Group Practice Credentialing & Enrollment Services: How to Get Paid Faster

Running a successful group practice requires efficient medical credentialing services to meet payer requirements and ensure timely reimbursements. The physician credentialing process can be complex, delaying insurance network enrollment and impacting revenue. Without proper healthcare provider credentialing, practices risk denied claims and lost income. Delays of 60–120 days can cost providers up to $1.2 million, while in-house credentialing costs $2,000–$3,000 per provider annually. Outsourcing reduces costs to $100–$200 per month, improving approval rates and minimizing administrative burdens. 

This guide explores how to get credentialed with insurance companies efficiently and why outsourcing is the best choice.

Understanding credentialing for group practice:  

Are you running a group practice? And you want to get credentialed? You are on the right page, we are here to give tips that can make the process more easier for you. Credentialing is crucial for your practice as it significantly impacts the financial well-being of your practice. 

Credentialing verifies healthcare providers’ qualifications to ensure they meet insurance requirements. It’s a crucial step for insurance-based practices, enabling providers to accept insurance and grow their patient base.

Why Medical Credentialing is Crucial for a Successful Practice

Medical credentialing is the backbone of a thriving healthcare practice, ensuring providers meet industry standards and insurance requirements. Without proper credentialing, practices face denied claims, delayed payments, and potential legal issues. On average, nearly 20% of all claims are denied, with some payers exhibiting denial rates as high as 80%. Additionally, as many as 60% of denied claims are never resubmitted, leading to significant revenue losses

Good credentialing for group practices the process not only helps providers gain insurance network access but also builds trust with patients and ensures compliance with state and federal regulations. By improving the process of group practice credentialing through automation or expert services, you can grow your practice and reduce the administrative burdens, improve the cash flow and focus on delivering quality patient care. 

How to Credential a Group Practice: A Step-by-Step Guide

Group practice Credentialing involves multiple steps to ensure providers can accept insurance and receive timely reimbursements. Here’s a simplified process:

• Complete the Provider Onboarding Form: Each payer has its requirements. Ensure all details, like Tax ID and NPI numbers, match billing records.

• Submit Required Documents: This includes W-9 forms, provider licenses, malpractice insurance, and a Provider Roster.

• Update CAQH Profiles: Keep provider profiles current to avoid delays.

• Stay Organized: Track applications and follow up regularly.

• Consider Individual Credentialing: Some providers may need separate credentialing for flexibility across practices.

Best Practices for Insurance Credentialing in Group Practices

Credentialing is a crucial step for group practices to become in-network with insurance companies and ensure smooth reimbursement. Here’s how to navigate the process effectively:

1. Ensure Complete and Updated Documentation

Any missing information can lead to credentialing delays. It is very essential to ensure that all the necessary documents including your CAQH profile, NPI, state licenses, board certifications, malpractice insurance and training certificates are updated.

2. Maintain and Re-Attest CAQH Profiles

Most of the insurers rely on the CAQH database for credentialing. Every healthcare provider must re-attest their CAQH profile every 90 days so they can keep their information valid. Failure to do this might also lead to claim denials and processing delays.

3. Track Applications and Follow Up Regularly

Credentialing applications can take anywhere from 60 to 120 days for approval. However, delays are common due to administrative errors, missing documents, or high payer workload. To prevent unnecessary setbacks:

• Keep a record of submitted applications, including submission dates and reference numbers.
• Regularly follow up with payers to confirm progress.
• Maintain copies of all submitted paperwork to quickly address any requests for additional information.

4. Submit Participation Requests Early

While waiting for Insurance Credentialing approval, submit participation requests to insurance networks. Some payers allow conditional participation, which enables providers to start seeing patients while their applications are being processed. This can help reduce revenue loss due to long credentialing wait times.

5. Understand Group vs. Individual Credentialing

In a group practice, credentialing for insurance can be done at two levels:

• Group Credentialing: The practice itself is credentialed as an entity, and individual providers are added as rendering providers. This approach ensures the continuity of contracts even if a provider leaves.
• Individual Credentialing: Each provider is credentialed separately, which is useful if they work across multiple practices or need personal network access.

6. Keep an Eye on Insurance Contracting Changes

Insurance companies often update their credentialing policies and provider participation criteria. Regularly review payer guidelines to ensure compliance and avoid disruptions in reimbursement.

7. Consider Outsourcing Credentialing

Handling credentialing in-house can be time-consuming and error-prone. Outsourcing to a credentialing specialist like HealthQuest can:

• Reduce administrative burden.
• Minimize errors and delays.
• Speed up approval by ensuring proper documentation and follow-ups.
• Allow providers to focus on patient care instead of paperwork.

Understanding Individual vs. Group Credentialing

Credentialing is a crucial process that determines how healthcare providers are enrolled with insurance payers. Practices can choose between individual credentialing or group credentialing, depending on their structure and needs.

Individual Credentialing

• Each provider is credentialed separately, maintaining their enrollment and billing under their Tax ID.
• This option is ideal for providers who work at multiple locations or may switch practices frequently.
• Offers flexibility but requires separate applications and maintenance for each provider, leading to higher administrative work.

Group Credentialing

• The practice itself is credentialed as an entity, and individual providers are added under the group’s Tax ID.
• Enrollment remains intact even if providers leave, reducing the need for re-credentialing each time a provider joins or exits.
• Best suited for stable, long-term group practices, as it simplifies the credentialing and billing process.

Common Challenges in Credentialing For Group Practice:

 

Credentialing a group practice involves dealing with several challenges that can impact efficiency and revenue. Key issues include:

Time-Consuming Procedures: 

Credentialing for group practice can take between 90 to 120 days for application review and sometimes extends to six months when multiple stakeholders are involved. This timeline can prevent healthcare providers from starting a practice or taking on new patients while delaying reimbursements. 

Complex Compliance Requirements: 

Taking into account various regulations and compliance standards across different states can be very challenging. It becomes very crucial for healthcare administrators to stay informed about the changing requirements. This complexity can result in misunderstandings and errors that complicate the credentialing process.

 

Administrative Burdens: 

Excessive paperwork and documentation management are significant hurdles for healthcare organizations. Credentialing teams typically spend about 21% of their working hours verifying details, which leads to inefficiencies. This adds stress to already stretched resources, especially for smaller practices lacking dedicated credentialing staff. ​

Data Accuracy and Integrity: 

Maintaining accurate and up-to-date credentials is essential, yet challenging. A significant 85% of credentialing approval requests include outdated, incorrect, or missing information. Ignoring these inaccuracies can cause delays, compliance risks, and revenue loss.

Staffing Shortages:

Credentialing departments in healthcare institutions are facing a staffing shortage averaging 35%. Such gaps can slow down essential processes, leading to delayed patient care and increased burden on existing staff. This creates a need for solutions that can address staffing shortages.

Overcoming Challenges in Group Practice Credentialing

Group Practice Credentialing can be complex, but a proactive approach can make the process smoother.

• Start Early: Delays are common, so initiate credentialing well in advance.

• Stay Organized: Maintain a checklist of required documents and track application timelines.

• Improve Expert Assistance: Credentialing specialists can navigate payer requirements and expedite approvals.

• Follow Up Regularly: Insurance applications can get lost; persistent follow-ups prevent unnecessary delays.

• Keep Profiles Updated:  Ensure CAQH and payer profiles remain current to avoid issues when re-credentialing or adding new providers.

Multi-State Variations in Group Practice Credentialing

Credentialing requirements vary across states, adding complexity to the group practice credentialing process. If your practice operates in multiple states, it’s crucial to understand state-specific regulations, payer policies, and licensing requirements.

Key Multi-State Credentialing Challenges:

Expanding a group practice across multiple states comes with significant credentialing challenges. While group practice credentialing services improve the process, each state has unique regulations, payer policies, and licensing requirements.

State-Specific Licensing Requirements

• Some states require additional certifications or background checks before credentialing approval.
• States like Florida and Texas have stricter Medicaid enrollment processes.

Varying CAQH and Payer Policies

• While CAQH serves as a national credentialing database, some states have additional attestation or verification steps.
• Certain payers require state-specific applications beyond CAQH enrollment.

Different Reimbursement Rates & Contracting Rules

• Insurance reimbursement rates and credentialing timelines differ from state to state, affecting revenue cycles.
• Example: Some states allow provisional credentialing, while others mandate full approval before billing.

Medicaid & Medicare Enrollment Differences

• Medicaid credentialing rules vary significantly. Some states require separate Medicaid applications, while others streamline enrollment through centralized databases.

Telehealth Credentialing Across States

• Providers offering telehealth services must comply with licensing laws in each state where they see patients.

Final Thoughts

Credentialing is the foundation of a successful group practice, ensuring compliance, seamless insurance reimbursements, and uninterrupted patient care. While the process can be complex, strategic planning, regular follow-ups, and staying updated with payer requirements can help avoid costly delays. However, given the administrative burden and high stakes involved, outsourcing credentialing services can be a game-changer for medical groups looking to optimize efficiency and maximize revenue.

Need help with credentialing? Contact Health Quest today at (415) 508-6537  for a free consultation!