, the contracts may be negotiated by a delegation that also handles credentialing. If the same provider returns to private practice, they will need to re-enroll themself all over again, contracting and credentialing once more. Failing to do so will result in more rejected claims, or reimbursement at a non-participating rate.

Tedious But Crucially Important

Credentialing and contracting are tedious processes that require a lot of work to accomplish effectively. It’s important to recognize the networks that make the most sense for you to become a part of, and prioritize those. This might depend as much on the community where you reside as the specialty you practice.

It’s also important to close-read your contracts for fine print that makes a big difference in the bottom line. One contract may appear on the surface to provide a higher rate of reimbursement, but after reading the fine print you may discover it actually results in a lower amount over time. Therefore, renegotiating contracts when the opportunity arises is also a crucial part of the process, in order to achieve a more favorable reimbursement as well as other clauses that may streamline your contracting and credentialing.

For a smaller practice, the most effective means of contracting and credentialing is likely to be outsourcing. At Healthcare Revenue Group, we specialize in medical billing services like credentialing and contracting, provided as part of a comprehensive billing services system. We will design and implement software that helps your practice to thrive, while collecting data that allows us to recommend revisions in your revenue cycle management that will ultimately help grow your practice at the pace you set. Contact us today about medical billing services for your private practice!

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