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Credentialing – Keeping it In-House vs. Outsourcing

Jan 14, 2011


Keeping It In-House vs. Outsourcing

Credentialing and recredentialing can be a major headache for many medical practices.  The process can be tedious, time-consuming and frustrating.  Further, most offices do not have the staffing to dedicate one employee to the entire process. In some cases, these credentialing responsibilities are very “hit and miss”. It is only once claims get denied or you get a very formal looking and somewhat intimidating letter from a health-plan or your states Department of Insurance that folks start to take the process seriously.


The decision concerning whether to delegate this duty to a third party really depends on the staffing of each individual medical office as well as the expertise level of the contracted party. After all, what you don’t want to do is hand over this task to someone else only to have it result in the same sort of disarray as it was in the home office.

Further, should the medical office fall behind in recredentialing duties with individual health-plans then there is a great likelihood that the physician will be decredentialed from the plan. This causes not only a denial of claims, but the physician usually is required to revert back to the credentialing process. This is much more time consuming than recredentialing and will provide a serious interruption in service for patients.

The advantage to outsourcing the spectrum of credentialing duties is that the professionals have experience and volume on their side. Additionally, they have standardized methods that allow for a streamlined process. The professionals also typically have direct relationships with payors (including HMO medical groups) and those relationships can provide for expedited processing.

Of course, the advantage to keeping credentialing duties in-house is the expense of a third party company.  However, if you weigh that fee against the potential loss of income due to a provider being decredentialed (coupled with the resulting denial of claims) many offices find it to be a wise investment in their medical practice.