Highlights About Medical Credentialing

The term medical credentialing takes us back to 1000 BC in Ancient Persia.  In Persia, medical credentialing referred to the process of qualifying for medical licensure. Herein, a physician had to treat three patients, and if all three lived, the phyisician could practice medicine for the rest of his life.

While the fundamental idea behind the term medical credentialing — validating and qualifying physicians to be able to securely practice medicine — remains the same today, the process for evaluation has changed dramatically over the millenia. The process today ensures that physicians and other healthcare professionals have received quality training, education, and are approved by state and federal law to practice medicine safely.

The modern practice of medical credentialing

Modern medical credentialing integrates a multitude of data points to ascertain whether or not a physician may enjoy the privilege to treat patients of a particular insurance company. Some key data collected include:

  • Medical career or practice history
  • Qualifications
  • Education
  • Residency
  • Licensing
  • Medical training
  • Specialty courses and certifications
  • NPI registration
  • DEA registration

A medical professional must review and update all dimensions of the medical credentialing process before starting a practice, accept patients belonging to particular insurance companies, or moving and expanding into new locations. Credentialing involves a variety of processes:


Privileging is the process of approving healthcare providers to carry out specific procedures by granting them a set of qualified accesses for the utility of healthcare facilities.

Provider enrollment

Provider enrollment is the process in which a healthcare provider effectively submits the data required by the various commercial and federal payers that the provider chooses to participate with.

Provider credentialing

Provider credentialing is the process of verifying the provider’s training, skills, abilities, experience, qualifications, education, license, etc. so to officially become a participant of a payer, thereby creating a legal contract to be able to treat patients with that payer’s plan.

Medical credentialing, in layman’s term, is a critical process of validating healthare practitioners thoroughly so that they can deliver care to patients and get reimbursement for the care delivered from payers.  Throughout the medical credentialing process, it is the federal government, states, and insurance companies decide if the healthcare practitioners meet their requirements or not.

Advantages of medical credentialing

Medical credentialing has benefits for all the parties involved, whether it be the practitioners, the insurers, or the patients. It develops a mechanism for quality assurance in the medical industry. It also assures the patients that the care they are receiving is delivered by a vetted provider and complies with the standards of the industry. Herein, the process enables patient reassurance, the mitigation of medical errors, and competitive pricing to attempt to optimize cost control.

Medical credentialing- who needs it?

  • Family Physicians
  • Neurologists
  • Orthopedic Surgeons
  • Cardiologists
  • Radiologists
  • Pathologists
  • Chiropractors
  • Dentists
  • Nurse Practitioners
  • Social Workers
  • Physician Assistants
  • Podiatrists
  • Family Therapists
  • Psychologists
  • Optometrists
  • Ophthalmologists
  • Otolayrngologists
  • Pulmonologists
  • Internal Medicine Physicians
  • Emergency Medicine Physicians
  • Dermatologists
  • Gastroenterologists
  • Allergists/Immunologists
  • Physical Therapists
  • Speech Langauge Pathologists
  • Rheumatologists
  • Audiologists
  • Inteventionalists
  • Neurosurgeons
  • And many more types of healthcare practitioners

Some things to know about medical credentialing

Medical credentialing is a wide system associated with a vast array of medical services, healthcare determinants, and quality standards.  For a deeper view of the system, here are the following things you should know about:

Practice restrictions for a healthcare professional during credentialing

It is restricted for a healthcare professional to work if his/her credentialing is on-going. He or she has to wait until the credentialing procedure is completed. This guarantees the highest quality of health services to each patient that they get from each medical professional.

If a practitioner chooses to diagnose the patients before having his/her training, qualifications, and educations examined thoroughly completed, he/she will be at legal risk. In fact, he/she can even get the license permanently revoked. Residents and medical students do not need medical credentialing within their training period, though they must be working completely under the direction of a licensed and credentialed physician.

Duration of the process

The initial enrollment material submission may only take between a few days to one week to complete; however, full process completion may also depend on the sub-processes, the field of practice, availability of the documents, appropriate filling of the documents, etc.  So, it is generally recommended to get the enrollment process done 90 days before your first day at work.

Speeding up the process

The more accurately you fill your application, the faster you will be able to get done with the process. You must also ensure that you submit all the required documents.  You may also consider getting in touch with your verification staff and request verifying that you have no outstanding licenses/permissions pending.  Any pending licenses might delay the credentialing process as well.

Medical facilities’ take on medical credentialing

Medical credentialing does not only ensure quality health services but also enhances a healthcare facility’s revenue cycle management processes to ensure reimbursements from payers occur without denials or retractions. This is why many medical facilities emphasize having a robust medical credentialing service team onboard.  If you are seeking help navigating the medical credentialing process, contact Avosina Medical Technologies today to resolve all your medical credentialing challenges!

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