Get Live Chat Request a Callback Get live demo

← Back

Key Steps for Successful Provider Credentialing

Reducing Claim Rejections | AdvancedMD

What is provider credentialing?

Provider credentialing is the process of assessing and establishing the provider’s competency and verifying the practitioner’s qualifications to practice medicine. It is a tedious process carried out by insurance companies. They verify the provider’s qualifications to check if they are capable of providing safe and high-quality patient care. Acquiring the necessary information for provider credentialing is a time-consuming process and might take up to three months to complete.

Practitioners working in a given practice might also need to undergo the credentialing process for evaluating the kind of services that they are licensed to provide such as internal medicine, psychiatric treatment, heart surgery, drug prescriptions, and such.

The complex process of provider credentialing takes multiple steps before acquiring complete clarity and is typically done for practices that are seeking affiliations with hospitals or any larger healthcare systems rather than individual practices.

Why is provider credentialing important for practices?

Provider credentialing is a crucial aspect of healthcare practices as it unleashes brand new revenue opportunities. Credentialing process allows the insurance payer to ensure the patients are undergoing treatment with a viable practice provider and allows them to refer new patients for the practice.

Credentialing ensures the safety and well-being of patients, thereby building strong trust between the healthcare provider, insurance companies, and the patients. It helps build a sense of responsibility for the healthcare practices and allows them to align effectively with the standards, avoiding any major errors and shortcomings.

If the credentialing process doesn’t go through properly, the payer will not cover the practice reimbursements for the rendered services. So, it is inevitable for practices to make sure that their credentialing process makes it to the end to ensure accelerated revenue streams.

Credentialing or re-credentialing, the healthcare practice’s income completely depends on it.

How does provider credentialing work?

Credentialing process is carried out either by the internal or external departments following the key steps. Let us look into the three fundamental steps to provider credentialing:

Data Gathering

The first step to provider credentialing involves the collection of all relevant data pertaining to the provider. These details are gathered from multiple sources and include information on the provider’s NPI numbers, license, work history, physician’s educational history, liabilities, board certifications, and state regulatory eligibility.

Data Verification

This is the most time-consuming step in the entire provider credentialing process. Once all the primary details are gathered, they are verified to ensure accuracy and reliability. This involves quite a lot of information exchange between the information sources, the credentialing department, and the provider. This step is carried out to identify any inaccurate or falsified information from the provider’s end.

If any issue is identified during this step, the provider must submit relevant information to rectify the detected matter in question.

Final Step In Credentialing

If all the verified data are found genuine, the credentialing body takes the final decision to grant clinical privileges to the provider. And once the provider is credentialed, they are entitled to practice medicine onsite.

How to improve the credentialing process?

Even after following the three crucial steps for effective credentialing, there might occur inefficiencies and errors, typically because of the lengthy and meticulous processing.  All data provided to the insurance companies must be accurate and any error, even a small number, takes the entire process back to square one.

Digital Systems

The conventional credentialing process takes a very long time which has providers halt their services for an uncertain period. And even after the process is over, they might be restricted from clinical privileges due to some unknown error in the credentialing process. This causes stakeholders to be on the verge of breaking with their cash flows compromised to a larger extent.

Paper-based credentialing is excessive to handle for providers and can take more than four months to complete. It not only affects the revenue streams of the provider’s practice but also slows down their ability to provide complete attention and care to the patients.

Shifting to digital systems will help ease most of the difficulties that a paper-based system possesses. It makes it easier for all parties to gain trust and handle each step with precision.


Practices or credentialing departments can leverage the efficiency of credentialing software to attain complete automation of the credentialing process. This way, the data gathering and verification procedures will take place much more quickly and accurately.


Outsourcing credentialing services will take a big load off the practices and allows them to save costs and time. It also brings out the best hands, capable of doing the credentialing process with absolute efficacy.

Cloud technology for remote credentialing

Incorporating cloud solutions for credentialing will allow all parties to exchange data within themselves, from anywhere, and from any device. Cloud technology is a proven platform that ensures complete security of the data. When all the processes go online with outright security, one can do the credentialing process at their convenience, remotely and securely.


The most important aspect of credentialing is consistency. Even after the first credentialing process lands you with successful revenue, practices must consider re-credentialing to make sure of their ongoing competency and relevancy at the time. The performance data is obtained at regular intervals post the first credentialing process. This way the practice performances are made clear to the credentialing body in an updated format which makes the re-credentialing process much easier and quicker.

Practices must make sure that they are applying cutting-edge technology and delivering the best patient care to attain successful re-credentialing.

Final Thoughts

Every healthcare organization must strive to uplift its credentialing process. Their focus must be on patients and the quality of services that are rendered to them. These expectations cannot be fulfilled if the practice manpower is completely focused on credentialing. And therefore, external credentialing bodies can be utilized for obtaining the desired results.

Credentialing, even after leveraging the best technology and solutions, must undergo stringent verification that only manual involvement can satisfy. So, ensuring the right manpower is unavoidable.

Practolytics logo
Practolytics partnered with AdvancedMD in 2013 to create a one-stop solution for all the medical billing, practice management, patient management, and revenue cycle management activities a healthcare practice need to carry out. A Platinum partner amongst 850+ billing companies, Practolytics is a 20+ year-old healthcare technology and revenue cycle management services company providing medical billing service solutions to 180+ practices of all sizes spreading across 31 states and serving more than 28 critical specialties. Practolytics with support from AdvancedMD billing software processes more than 2.5M claims annually, collecting more than $500M for its clients. End-to-end services include medical billing, medical coding, chart audit, credentialing, eligibility, benefits verification, and preauthorization services. The company’s diverse background in every aspect of healthcare allows it to maximize revenue and consistently deliver optimum results.


Other Resources Related to This Topic

No results found

“The money I have invested in AdvancedMD is miniscule compared to the return. I have never been more efficient – ever – in my professional life as I am now.”

Jed Shay, MD
The Pain Care Center

Read the story  ›

“[Our] patients are very well-educated and well-informed, and they want to see results quickly. The practice has to run extremely efficiently and be accessible to them. The nice thing about [AdvancedMD] is it has allowed me to be more efficient both in and out of the office. Now I don’t have to come back into the office, which is great for my family and everything else. It saves me a lot of time – probably an hour a day on the three days I work in the second office.”

Keith Berkowitz, MD
Center for Balanced Health

Read the story  ›
Estaban Lavato, MD - La Loma Medical Center

“The best thing I ever did in private practice was getting AdvancedMD—it has liberated me.”

Estaban Lavato, MD
La Loma Medical Center

“Having integrated practice management and EHR is absolutely wonderful, you don’t have to flip back and forth between systems—all of your information is at hand when needed.”

Raju Raval, MD

Read the story  ›