Is Your Revenue Cycle Leaking Cash? Why Credentialing and Re-Credentialing Are Critical
Running a successful medical practice requires more than excellent patient care. Your financial health depends heavily on the efficiency of your revenue cycle management (RCM). One of the most overlooked — and most damaging — threats to your cash flow is credentialing and re-credentialing.
Whether it’s a new provider whose credentialing hasn’t been completed or an established physician who missed a re-credentialing deadline, the result is the same: denied claims, delayed reimbursements, and revenue slipping through the cracks.
In this blog, we’ll break down:
What credentialing and re-credentialing really mean
How lapses impact revenue cycles
Common mistakes that cost practices thousands
Proven strategies to protect your revenue
How MBW RCM can help seal these leaks once and for all
Understanding Credentialing: The Foundation of Reimbursement
Credentialing is the formal process of verifying a provider’s qualifications, including education, training, licensure, board certifications, work history, malpractice insurance, and professional references. Payers (commercial and government) and facilities (hospitals, surgery centers, etc.) require it before approving you for participation in their networks.
Why It Matters
No credentialing = no payment. Claims from uncredentialed providers are automatically denied.
In-network visibility. Without payer approval, your providers won’t appear in directories, making it harder for patients to find them.
Compliance and trust. Credentialing protects patients and ensures you meet regulatory standards.
Credentialing ≠ enrollment. Credentialing verifies qualifications, while enrollment secures contracts and payment arrangements. Both are required before you can bill insurers.
🔗 Credentialing 101: What resident physicians need to know – American Medical Association
⏳ Timeline: Credentialing can take 90–120 days or more, depending on payer systems and documentation issues.
The Hidden Cost of Uncredentialed Providers
Hiring a new physician, nurse practitioner, or specialist is exciting — but if their credentialing isn’t complete, every claim they generate is at risk.
Revenue Impacts
Claim denials: Insurers reject claims from providers who aren’t yet approved.
Delayed reimbursements: Even if approved later, backdating is rare; most claims will remain unpaid.
Lost patient volume: Patients may avoid out-of-network providers, shrinking visit counts.
Administrative overload: Staff waste hours appealing denials and rebilling.
💡 Example
A practice hires a new family physician in January. Their CAQH profile isn’t fully updated until March, and payers take until June to approve. For six months, claims from that physician are denied.
With 25 patients a week at an average reimbursement of $100, the practice loses $65,000 in revenue.
🔗 PECOS Revalidation Info – Centers for Medicare & Medicaid Services
Credentialing Is Not One-and-Done: The Role of Re-Credentialing
Once a provider is credentialed, the work isn’t over. Re-credentialing (or revalidation) is required at regular intervals:
Commercial Payers: Every 2–3 years
Medicare PECOS: Every 5 years (ownership, location, and NPI must be revalidated)
Medicaid: Varies by state, often every 3–5 years
NCQA 2025 Standards: Monthly monitoring of licenses, sanctions, and malpractice actions is now mandatory
The Risks of Missing Deadlines
Billing deactivation: Medicare deactivates billing privileges if revalidation is missed — all claims stop immediately.
Network termination: Commercial payers remove providers from networks, cutting off patient access.
Unpaid claims: Even if you continue seeing patients, every claim submitted after a lapse is denied.
Reputation damage: Patients may lose trust when their provider is suddenly out-of-network.
💡 Example: A cardiologist fails to revalidate Medicare enrollment by the deadline. Their billing privileges are deactivated, and the practice loses 3 months of Medicare revenue before re-enrollment is complete — an unrecoverable six-figure loss.
Common Credentialing & Re-Credentialing Mistakes
Here are the pitfalls that most often sink practices:
Starting too late. Credentialing takes months. Waiting until a provider’s start date means guaranteed revenue loss during their first months of work.
Incomplete documentation. Missing malpractice histories, unexplained gaps in work history, or expired DEA licenses cause applications to stall or be denied.
Poor tracking. Without a central system, re-credentialing deadlines slip by unnoticed. A single missed date can halt claims across entire payer networks.
Mixing credentialing with enrollment. Many practices mistakenly think credentialing alone allows billing. In reality, both credentialing (verification) and enrollment (payer contracts) are required.
No ongoing monitoring. Licenses, DEA registrations, and board certifications can expire mid-cycle. If not monitored, this triggers denials and compliance risks.
💡 Expanded Insight: Each of these mistakes is preventable with proactive systems and clear ownership. The cost of prevention is minimal compared to the thousands lost in denials.
How to Protect Your Revenue Cycle
To keep your revenue cycle watertight, you need proactive credentialing management:
Centralize tracking. Maintain a credentialing dashboard or calendar with automated alerts for expirations.
Use technology. Regularly update CAQH, PECOS, and Medicaid portals; use credentialing software or RCM tools to prevent errors.
Assign responsibility. Designate one team member (or outsource) to own credentialing and re-credentialing tasks.
Plan for new hires. Start the credentialing process at least 120 days before a provider’s start date.
Implement continuous monitoring. Monthly license checks and sanction reviews protect against sudden compliance issues.
Conclusion
Credentialing and re-credentialing are not just paperwork — they are revenue safeguards.
Every uncredentialed provider and every missed re-credentialing deadline is a hole in your revenue cycle. Left unchecked, those holes can bleed thousands in unrecoverable revenue, frustrate your billing team, and put your compliance standing at risk. Explore the Types and Challenges of Credentialing in Medical Billing.
How MBW RCM Can Help
At MBW Revenue Cycle Management, we specialize in closing the gaps in credentialing and re-credentialing.
We handle initial credentialing, enrollment, and re-credentialing across Medicare, Medicaid, and commercial payers.
We provide continuous monitoring to ensure licenses, DEA registrations, and board certifications never lapse.
We streamline CAQH, PECOS, and payer updates to minimize delays.
We safeguard your practice from claim denials, billing deactivation, and costly interruptions.
Ready to stop revenue leaks? Partner with MBW RCM today — we’ll handle the credentialing details so you can focus on patient care and growth.
