Credentialing Issues In Healthcare

5 Critical Credentialing Issues In Healthcare

With so much competition in almost all industries worldwide, every industry nowadays will face high demands and challenges. This is especially seen In the healthcare sector. Maintaining high standards is crucial to ensure that the best medical care is provided to their patients. 

In this article, we are going to discuss about credentialing issues in healthcare. So, keep reading carefully.

Credentialing is followed by medical practitioners to lower medical errors. Successful credentialing includes a detailed view of the practitioner’s qualifications, experience, and others. In the case of patients, credentialing gives them ease that they are being cared for by professionals. Ensuring that the staff hired will avoid the risk of lawsuits and other problems. A successful credentialing process is also equally important for insurance companies, as it allows them to have competent providers, which helps in reducing the cost of treatment and maintaining quality. 

Doctors, nurses, and other medical practitioners need to get credentialed. It’s just about getting credentialed, you need to know the process properly as well, so there are minimum mistakes done. Here are some of the common mistakes you need to take care of.

How Credentialing Works

Before we jump on to the errors, let’s first look at how this process works. To start, you are required to start filling out the credentialing forms and applications, which also requires you to gather all the necessary paperwork and documents. Then there is a long wait for verifications and clarifications, and if required additional documents are also provided. If everything goes smoothly, you get enrolled and can update the billing process with the insurance provider.

This whole process is no easy task! There is a lot of paperwork involved that needs to be completed with the highest possible accuracy. Then come the legal implications and deadlines, all of this combined takes a lot of time and if not done properly, it can cost the company a lot of money.

So, by these credentialing issues in healthcare can lead to disappointments.

Mistakes While Credentialing

As mentioned above credentialing is a task that requires a lot of time and is very complex. So there is a lot of room for errors to take place, which results in big financial losses. Mistakes in this process put the entire enrolment process at risk, and in some cases, there could be legal complications as well. 

Time And Planning

The credentialing process involves several verification processes. For the whole process to be completed it normally takes around 3-4 months, depending on the scenario. There is also the collection of related documents for the application which only increases the time. It is seen in many cases that the staff fail to plan for this time. The health care provider doesn’t know what to do when their application is pending.

Professionals have to wait further to start consulting the patients and render their services, due to which the valuable time of the doctor is wasted. Another issue is that unless the new practitioner is credentialed and enrolled, the insurance companies cannot repay the bills from their services, causing a serious loss for the hospitals. Improper planning required for processing the application is a common issue we see today.

This is also one in credentialing issues in healthcare.

Mistakes In Data Entry

When the credentialing application lacks accuracy, it’s probably because of data entry errors such as:

  • Typo errors-This is when wrong or changed information is entered which leads to confusion. It is important to double-check the data entered. Failing to do so increases the chances of misspelled titles, wrong email addresses, errors in license numbers, etc.
  • Missing information-Absence of data or, even worse, omitting a required document completely due to mix-ups is one of the most common credentialing mistakes that need to be avoided while putting together the documents.
  • Improper documentation-Poor organization of documents, leads to issues like ambiguity and confusion during the application process, often leading to resubmission.

Errors During The Application Process

  • Incomplete application-If an application includes any part of it that is blank or relevant documents are not attached, it is deemed incomplete. Making it crucial to have the documents that show the career history of the medical provider, from the date he/she got licensed to the date of verification.
  • Improper authorization-In some cases, applications lack the required signatures from the individuals involved, which is considered as a great credentialing mistake leading to rejection.
  • Delays-Delays while handling queries is another situation where the credentialing process gets stuck. Most of the time this goes unanswered and is often ignored by the clinic staff during a busy schedule.

These errors are also lead to credentialing issues in healthcare.


  • Ignorance of the staff- When staff members are assigned to do credentialing work, in many cases it is seen that the ignorance on their part regarding the demands of the insurance provider messes up everything. 
  • Not confirming the standard regulations in practice-All insurance companies have different criteria that need to be met regarding their credentialing process. Not being compliant delays the process.
  • Not knowing the specifics of the specialty being practiced-Lack of experience in credentialing is also another issue leading to errors. Specific documents are needed to prove competency at the time of the credentialing process.
  • Lack of awareness of legal implications-The clinical staff in charge of doing the credentialing work may not be completely clear about the implications of the application. The lack of awareness of legal jargon is understandable but can lead to legal problems.

Mistakes During Enrollment

The enrolment process is related to billing so any errors in this area cause disturbance in the revenues.  

  • The application process does not meet the insurance provider criteria-Every insurance company has a different set of rules and regulations when enrolling a new provider. Not meeting the provider criteria is quite common.
  • No clarification from the companies-Insurance companies come up with multiple queries and clarifications. If the staff is not assigned the right roles, the payment process gets delayed.

Why Not Outsource?

Looking at all the possible credentialing mistakes mentioned above, the credentialing process done internally may not be a great idea. Credentialing takes away precious time from the staff, which instead can be used for patient care. Credentialing instead increases the burden on the staff by handling huge piles of paperwork. 

To overcome on all credentialing issues in healthcare, you should outsource.

So why not try outsourcing? Outsourcing to the process is great just for two reasons, time and money. These organizations have talented people who are experienced in the process of credentialing.

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