Intro to Medical Credentialing: What New Practices Should Know

Launching a new medical practice is exciting—but before you can start seeing patients and submitting claims, there’s one essential process that must be completed: medical credentialing.

Medical credentialing verifies a provider’s education, training, work history, and professional standing. It’s the formal process payers and hospitals use to determine whether a provider meets their standards for care and compliance. And credentialing isn’t optional. It’s a legal and financial necessity. Without it, your practice can’t bill insurance companies or legally operate under many payer contracts.

Whether you’re a physician opening your own practice, or a practice manager supporting a new multi-specialty group, understanding the credentialing process is needed for a smooth launch.

The Three Phases of Credentialing

1. Credentialing

This initial step for medical credentialing involves collecting, verifying, and validating a provider’s background information. You’ll submit:

• Medical school diplomas and training certificates
• Residency/fellowship details
• Licensure and DEA documentation
• Work history and references
• Malpractice insurance certificates
• Board certifications (if applicable)

This data is typically submitted through paper forms, a credentialing software system, or a platform like CAQH ProView, which allows providers to securely upload and manage their information for most major payers​.

2. Privileging

This phase is specific to hospitals and institutions. Privileging is the process of determining what specific procedures or treatments a physician is allowed to perform. It is based on their specialty, training, and demonstrated competency. In smaller outpatient practices, privileging is less formal but still important for internal protocols and EHR configuration.

3. Payer Enrollment

Once credentialing is complete, providers must enroll with insurance companies, including Medicare, Medicaid, and commercial payers. Enrollment connects your credentials with specific payer systems, enabling claim submission and reimbursement. No enrollment means no payment.

Why Medical Credentialing Matters for New Practices

For new practices, the importance of credentialing cannot be overstated. Without it, even the most skilled and well-equipped physicians are unable to bill insurers or legally treat insured patients. The implications stretch across compliance, revenue, and even brand reputation.

Credentialing ensures legal and regulatory compliance, acting as a safeguard against fraud and malpractice. It also lets patients and peers know a provider is thoroughly vetted and trustworthy. More tangibly, it enables the newly launched practice to join insurance panels, making services accessible to a broader patient population and supporting financial viability.

In short, medical credentialing is the infrastructure that bolsters every other aspect of your operations. Skipping or delaying it will cost your practice valuable time, money, and credibility.

How Long Does Credentialing Take?

The credentialing timeline is one of the most misunderstood parts of the process. Many new providers assume it can be completed in a matter of weeks, but the reality is that full credentialing and enrollment can take three to six months—sometimes longer, depending on payer responsiveness and documentation accuracy.

This timeline isn’t arbitrary. Each payer has its own procedures and verification checkpoints. Applications are often delayed by missing information, outdated documents, or simple clerical errors. In some cases, backlogs at insurance companies can further stretch the wait. It’s critical to use great care when submitting documentation, or seek the support of medical credentialing services to avoid delays due to errors.

Industry experts, including the American Medical Association, recommend starting the process at least 180 days before your practice opens. The earlier you begin gathering documentation and initiating contact with payers, the better positioned you’ll be to launch without disruption.

Discover how WRS Health medical credentialing services can help your new practice launch on time.

CAQH ProView: A Helpful Credentialing Tool

Although not legally required, CAQH ProView has become an industry standard for provider credentialing. Created by the Coalition for Affordable Quality Healthcare, the system is accepted by most commercial insurance payers and streamlines the submission of your credentials.

Using CAQH, providers can create a centralized profile that houses all necessary documents and demographic information. The initial setup takes a couple hours, and once complete it becomes significantly easier to share your information with multiple payers.

You will need to re-attest that your profile is current every 90 days, but this requirement is simple and quick. Keeping your CAQH profile updated ensures continuous eligibility and can reduce the risk of processing delays with insurers. For busy practices managing multiple providers, this centralized approach is a game changer.

Credentialing vs. Contracting: Know the Difference

New practice owners often confuse credentialing with contracting, assuming they’re interchangeable. While they’re closely linked, they serve different purposes in your payer relationships.

Credentialing is the process of verifying your qualifications and assessing your capacity to deliver care. It’s rooted in confirming clinical and professional standing.

Contracting, on the other hand, happens once credentialing is approved. This is the stage where providers enter into legal agreements with payers that define reimbursement rates, claim submission procedures, and practitioner obligations.

Some payers handle both processes together, while others insist on completing credentialing before initiating a contract. Understanding how each insurer operates—and managing those timelines accordingly—is key to avoiding delays in billing and reimbursement.

The Benefits of Using Medical Credentialing Services?

As you weigh how to approach credentialing, one important decision is whether to handle it in-house or outsource the process to a professional medical credentialing service.

Managing credentialing internally can be cost-effective, especially for small practices with minimal payer enrollment needs. However, it demands significant time and attention to detail—often upwards of 20–30 hours per provider across multiple applications with continued demands for maintenance. The risk of error or incomplete documentation is high, particularly if the staff managing the process has other operational duties.

Credentialing services, on the other hand, are designed to make the process faster, cleaner, and less stressful. These professionals are familiar with payer nuances, submission preferences, and common pitfalls. They monitor the status of each application, follow up with insurers, and ensure deadlines are met. While there’s a fee involved, the value of avoiding costly delays and denied claims is considerable—especially in the critical early months of a new practice.

Best Practices for Credentialing Success

Whether you choose to handle credentialing yourself or outsource it, a few best practices can dramatically improve your success rate and turnaround time.

Begin by gathering all required documentation early in the process. This includes medical school diplomas, license numbers, board certifications, CVs, malpractice insurance details, and employment histories. Having digital copies of each item, saved securely in an accessible folder, will streamline the application process for each provider and payer.

Maintaining an up-to-date CAQH profile is also vital. Treat it as a living document that needs quarterly attention, even if no major changes have occurred. Insurers rely on CAQH for the latest version of your credentials, and failing to update your profile can lead to application rejections or billing suspensions.

Another smart strategy is to create a tracking system for each payer application. Credentialing timelines vary widely, and it’s easy to lose track of where things stand. A simple spreadsheet or practice management software module can help you monitor submission dates, required forms, and next follow-up steps.

Finally, be proactive. Insurers may not notify you if something is missing or delayed. Regular follow-up calls or emails—every two to three weeks—help ensure your application isn’t buried in someone’s inbox.

Re-Credentialing and Ongoing Maintenance

One of the most misunderstood aspects of credentialing is that it’s not a one-time task. Credentialing is continuous. Most insurance companies require re-credentialing every two to three years to verify that providers remain in good standing. Hospitals and health systems may have even shorter review cycles.

Failing to complete re-credentialing on time can result in loss of privileges or payer contracts, interrupting your ability to bill and get paid. That’s why ongoing monitoring of license renewals, CME credits, and insurance attestations is critical.

If you’re using medical credentialing services, many offer maintenance plans that alert you to approaching deadlines and manage re-submissions. If you’re handling it yourself, set calendar reminders and designate a staff member to oversee ongoing updates.

Launching Your Practice With Confidence

Medical credentialing may not be the most glamorous part of opening a new practice, but it is one of the most essential. Done well, it lays the groundwork for financial stability, regulatory compliance, and patient trust. Done poorly—or neglected altogether—it becomes a roadblock that can stall your operations and jeopardize your reputation.

As you prepare to launch, treat credentialing with the same level of diligence and professionalism as your clinical setup. Start early, stay organized, and don’t hesitate to seek out credentialing support if needed.

Whether you’re a solo provider or managing a multi-physician group, credentialing is the key that unlocks your ability to serve patients and get paid for your care.