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  • Eva Ahlawat

Demystifying Credentialing: Types, Steps & Benefits in Medical RCM


Medical credentialing process for RCM

In the rapidly changing world of healthcare the RCM has become increasingly important as it stands as the central pillar of any financial system for healthcare providers. Credentialing, a complex and multifaceted process during RCM, that requires checking of qualifications, licensure, and competencies of healthcare professionals is often overlooked. Credentialing is not merely a technicality; it plays a pivotal role in maintaining the integrity of patient safety and financial procedures and serves as the foundation for trust and establishing the market’s credibility within the healthcare ecosystem.


There is no exaggeration about its paramount nature in the RCM. Credentialing achieves this objective by ensuring that healthcare providers meet the necessary levels of qualification and meet the stipulated expectations. These qualified providers make claims processing smooth, eliminate reimbursement delays, as well as reduce the possibility of denied claims – all of which have a significant impact on the revenue cycle. In the same way, credentialing works as a key connection between clinical competence and financial performance underlining its value in revenue cycle.

Medical Credentialing Process: Steps and Best Practices

The medical credentialing process is a comprehensive and stringent MRO (Multi-stakeholder Responsibility) that entails distinct stages and players. It normally starts it all with the verification of necessary documentation which could include professional licenses, board certificates, educational documents, employment history, and liability insurance.


  • Upon data collection's completion, the second step is primary source verification, accomplished by contacting issuing offices to verify the authenticity and value of the submitted information. This step is the vital stage through which the accuracy and authenticity of the credentialing process is assured.

  • The credentialing team or the specified authority then conducts primary source verification on the submitted documentation. Upon completion of this process, the committee or the specified authority reviews the application credentials against the set standards and criteria. Such review will include reference checking from peers and background checks as well as look into any disciplinary actions taken or malpractice claims made against respective dentists.

  • Sustainable approaches to efficient and effective credentialing utilize technology and automation to accelerate processes, adhere to uniform credentialing policies and procedures, and keep the channels of communication open with providers so that the immediate attention can be provided to the discrepancies or concerns.

  • Supervising and granting new credentials after a credential may change on repeated basis is also an imperative procedure in the credentialing process. Periodic re-credentialing ensures that providers remain up to date on terms and conditions set forth by the relevant authorities.

Types of Credentialing in Healthcare

Healthcare sector distinguishes different credentialing as they are related to the specificity of the job, the specialization or the organization’s complexity. Primary source verification is the most extensive form of credentialing because all the credentials are directly verifiable with the original issuing authorities. Although on-site credentialing is the traditional approach where the practitioner's credentials are verified by the healthcare organization, delegated credentialing is a procedure where the credentialing process is delegated to other organizations like health plans or CVOs (Credentialing Verification Organizations).


Credentialing for specialties is another pertinent factor that should not be left without considering because certain specialties might have a set of unique requirements and standards, above the basic, general credentialing criteria. For example, the surgical specialties are going to need more verification of the procedure logs and case volume, but the care providers will be evaluated to ensure that they are proficient in the various fields like preventive care and chronic disease management.

RCM Credentialing Benefits and Significance

Placing the credentialing in a revenue cycle process is a convenient practice that comes along with many benefits. Firstly, a prominent issue to keep in mind is that it assures that healthcare providers not only fulfill the necessary qualifications but also competencies, hence enhancing patient safety and the quality of care that the practitioners provide.


In addition, systematic credentialing facilitates smooth receipt and repayment procedures hence, minimizing the potential and delays due to unfinished or inaccurate information on providers. This effectively helps the organization to increase its financial performance and the revenue collection process improvements.


As outlined in a recent study, parties having strong credentialing mechanisms tended to have 15% lower claim denials and 20% increase in first the time in which a claim is accepted rate. These figures point out the practical economies of credentialing in the form of revenue optimization and management.

Provider Enrollment in Healthcare

Provider enrollment and credentialing processes are inextricably bound together emotionally as these are procedures that involve registering healthcare providers with Medicare, Medicaid, and private insurance companies and other payer organizations. Patient registration stage is particularly important for them to be considered as eligible and for providers to join different healthcare systems.


Credentialing, instead of having to do with checking one’s credentials, becomes a process that verifies their competencies and qualifications. However, enrollment, more centralized around contracts and administration, focuses on the administrative and contractual areas. Nonetheless, the two mechanisms complement each other as most payers, along with the enrollment validation, may need to require credentialing.


The optimization of provider enrollment processes in RCM can be achieved with the application of real-time database maintenance, technology-based data management systems and the development of efficient workflows for provider applications and renewals.

RCM Accreditation in Medical Billing

Medical billing accreditation is a vital tool for the establishment of professional standards and the development of the best community practices across the healthcare industry. The Joint Commission, the American Healthcare Association (AHA), and the Certified Revenue Cycle Professional (CRCP) program are all accreditation bodies that provide uniform professional knowledge and standards for individuals as well as organizations through their certification process.


Using accreditation in conjunction with credentialing in the RCM lends credence and weight to any healthcare institution's reputation. By ensuring that all their certification standards are in line with the accreditation standards, organizations would be able not only to manifest their dedication to quality and compliance but also of becoming an industry leader in this area, with stakeholders' support and trust gaining as a result.

Credentialing and Privileging in Healthcare

Although both terms are frequently used alternately, in the healthcare industry, credentialing and privileging are two separate yet dependent processes. Credentialing was aimed at certifying the qualifications and competencies of healthcare providers, whereas privileging concerns itself with the clinical privileges that individual providers are granted as a result of having satisfied the requirements for the credentials, their scope of practice, and what the organization requires and can handle.


Usually, the screening of provider personal files is an organizational process that includes reviewing a provider's credentials and competencies to check the services or procedures a provider can perform in the healthcare facility.


These processes are continuously investigated and constantly updated to ensure they not only come in line with the current standards and regulations but also the evolving needs of the organization. Healthcare institutions need to set up robust supervising programs for both the endorsement and the permission to provide care so that patients get the best possible care and that it remains safe.

Credentialing Verification in RCM

The foundations of the certification procedure lie in testing – an act of checking whether the candidate’s credentials and qualifications are true. Credential verification is a prerequisite to run an impeccable credentialing process and concurrently hinders the chances of counterfeit, false, incorrect, or misleading information being incorporated.


PSV (primary source verification) is the most efficacious method of credentialing verification that is available, and it is considered as the gold standard too. This can directly be executed by going to the sources of the documents like institutions, boards, and certifying authorities in-charge, to find out the validity of the documents presented.


To achieve precision and verification, healthcare organizations more often used specialized helps like the National Practitioner Data Bank (NPDB), Federation of State Medical Boards (FSMB), and individual state licensing authorities' databases.

Revenue Cycle Management Certification

In the dynamic and constantly transforming environment of the revenue cycle management (RCM), the achievement of professional certifications turns out to be a beneficial exclusive characteristic of healthcare specialists. Certifications go beyond being mere proof of skills and effort, but they show employers a level of competitiveness in the work arena and a qualification for promotions and better opportunities.


Several different healthcare finance and billing organizations provide revenue cycle management certifications, e.g., American Association of Healthcare Administrative Management (AAHAM), Healthcare Financial Management Association (HFMA), and Healthcare Billing and Management Association (HBMA)


Certification has become the norm in many settings and a widely accepted and respected profession. A few of these certifications are the Certified Revenue Cycle Professional (CRCP), Certified Revenue Cycle Specialist (CRCS), and Certified Billing and Coding Specialist (CBCS) which cover various field of revenue cycle management which include medical coding, billing, compliance, and revenue cycle operation.


Getting the revenue cycle management certification has several benefits such as being up to date with the industry's standards and practices, increasing reputation as a professional, and understanding current regulations and latest trends in the industry.

Credentialing Compliance in Medical Billing

Compliance is one of the most important aspects in medical billing as well as in revenue cycle management and credentialing is a key component in that process as it helps organizations follow applicable laws, regulations, and industry standards. Providing inadequate or inaccurate information can lead to unwanted financial consequences, e.g., denying claims, fines, and legal responsibility.


Credentialing requirements for compliance in medical billing can be different as some depend on the specific rules and regulations of a certain payer, state, and healthcare setting. Nevertheless, among these common conditions are maintaining updated professional licenses and board certifications, besides keeping appropriate malpractice insurance.


Strategies in RCM on compliance through credentialing incorporate establishment of credentialing policies and procedures that are compensatory, continuous audits and reviews and timely re-credentialing and renewals. Moreover, through implementing technology solutions and automated systems, compliance steps can be simplified, and incorrect results prevented too.

Credentialing Requirements for Healthcare Providers

All healthcare providers, regardless of whether they are surgical, internal medicine, or specialist doctors, that offer their clinical services in separate locations must fit specific credentialing requirements to ensure safe, quality, and compliant healthcare. The standards mainly refer to the same components of education such as certification, licensure, board certification, and standards of experience.


Educational requirements often start with a minimum degree or certification from a nationally recognized credentialing institution, which can be such as a medical school, nursing program, or allied health program. Licensure is a critical requirement because they are healthcare providers. They must always obtain and regularly renew their licenses issued by the appropriate state or regulatory body.


Certifications of boards (which are usually specific by their nature to a certain medical field) symbolize a prominent level of knowledge and skills in a specific field of medicine. Furthermore, most certifying bodies demand the minimum of years of clinical practice, or the number of cases loaded with procedures and patient encounters

It is noteworthy to highlight that credentialing criteria may differ according to the practitioner group and the healthcare setting or agency. The practice of health care professionals should be to stay up to date and make sure that they follow the rules set by the credentialing mandates during their career.

Wrapping Up:

Credentialing is a multifaceted and centralized process in RCM that governs patient safety, conformity, and continued financial sustainability of healthcare companies. Through credentialing the competence and the qualifications of healthcare providers are proved, therefore the integrity of the health care system is upheld and trust among the associated stakeholders is increased.

Do you want to dive deeper into the intricacies of well-established RCM (Revenue Cycle Management) services that can holistically transform your healthcare firm’s revenue cycle? If you are ready to supercharge your insurance reimbursements and unlock the full potential of your revenue cycle, schedule and connect with our RCM experts at Evolve BPO and change the way your organization reaches new heights of success in healthcare revenue management.

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