Credentialing healthcare providers is essential for maintaining compliance, ensuring patient safety, and securing insurance reimbursements.
It's crucial to grasp the financial implications of credentialing, as these direct and indirect costs can accumulate, potentially affecting a practice’s operations and bottom line.
For example, this is the financial reality of provider credentialing:
- The average revenue loss from credentialing delays is $6,000-8,000 per provider monthly
- Time cost: 60-90 days average credentialing timeline
- Administrative cost: 20+ hours of staff time per application
- Technology investment: $50-300 per user monthly
Recognizing these costs and implementing strategies to streamline credentialing is not only beneficial but necessary. This can save your practice time, money, and resources, allowing you to focus on what matters most: delivering quality care.
In this article, we’ll:
- Provide a detailed breakdown of the costs associated with credentialing healthcare providers
- Explain why these costs occur
- Share actionable strategies to optimize the process and minimize expenses
Let's begin
Understanding the credentialing process
Credentialing isn’t just paperwork. It’s the meticulous process of verifying a healthcare provider’s qualifications, including education, training, licenses, certifications, and professional history. This process ensures that providers meet regulatory, institutional, and insurance standards.
The key elements of credentialing include:
- Primary verification requirements
Primary verification confirms that a healthcare provider's qualifications, credentials, and professional background are authentic and meet regulatory and organizational standards.
It ensures that the provider is competent, licensed, and legally authorized to practice medicine. This involves validating licenses, degrees, board certifications, and work history.
- Timeline expectations
The credentialing process can take 60–90 days for providers already licensed in a state. It can take longer for those not licensed in a state (between three to four months). The timeliness depends on factors like third parties' responsiveness and the complexity of the provider's background. Delays can also disrupt operations and revenue streams, making efficiency a priority.
- Stakeholders and accrediting bodies
Credentialing involves healthcare providers, hospitals, insurance panels, and regulatory bodies like:
- NCQA (National Committee for Quality Assurance): The NCQA ensures quality and accountability in healthcare
- URAC (Utilization Review Accreditation Commission): The URAC is a nonprofit organization that focuses on promoting healthcare quality through accreditation
- The Joint Commission: This commission sets performance standards for healthcare organizations
Direct credentialing costs
Direct costs are those immediately connected to the credentialing process. They include fees for applications, verifications, and other essential steps.
- Application fees
Application fees vary depending on the level of credentialing and the organizations involved:
- State Medical Board Fees: These cover licensing and renewals. The application fee is between $750 and $800, the competency-based test is between $1400 and $1950, and the oral exam is between $1540 and $1900
- Insurance Panel Enrollment Fees: Healthcare providers must pay $100 to $200 per application to join insurance networks, enabling them to bill insurance companies
- Hospital Privileging Fees: There are no costs attached to getting hospital privileges
- CAQH ProView Fees: Though free for individual providers, organizations using CAQH for credentialing might incur costs for additional features or bulk verifications
Primary source verification costs
Primary source verification confirms the legitimacy of a provider’s credentials:
- Education and Training Verification: These include costs to confirm a provider’s degrees and residencies. These costs can also include traveling internationally or locally to collect or confirm certifications
- Board Certification Verification: This can cost up to $395 per provider
- Background Check Fees: Depending on the depth of the check, costs can range from $50 to $250
- Malpractice History Reports: Providers or organizations may pay $9 to $12 per physician to verify malpractice insurance and claims history
- License Verification Fees: Varies by state, often between $40 and $100 per license
Check out this complete guide to medical licensing costs.
Indirect credentialing costs
Indirect costs often impact staff workloads, operational efficiency, and organizational budgets.
- Administrative resources
Credentialing is resource-intensive, requiring significant staff time:
- Staff Time and Labor Costs: Credentialing specialists or admin staff spend hours collecting documents, making follow-ups, and verifying details. Salaries for credentialing specialists average $45,918 to $57,693 annually
- Training Requirements: Staff must stay updated on regulatory changes and best practices. The cost for this depends on the training methods used. However, the average cost to train an employee is $5,000
- Documentation Management: Securely organizing and storing records is labor- and technology-intensive. A document management software cost between $15 to $200 per month
- Technology and software
While technology can streamline processes, it adds to upfront and recurring costs:
- Credentialing Software Licenses: Most software subscriptions are billed monthly, typically based on the number of users or the level of access provided. Costs generally range from $50 to $300 per user each month
- Database Subscriptions: Access to national provider databases often comes with subscription fees. The NPDB (National Practitioner Data Bank) charges $2.5 to $3 per practitioner
- Electronic Verification Systems: These systems reduce manual work. Platforms like E-verify are often free
Hidden costs and considerations
Beyond direct and indirect costs, credentialing involves hidden expenses such as:
- Revenue Loss During Waiting Periods: Providers can’t bill insurance or see patients until credentialing is complete, causing delays in revenue generation
- Reapplication Fees for Expired Credentials: Missing renewal deadlines can lead to additional fees and delays
- Rush Processing Fees: Expediting credentialing can cost hundreds of dollars per provider, often upwards of $200
- Cost of Credentialing Errors: A missed verification step could delay the credentialing process
Cost-saving strategies
With credentialing being a significant expense, it’s essential to explore cost-saving strategies:
- In-House vs. Outsourced Credentialing: Outsourcing reduces administrative burden and error rates but can be expensive upfront. However, in the long run, it’ll turn out to be cost-effective. In-house credentialing is more cost-effective for practices with well-trained staff and lower provider volumes
- Bulk Application Submissions: Submitting multiple applications simultaneously saves time and reduces costs associated with individual submissions
- Early Renewal Practices: Monitoring expiration dates and renewing early prevents rush fees and reapplication costs
- Technology Automation Benefits: Automating credentialing reduces labor costs, minimizes errors, and accelerates processes
- Group Enrollment Opportunities: Larger practices can negotiate discounts or shared services for credentialing
ROI of efficient credentialing
Credentialing isn’t just a cost. It’s an investment that can yield tangible returns. Here’s how:
- Revenue Generation Potential: Faster credentialing means quicker patient onboarding and billing
- Risk Mitigation Benefits: Proper credentialing prevents compliance penalties and legal risks
- Patient Satisfaction Impact: Efficient credentialing ensures a smooth and seamless patient experience
- Competitive Advantage: Credentialed providers improve a practice’s reputation and attract more patients with faster go-to-market
Cost breakdown examples
Initial credentialing setup costs for a solo practice provider may range from $200 to $500. Insurance panel applications cost $100 to $200, while database management costs $50 to $100 monthly.
Multi-provider practices benefit from economies of scale. Due to shared resources and technology, credentialing costs an average of $325 per plan per provider.
Budget planning tips
Credentialing costs can be managed through the following ways:
- Timeline-Based Budgeting: Plan costs based on application timelines to avoid financial strain
- Essential vs. Optional Costs: Prioritize must-haves like licensing and software while postponing non-urgent upgrades
- Emergency Fund Recommendations: Allocate funds for unexpected credentialing delays or errors
- Cost Tracking Methods: Use credentialing software to monitor and analyze credentialing expenses over time
Conclusion
Credentialing a healthcare provider is a complex and resource-intensive process with visible and hidden costs. However, strategic planning, technology adoption, and efficient processes can transform credentialing from a financial burden into a growth opportunity for healthcare organizations.
Looking for a more innovative way to manage credentialing? Assured offers comprehensive solutions to streamline credentialing, reduce costs, and help your practice focus on patient care. With Assured, you can quickly get multi-state licenses for any provider, slash credentialing time by 80%, and speed up provider enrollment with any payer by 30%.
So, what are you waiting for? Explore Assured today by booking a demo.
