Credentialing vs. Billing

When a practice experiences delayed payments or unexplained claim denials, it’s easy to assume the problem lies with billing. But in many cases, the issue starts before the first claim is ever submitted—during credentialing.

Credentialing and billing are two separate—but tightly connected—processes. When one fails, the other suffers.

In this article, we’ll break down the difference between credentialing and billing, explain why both matter, and show how better alignment between the two can protect your revenue cycle from costly delays.

✅ What Is Credentialing?

Credentialing is the process of verifying that a provider is qualified to deliver care and is approved to bill insurance companies. It involves:

• Verifying education, licensure, and training

• Submitting enrollment applications to insurance payers

• Becoming an in-network provider (when applicable)

• Receiving an effective date for billing eligibility

🕒 It can take 60–180+ days for a provider to be fully credentialed with an insurance company. During that time, submitting claims can result in denials or reduced reimbursements.

💸 What Is Billing?

Billing (or revenue cycle management) is the process of submitting, tracking, and collecting reimbursement for patient care. It includes:

• Coding and claim submission

• Payment posting

• Denial management

• Patient invoicing and collections

Even the best billing teams can't collect payments for a provider who isn’t properly credentialed or listed with the payer.

🔄 Where the Processes Overlap (and Why It Matters)

Credentialing Affects...

Billing Consequence

Delays in enrollment

Delayed or denied claims

Missing effective dates

Retroactive payments not possible

Out-of-network status

Lower reimbursement or patient balance

Incorrect NPI/taxonomy

Claim rejections

Common issue: A new provider begins seeing patients before credentialing is finalized, only to discover weeks later that none of those claims can be paid.

🧠 How to Align Credentialing & Billing for Success

1. Start Early
   Begin credentialing at least 90–120 days before a provider’s start date. If possible, don’t schedule them with patients until you have an effective date from the payer.

2. Track Enrollment Status Closely
   Use a system (spreadsheet, CRM, credentialing software) to track application statuses, payer responses, and effective dates.

3. Coordinate Between Teams
   Billing teams must know when a provider is active with each payer. Likewise, credentialing teams should alert billers about any issues or changes.

4. Use Provisional Billing Where Allowed
   Some payers allow billing under a supervising provider’s NPI during credentialing. Know the rules—and risks—before you proceed.

5. Verify Every Payer Contract
   Just because you’re credentialed doesn’t mean you’re in-network. Review each contract to confirm participation, reimbursement rates, and billing requirements.

🧾 Final Thoughts

Credentialing isn’t just paperwork—it’s the foundation of your billing process.

When your credentialing and billing teams work together, you avoid:

• Delayed revenue

• Rejected claims

• Frustrated providers and patients

If you’re struggling with enrollment backlogs, denied claims, or unclear payer statuses, it’s time to unify your credentialing and billing workflows.