Unleashing Revenue Potential: A Guide to Credentialing and Billing in Urgent Care

In urgent care, effective credentialing and billing are not mere administrative tasks — they are pivotal components in driving revenue and ensuring smooth operational flow. And with ever-changing payer requirements and the growing complexity of provider enrollment, clinic administrators and owners need to be proactive. This post breaks down expert strategies, answers common questions, and offers actionable tips to streamline your processes and improve your bottom line.

Understanding Credentialing in Urgent Care

Credentialing is the process of verifying a provider’s qualifications to ensure they meet the standards required by insurance companies. It is the backbone of any billing process in healthcare. In urgent care settings, where patient interactions are often one-off, providers must be fully credentialed before they can begin billing. This is especially critical because:

• Providers must be fully credentialed before claims can be submitted. Any delay can directly affect revenue
• Some contracts require individual provider credentialing, while others use facility credentialing. Understanding the difference is key to avoiding claim denial
• Payer requirements vary by state, region, and contract type. It is vital to stay updated on what documents are needed and when

Contracting and Credentialing: The Urgent Care Challenge

Urgent care practices face unique challenges that differentiate them from traditional primary care settings:

• Short-term patient interaction: Unlike longitudinal care, urgent care often involves one-time visits, so providers must be billing from day one
• Variable payer requirements: Some payers require a specific set of documents (such as BLS certification or board certifications), and these can change at any time
• Extended turnaround times: Post-COVID staffing shortages and evolving processes mean credentialing may take much longer than the typical 90 to 120 days. Practices must plan accordingly to avoid revenue gap

Types of Credentialing: Individual vs. Facility

Credentialing in urgent care comes in two main forms, and each has significant implications for billing and reimbursement:

• Individual provider credentialing: Each provider must be independently verified and approved before they can bill for services
• Facility credentialing: The clinic as a whole is credentialed, allowing all licensed providers to bill once the contract’s effective date is set

How these different models affect provider turnover and reimbursement timelines, especially in high-volume urgent care settings, has a significant impact on revenue. So it’s important to understand the distinctions between individual and facility credentialing to ensure that your billing process is set up for success from the outset.

Navigating Recredentialing Requirements

Recredentialing is an ongoing process that ensures providers continue to meet the required standards over time. Here are a few practical ways to manage it effectively.

• Track deadlines: Implement systems to monitor credentialing and recredentialing dates rigorously
• Document changes: Keep comprehensive records of any updates or changes in payer requirements
• Proactive communication: Ensure that your team responds promptly to recredentialing notices to prevent any interruptions in service or revenue

Effective management of recredentialing not only safeguards against service disruptions but also impacts your long-term revenue stability.

Avoiding Common Credentialing Mistakes

Even well-run clinics can fall prey to common errors in the credentialing process, which can lead to billing complications and revenue loss. These errors often include:

• Incomplete documentation: The risks of missing essential certifications or licenses.

• Misunderstanding payer requirements: How variations in requirements can lead to confusion and delays
• Lack of direct communication: The pitfalls of relying solely on generic portals rather than establishing direct contacts with payer representatives

You can also get more detailed tips in our blog How to Avoid the Top 5 Mistakes in C&C

Best Practices for Billing and Contracting

Optimizing your credentialing process helps reduce claim denials and enhance revenue opportunities. Here are a few action steps you can take immediately:

• Understand the contract language: Credentialing requirements are typically found in the provider manual rather than the contract itself. Read these documents carefully and consult with your credentialing vendor if needed
• Educate your team: Make sure your front desk and administrative staff are well-versed in basic credentialing and contracting concepts. This helps in directing patients to the correct providers and prevents billing errors
• Monitor recredentialing dates: Missing a recredentialing deadline can lead to significant revenue loss. Implement a robust tracking system to manage these timelines effectively
• Advocate for your practice: Given the complexity of payer requirements, regular advocacy and communication with insurance companies are necessary to ensure you’re receiving the correct reimbursement

Accelerate Credentialing, Simplify Contracting, and Stay Compliant

Delays in credentialing and contracting don’t just stall your practice — they impact your revenue. Experity’s optimized contracting, credentialing, and compliance services through our RCM team help you onboard providers 3X faster, achieve 50% quicker payer enrollments, and ensure continual regulatory compliance. Our real-time dashboards keep you informed of every step, proactively surfacing potential delays or compliance gaps before they become costly issues.

With AI-driven analytics and a dedicated Customer Success Manager committed to your success, Experity helps you maintain rigorous compliance standards, reduce administrative burdens, and streamline your path to reimbursement.

Learn More About Experity’s RCM Services