Top Myths on Provider Credentialing Decoded

Healthcare professionals spend around $2000 to $5000 to pay for their provider credentialing services every year. However, not all of them are aware of the various complexities of the procedure. Credentialing is a lengthy process that takes at least 120 days to complete. In many cases, where the information is incomplete or incorrect, the method could get delayed further with a range of paperwork traveling to and fro from the provider’s end to the credentialing team.

However, there are various confusions regarding the provider credentialing process. Without proper guidance, providers and new healthcare organizations could suffer from multiple delays. Provider credentialing affects the functioning of the organization. Improper credentials could lead to a severe loss of revenue for the health systems. Experts believe that debunking the myths around the procedure is the only way to move forward.

This article will take you through 5 such myths about the provider credentialing process that go around the American medical industry and will decode them for you. Read on to know more.


Provider credentialing is essential for Traditional Health Insurances.


  • Patients are moving beyond traditional health insurance and choosing platforms to exert more control over their expenditures.
  • Statistics show that health plans offered by traditional health insurance carriers have an increasing out-of-pocket cost for the patients.
  • These high-deductible health plans are not very popular among the patients in the current scenario. They are looking for options where they can have a desired clinical outcome without paying high-end bills.
  • Patients are leaning towards concierge care plans where they have a direct agreement with the provider organizations.
  • These plans are more popular, particularly in the case of group clinics. Therefore you don’t need to have your provider credentialing done necessarily with traditional health insurance panels to move forward.


There are no two ways to get your provider credentialing done if a payer declines your application in the beginning.


  • The truth to this statement is that provider credentialing is a lengthy and cumbersome process. You need to do your best to enroll yourself in an insurance panel of your choice.
  • That being said, there are several instances where providers could get into the panel even after an initial period of rejection.
  • The credentialing team needs to know that they can put their application for appeal and second appeals so that the panel can decide on it later on.
  • The application should also be complete with all required information to make sure that the panelists know how the new member could benefit from their plan.
  • Negotiating terms of the place in the panel is another way providers can get their way into the system. They must prepare themselves with the correct answers for the questions that might be thrown at them.


Credentialing and enrollment processes are not a part of the revenue cycle management of the provider organization.


  • Provider credentialing and enrollment of providers are often not known to be a part of the revenue cycle management.
  • However, with any single mistake in the credentialing information or enrollment procedure, the reimbursement of the providers could take ages to recover.
  • Crucial processes like primary source verification of the provider’s information lead to complete credentialing of the healthcare professional.
  • Insurance panels ask for several pieces of information in their credentialing packet. Without proper documentation of each field, the reimbursement could get stuck.
  • Apart from all these, according to the definition of the revenue cycle from the Healthcare Financial Management Association and Healthcare Information and Management Systems Society, credentialing falls under the scope of the process.


You cannot question or appeal for any point that the surveyor has raised until after the results are out.


  • What most people do not know is that you can appeal your case while your surveyor is still on-site and has raised an issue.
  • To appeal, however, you should know your policies and other important legal terms like the bylaws language and accreditation language well.
  • Experts advise that you should have a legal professional or a manager, physician leader, or Quality VP with you so that they can counter the case with valid points.
  • The idea is to check for any potential area of non-compliance in the system early on in the process so that you do not face any issues with it later on.
  • Make sure that you know when and how to present your case so that the results work in your favor and the issues are resolved before they escalate.


You should perform the provider credentialing process after hiring the healthcare professional.


  • Most provider organizations follow this rule when it comes to the provider credentialing procedure due to the urgency of hiring professionals in the organization.
  • However, preparing for the credentials during or after the onboarding process of a provider into the organization could prove to be highly risky for the inflow of revenue.
  • Experts suggest that the credentialing process should be the first one on the list in an organizational workflow.
  • Any issues in the credentials of the provider, later on, could lead to inconveniencing the patients in many ways.
  • It is advisable to avoid doing double time on credit when you could start with your credentialing procedure with sufficient time in hand.


How to Prepare yourself for Provider Credentialing:


  • The best way to move ahead with the several steps of the provider credentialing procedure is to take professional help.
  • You can get in touch with several leading revenue cycle management companies that provide staff training services for your in-house team to get updated on the various steps of the process.
  • You can also outsource your credentialing work to these companies that have competent teams of expert professionals to handle each step of the way.

We hope this article helped you clarify certain common myths of provider credentialing procedures. What kind of myths around the provider credentialing process have you come across? Let us know in the comment section below. We will get back to you. Subscribe to our blog to know more about healthcare management, current revenue cycle management issues, and healthcare technology. Follow us on Facebook, Instagram, Twitter, and LinkedIn for daily updates on the American medical industry.


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