Credentialing Corner

Navigating the Complexities of Medical Credentialing Services Tips for Success

Medical credentialing is a critical step in the healthcare business for ensuring that healthcare personnel are certified and competent to treat patients. Medical credentialing services assist healthcare organizations and clinicians in maintaining standards of care and reducing the danger of malpractice litigation. This article will discuss a collection of best practices for credentialing in healthcare provided below.

12 Tips for Effective Medical Credentialing

12 Tips for Effective Medical Credentialing

1. Begin The Licensing Process

Once you choose to practice in your field, beginning with the licensing procedure as soon as possible is vital. For new practitioners, it is crucial to begin the credentialing process for a quick transition from academia to practice. Different licensing procedures apply to various practitioners, and every practitioner might take a varied amount of time. For instance, PAs (Physician’s Assistants) must be certified by the National Commission on Certification of Physician’s Assistants. Moreover, this certification procedure may include numerous phases, such as proving citizenship and schooling, and may need peer references.

2. Track Credentialing Applications

Maintain a record of Credentialing Applications. Once a credentialing application is filed to an insurance company or organization, keep track of its progress. Feel free to contact an insurance company to inquire about the status of an application. It is very unusual for payers to hold aside applications that need more information and then fail to notify providers promptly.

3. Subcontract Medical Credentialing Services

Medical credentialing is a very long process that requires a lot of expertise. Furthermore, even errors in the procedure lead to aggravating problems later on. Working with the providers may be one of the most excellent credentialing ideas you can use. A medical credentialing specialist evaluates credentials inside the organization and ensures everything is documented correctly when you outsource provider credentialing to a firm like PrognoCIS.

4. Be Aware Of Your State’s Regulations

Credentialing requirements for medical practitioners vary by state. This becomes significantly important when an organization hires providers who travel from one region to another to provide healthcare services. In these cases, when the medical credentials for the providing state are not being updated or taken casually, this might cause issues when claims are made to receive reimbursements for services rendered by the providers.

5. Keep All Physician Contact Information Up to Date 

Something as simple as a wrong address for a provider or peer reference can cause problems with medical credentialing. Therefore, ensure all contact information for physicians or other providers is updated periodically. If clear lines of communication are not available for any given provider, this can slow down processes when a provider’s credentials are up for question by a payer.

6. Avoid Making Common Mistakes

Avoid Making Common Mistakes

The best practice of medical credentialing suggestion is to be aware of common mistakes, as easy as they may appear. The most common mistakes may delay or interrupt the credentialing procedure when done to a provider. According to Physician’s Practise, up to 85% of applications used for credentialing need more critical information than the payer needs to execute the credentialing application. The requirements may include things like:

  • Gaps in the history of practice that need to be filled
  • Inadequate reporting of any history in the clinical field
  • Typos or errors in data input

7. Get a Special DEA Number

It is required for doctors to get DEA (Drug Enforcement Administration) numbers before writing prescriptions. Providers usually need a number for each state where they want to offer services, but specifications might change. After applying through the DEA website, it may take several weeks for it to be completed.

8. Follow Development with Cutting-Edge Monitoring Software

Licenses, serial numbers, and forms of identification with expiration dates may be present in a provider’s credential file. There may be issues with credentialing if these documents expire unexpectedly. Apart from that, the organization should keep track of each supplier’s credentials’ expiration dates. This guarantees that outdated papers are updated without causing any delays and in a timely way.

9. Obtain an NPI Number

Care providers are issued National Provider Identifiers (NPIs), but it is necessary for a healthcare provider to keep NPI information current. If any healthcare provider or member of the clinic/hospital does not have an NPI or the information they provided falls out incorrect, payers will likely deny the claim. As a result, if the status of a practitioner changes, the National Plan and Provider Enumeration System (NPPES) must be updated via the NPPES website.

10.  Maintain Digital Files

Although maintaining at least one digital file where all credentialing papers can be saved is essential, maintaining hard copies of credentialing files is also crucial. Remember this medical credentialing best practice, as it might help you save a lot of time in the future. You will have a single, easily accessible file where everything is digitally accessible when a payer wants credentials. Include all documentation required to verify identification or experience, such as diplomas, state licenses, DEA paperwork, passports, and driver’s licenses.

11. Logs of the Request Process and Clinical History

A frequent need for demonstrating healthcare employment history is clinical history. Request the records of the procedure and save them on file to explain any provider’s clinical history. Usually, the department in charge of paying for a provider’s services can provide an activity log that can be utilized to record the clinical history.

12. Review Negligence Claims

In addition to credentialing information, a thorough record of prior claims, insurer data, and malpractice insurance policy numbers should be kept on file. Ensure that any new suppliers have an insurance certificate on file as well.

Trust a Medical Credentialing Specialist to Help 

Trust a Medical Credentialing Specialist to Help 

The credentialing procedure is challenging to manage and takes a lot of time, even with best practices for medical credentialing. The process is made more efficient by bringing in a specialist with knowledge in credentialing.


Medical credentialing services are crucial to ensure that healthcare practitioners are certified and able to treat patients. Healthcare organizations may preserve patient safety, boost income, lower the danger of malpractice claims, and improve their reputation by checking and assessing the qualifications of practitioners.