Credentialing: The Gatekeeper of Healthcare Access and Reimbursement 

In the healthcare ecosystem, credentialing is more than a bureaucratic hurdle — it’s the linchpin of successful revenue cycle management, patient trust, and legal compliance. For urgent care centers and primary care practices alike, credentialing determines whether providers can deliver reimbursable care to insured patients and participate in insurer networks. Poorly managed credentialing can lead to revenue loss, legal exposure, and reputational damage. 

What is Credentialing? 

Credentialing is the formal process by which payers — commercial insurance companies, Medicare, and Medicaid — verify the qualifications, training, licensure, and work history of healthcare providers. It is a prerequisite for reimbursement, as only credentialed providers can bill for services rendered to insured patients under most plans. 

Often confused with contracting, credentialing is just one part of the puzzle. Contracting involves negotiating the terms of reimbursement and services, while credentialing is the process of validating the provider’s qualifications to practice under those agreements. 

Why Credentialing Matters in Urgent Care 

In urgent care, patient access and payer reimbursements hinge on network participation. If a provider or facility isn’t credentialed and in-network, patients may be forced to pay out of pocket, often leading them to seek care elsewhere. This is particularly risky when opening a new urgent care center. Launching operations before credentialing and contracting are complete can result in low volumes and poor revenue—a potentially fatal misstep. 

Credentialing also directly impacts billing accuracy and legal compliance. Submitting claims under the name of a provider who did not perform the service can result in severe penalties under the False Claims Act, including substantial fines and even criminal charges. 

Credentialing: The 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 following provider changes 

• Confusing payer-specific rules for different provider types 

Some states have passed laws to standardize credentialing timelines. For example, Washington state mandates that health 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 (MD/DO), nurse practitioners (NPs), and physician assistants (PAs) all face different criteria. Some payers, such as Blue Cross Blue Shield of Georgia, have issued amendments requiring nonphysician practitioners (NPPs) to be credentialed and to bill under their own NPI, sometimes resulting in reduced reimbursement. 

Moreover, providers with a background in emergency medicine may struggle to get credentialed as primary care providers, especially when a center attempts to contract under a primary care designation rather than urgent care. 

Primary Care vs. Urgent Care Credentialing 

Credentialing requirements differ notably between urgent care and primary care contracts: 

• Primary care typically requires individual provider credentialing, patient assignments, and supports services like wellness visits, vaccinations, and chronic disease management. 

• Urgent care, on the other hand, may only require facility-level credentialing and pays a flat rate per visit. It excludes routine preventive care in many cases. 

Some operators choose to open under primary care contracts to access otherwise closed networks, but this demands clinical workflows, staffing, and inventory aligned with primary care delivery. 

The Rise of Hybrid Models — and Their Credentialing Complexity 

In response to provider shortages and patient demand, many urgent care centers are now incorporating primary care services. This hybrid model opens doors to new patient populations and enhances community engagement — but it also introduces a labyrinth of credentialing requirements. 

Centers operating both services under one roof often need two separate tax IDs, contracts, and credentialing tracks — one for urgent care, and one for primary care. 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. 

Why Hire a Credentialing Professional? 

Given the stakes, many centers opt to outsource credentialing to specialists who understand payer nuances, state laws, and evolving compliance mandates. 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 

Hiring professionals early —  preferably before site selection and lease signing—can ensure a smoother opening and better payer engagement. 

The Strategic Role of Credentialing in Startup Success 

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. 

Conclusion: Credentialing as a Cornerstone of Viability 

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. 

Whether you’re launching a new facility, adding service lines, or expanding into a new market, your ability to manage credentialing efficiently and correctly could be the difference between a thriving clinic and one that never gets off the ground.