Every day a provider spends sitting idle awaiting the “seal of approval” from a payer equates to days of lost revenue for your practice. In the world of revenue cycle management within the complex healthcare arena, the timeline of the credentialing timeframe is no small task—it represents your cash flow pipeline. Tired of always hearing “it is still in the works”? You need to know how to work the system in order to make the difference.
Credentialing is the stringent evaluation of a provider’s credentials, which include education, training, licensing, and practice experience. This is known as the “due diligence” exercise that payers undertake to reduce their risks and safeguard patients.
The reason why the process takes so long is that PSV is a requirement. Payers don’t simply rely on the CV; they verify it with educational institutions, residencies, and boards. The NCQA stipulates that primary source verification be used for credentialing purposes. Since this involves a wait-and-response mechanism with third parties, it usually causes delays.
Typically, the credentialing timeframe takes anywhere from 90 to 120 days. But this period may vary depending on the efficiency of the payer’s process as well as past experiences between the payer and provider. Knowing the steps can help prepare you for the process.
Within the first 30 days, the payor obtains the application and initiates PSV. This process involves verifying your DEA registration, malpractice insurance, and employment history. In case the university registrar is on vacation or your former employer takes too long to reply, this process stops right away.
After verification of the information, it moves on to be evaluated by the credentialing committee. The Credentialing Committee usually convenes only once in a month. Missing even just one day from submitting means that you automatically extend your credentialing timelines by 30 days.
Approval does not necessarily imply that you have permission to bill for the service. The insurance company is responsible for “loading” the healthcare provider in their claims management system. This process will take around 15-30 days after approval.
Pro Tip: It should be noted that this process demands constant attention. Organizations such as P3Care credentialing services help fill this void through direct communication between the practice and payer committee representatives.
The journey to success is not always a smooth road. There are many factors that may be accelerating or slowing you down.
The General Practitioners’ journey towards credentialing is relatively easier than that of a neurosurgeon or a mental behaviorist. The specializations that necessitate hospital privileges and/or specialized board certifications will take more time to be processed because they entail PSV.
“Clean Claims” can also be applied to credentialing. If there is just one date missing from a 10-year employment history, or if the malpractice COI has expired, then it will result in an RFI (Request for Information), and that restarts the clock inside the payer’s office again.
Large payers such as Blue Cross Blue Shield and Aetna process thousands of applications at one time. There is often an influx at certain times of year, such as July, when students from new areas graduate. Additionally, some payers have “closed panels.”
Even though they are sometimes used synonymously, they are two different processes:
| Process | Entity | Typical Duration |
| Credentialing | Insurance Payers | 90–150 Days |
| Privileging | Hospitals/ASCs | 30–90 Days |
| Enrollment | Medicare/Medicaid | 60–120 Days |
Credentialing delays can be considered “silent killers” of practice profits. Should a physician earn $2,000 a day in charges, a delay of just two months costs the practice $120,000 in gross revenue. However, considering that you still have to pay the physician’s salary during the “waiting period,” the financial losses are greater. For instance, a practice in Florida has been noted to report a loss of $400,000 in revenues because of a five-month delay in the credentialing process for two physicians.
Struggling with follow-ups? P3Care’s credentialing services automate the follow-up cycle, providing real-time updates so your administration can focus on patient care rather than hold music.
The Council for Affordable Quality Healthcare (CAQH) serves as an information repository for providers. You need not submit 20 forms via paper to 20 payers; you simply upload one single form to the CAQH ProView portal. All major payers extract their information from this portal, resulting in a substantial reduction in the manual data input process during the credentialing timelines.
In-house management calls for the need of having an in-house specialist working on credentialing full-time and having intimate knowledge about the ever-changing criteria set by each and every major insurer. In case your office manager has other duties such as managing credentialing along with billing, scheduling, and patient care, it is natural that your credentialing timeframe will be delayed because in-house staff do not have access to specialized software and contacts that can help in overcoming any bureaucratic issues.
In case you outsource your credentialing process to an experienced medical billing company like P3Care, there is bound to be a marked improvement in the credentialing process because P3Care has built up contacts with payers and has an automated process of tracking applications for timely submission of responses. While your in-house staff checks for updates every few weeks, a dedicated team will check on the application process on a daily basis with weekly follow-ups.
Example: By outsourcing the credentialing process to an agency like P3Care, practices have reduced the credentialing time period by up to 25-30%.
Understanding how long credentialing takes serves as the foundation for your practice’s financial stability. Knowing the timeline of the credentialing timeframe and adopting an active attitude when it comes to documenting everything ensures that your healthcare providers concentrate on taking care of their patients without worrying about any bureaucratic issues.
Do not let simple delays in completing unnecessary documentation hinder the performance of your practice by keeping it in losses. By choosing to cooperate with the professionals at P3Care, the complicated process will turn into a quick way to get enrolled.
A standard timeline usually spans between 90 and 120 days after the application has been filed.
Yes, but technically not until the file is fully loaded; it needs to be treated as an out-of-network practice.
The Medicare (PECOS) process is typically quicker, generally within 60-90 days, but only if the application is completely correct.
Most common among the causes of delays is the presence of incomplete or erroneous information on the employment record or expired support documentation.
Your CAQH attestation needs to be re-attested every 90 days to maintain an active profile for payer access.
