1. Science / Technology

Credentialing in Medical Billing: Everything You Need to Know

Disclaimer: This is a user generated content submitted by a member of the WriteUpCafe Community. The views and writings here reflect that of the author and not of WriteUpCafe. If you have any complaints regarding this post kindly report it to us.


Credentialing in medical billing is mandatory, and insurers require health practitioners. It is so that health providers can serve insurers’ customers after verifying themselves.  

Credentialing in medical billing is the process that all healthcare service providers perform to become enlisted with insurance companies. Only trusted, vetted, and verified insurance companies include healthcare providers to serve their customers.  

Upon successful credentialing in medical billing, the healthcare provider is part of an insurer’s network of hospitals, care providers, health centers, clinics, or medical centers. After successfully applying and receiving the credential as a listed service provider, a healthcare operator can receive reimbursements. The reimbursements are received from the insurer.  

The insurer pays the healthcare operator for the services rendered to their customers by the healthcare operator. The agreement terms between the insurer and healthcare service provider are a contracting or provider credentialing agreement.  

Credentialing in medical billing turnaround times varies because there are several factors involved. Government programs such as Medicare have their provider enrollment, chain, and ownership system (PECOS). The approval of provider enrolment and provider credentialing in medical billing is faster than commercial insurance providers, and Medicare has an average approval time of 41 days. On the other hand, commercial insurance carriers can take anywhere from 60 to 180 days. Therefore, this is a game of waiting, hurrying, and waiting again.  

Insurance companies have varying standards and policies for enlisting healthcare service providers. When the government and international regulatory policy changes come into effect, there could be a modification in the credentialing in medical billing requirements. This could warrant another cycle of credentialing by the healthcare service provider.  

Healthcare service providers are willing to re-credential after initial credentialing in medical billing exercises to access a wider pool of patients. Given the penetration of insurance providers into the market, most people will be covered very shortly under insurance policies. But re-credentialing without using automation can be expensive considering that healthcare service providers already have administrative overheads.  

Some insurance companies treat credentialing quality in medical billing efforts as a precursor to providing contracts. The level of contract, the facilities offered within, and the scope of operational flexibility for the healthcare provider are determined by the process of medical credentialing. Credentialing is an active and trusted source of verification for patients. Many patients do not consult physicians or visit hospitals, not in their insurer’s network.  

Healthcare providers always want to expand their reach and be enlisted by several insurance providers. But meeting the insurers’ rigorous set of rubric requirements can be overwhelming. The amount of paperwork involved in credentialing service is substantial. 

For credentialing in medical billing, healthcare operators sometimes need to work with CAQH solutions and PECOS for this purpose. It could involve some training, and some costs could arise associated with it. Therefore the need of the hour is a credentialing in medical billing solution that provides intelligent healthcare automation. The level of automation applied in the solution can streamline the application process.  

A credentialing in the medical billing system that is agile and adaptable can complete the application process, reduce errors, suggest improvements, and expedite the process. This will allow the healthcare service provider to become a contractor in the quickest time possible. They can start receiving insurance money or benefits for the services rendered to the insurer’s customers.



Welcome to WriteUpCafe Community

Join our community to engage with fellow bloggers and increase the visibility of your blog.
Join WriteUpCafe