What 50 conversations with healthcare practices taught us about credentialing

Over the past few months my team and I spoke with close to 50 surgeons, practice owners, administrators, and advisors. Orthopedics, cardiology, prosthetics and orthotics, FQHCs, ambulatory surgery centers, multi-specialty groups. We were there to talk about prior authorization and claims denials.

Credentialing came up anyway. Almost every time. Usually as the third thing someone mentioned, not the first.

Every provider has to be enrolled with every payer they bill, at every location they practice. Re-credentialing runs on recurring cycles, staggered across payers, so there is never one date to plan around.

Enrollment is one clock among several. State licenses, DEA registration, board certification, and payer enrollment each sit on separate schedules. Facility privileging is a related but distinct track. DEA is worse than most people expect: it is issued per location and expires every three years, so a surgeon who stores or dispenses controlled substances at three sites carries three registrations with three dates [USDOJ].

Underneath all of it is paper. Re-credentialing packets, revalidation forms, license and DEA scans, collected and submitted separately for every payer.

For a solo practitioner this is a list. Add providers and locations and it becomes a matrix. Provider by payer by location, every cell on its own clock with a different renewal workflow.

Not one person we spoke with described a lapsed credential as a credentialing problem. They described it as a denials problem, a billing problem, or a quarter where revenue came in soft.

A gapped credential does not announce itself. A provider falls out of network. A packet slips past its deadline. Nothing happens. The first signal is a denied claim weeks later, coded for a reason that has nothing obvious to do with credentialing. Somebody has to dig to find out the provider was not enrolled with that payer on the date of service.

By then the window is closing. Retroactive enrollment, where a payer offers it at all, typically runs 30 to 90 days and requires a formal appeal. Once timely filing passes, the money is gone.

That lag is why credentialing almost never gets named as the top pain point, even when it is costing real money. While it is happening it does not feel like credentialing. It feels like noise.

For example, take one orthopedic surgeon at a mid-sized practice. One commercial payer, roughly 20 percent of the panel. One quarter of gapped enrollment:

That is around $200,000 in charges, roughly $70,000 in collections at a 35 percent net collection rate. One provider. One payer. One quarter.

Spread that across a matrix and it stops being a line item. It becomes slightly worse numbers everywhere.

This is not a fringe problem. MGMA polled 425 practices in August 2021 and found 54 percent reported credentialing-related denials had increased that year, driven by delayed applications, providers dropped from networks without notice, and payers assigning incorrect taxonomies. [MGMA]

The window has tightened since. NCQA cut its credentialing standard for 2026 to 120 days for accredited organizations, down from 180. Certified organizations went from 120 to 90. [NCQA]

Larger organizations often dedicate a person to credentialing. We spoke with one organization where a single credentialing specialist covered all providers. A 12-doctor practice had three FTEs on back-office work with credentialing folded in. Smaller practices use Excel and calendar reminders.

One practice built a custom internal tool for exactly this. It failed. They went back to spreadsheets.

From the outside credentialing looks like a database problem. Providers, payers, dates, statuses. So you build a database, but nobody is watching the dates, and that is true in a custom tool, a spreadsheet, or a filing cabinet. The bottleneck was never where the data lived, it was that no one checks it until something breaks.

Prior authorization varies enormously by specialty. Cardiology groups describe it as a manageable burden. Orthopedics groups describe it as a daily fire.

Credentialing did not vary. Orthopedics, prosthetics and orthotics, FQHCs, cardiology, ambulatory surgery centers, multi-specialty groups. Same mechanics, same failure point, same silent cost. That consistency is what convinced us this was not a niche problem.

Credentialing was never the first pain point anyone mentioned, and it came up anyway, across every specialty.

Does any of this sound familiar? We built our approach directly from these conversations. Book a 30-minute call and we'll walk you through it.