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Download the article PDF: Credentialing The Gatekeeper Of Access And Reimbursement
Phyllis Dobberstein, CPC, CPMA, CPCO, CEMC, CCC
In the healthcare ecosystem, credentialing is more than a bureaucratic hurdle—it’s the linchpin of successful revenue cycle management. For urgent care centers, credentialing determines whether providers can be reimbursed for the care they deliver to insured patients and whether they can participate in insurer networks.
Credentialing is the formal process by which payers—commercial insurance companies, Medicare, and Medicaid—verify the qualifications, training, licensure, and work history of care providers. It is a prerequisite for reimbursement, as only credentialed providers can bill for services rendered to insured patients under most plans. Not to be confused with contracting—which involves negotiating the terms of reimbursement and services—credentialing is the process of validating the provider’s qualifications to practice under those contracted agreements.
Why Credentialing Matters in Urgent Care
In urgent care, payer reimbursements hinge onnetwork participation. If a provider or urgent care center isn’t both credentialed and contracted as part of the payer’s network, patients won’t be able to take advantage of their insurance coverage to pay for the visit, often leading them to seek care elsewhere. This is particularly risky when opening a new urgent care center. Seeing patients before credentialing and contracting are complete can result in low patient volumes and poor revenue.
Even if a visit can be reimbursed out-of-network, insurer payments are often issued directly to the patient, and it can be difficult for the urgent care to collect that payment retrospectively.
The Credentialing Process and Its Pitfalls
Credentialing is notoriously slow and complex. On average, it can take 8 to 12 months from application to approval. This is due to variability across payers, evolving requirements, and administrative bottlenecks. A few common pitfalls include:
- Missed application deadlines
- Incomplete documentation
- Failure to update payer records
- Confusing payer-specific rules
Some states have also passed laws to standardize credentialing timelines. For example, Washington mandates that health insurance carriers must process completed applications within 90 days, with an average response time not to exceed 60 days.
Provider Types and Credentialing Eligibility
Credentialing rules vary based on provider type. Physicians, nurse practitioners, and physician assistants must each meet different criteria. Some payers, especially Blue Cross Blue Shield organizations, require nonphysician practitioners to be credentialed and to bill under their own National Provider Identifier, sometimes resulting in lower reimbursement when compared to that of physicians.
Moreover, provider categories matter. Providers with a background in emergency medicine, for example, may struggle to get credentialed as primary care providers, especially when a center aims to contract under a primary care designation rather than urgent care.
Credentialing requirements differ notably between urgent care and primary care contracts:
- Primary care typically requires individual provider credentialing, patient assignments, and delivery of specific services like wellness visits, vaccinations, and chronic disease management.
- Urgent care, on the other hand, may only require facility-level credentialing and typically earns a flat rate per patient visit. It excludes routine preventive care in many cases.
Hybrid Models
Centers operating both urgent care and primary care services under one roof often need 2 separate tax IDs, separate payer contracts, and separate credentialing tracks. Each line of business may require its own providers, billing processes, and even distinct physical spaces to remain compliant with payer policies.
Running a parallel model—distinct but co-located urgent and primary care operations—can optimize patient access while minimizing operational conflicts. It also allows clear differentiation in billing and credentialing for each service line.
The Strategic Role of Credentialing in Startup Success
Given the stakes, many centers opt to outsource credentialing to specialists who understand payer nuances, state laws, and evolving compliance mandates. Hiring professionals early—preferably before site selection and lease signing—can ensure a smoother center opening and better payer engagement.
Credentialing professionals provide value by:
- Navigating closed networks and identifying payer opportunities
- Interpreting ambiguous or conflicting payer requirements
- Maintaining up-to-date credentialing statuses
- Reducing denials and legal risks through clean, compliant processes
Credentialing doesn’t just support operations—it’s central to strategic planning. When launching a new urgent care, understanding the payer landscape in advance is critical. Some insurers may not accept new providers in certain markets, citing saturation or vertical integration with their own care networks.
A payer landscape review, conducted during the feasibility phase, can reveal whether contracts are realistically obtainable and which networks to prioritize. This step often determines whether a startup can succeed—or should reconsider its market entry.
Credentialing is not merely a back-office function. It is a strategic lever that affects access, revenue, compliance, and growth. In an increasingly complex healthcare environment, successful urgent care and primary care operators treat credentialing as a core function—worthy of expert attention, dedicated resources, and careful planning.
Phyllis Dobberstein, CPC, CPMA, CPCO, CEMC, CCC, is Revenue Integrity Manager at Experity.
Read More
- Credentialing: Why Should I Hire a Professional?
- Due Diligence is Critical When It Comes to Credentialing
