Credentialing might not be the flashiest part of the revenue cycle, but it’s one of the most critical. For radiology groups, a breakdown in this process can quietly drain millions in lost revenue. In this episode of Office Hours, Stuart Newsome sat down with credentialing veteran Rebecca Barnes and RCM operations leader Peggy Kelly to unpack why credentialing often gets sidelined, the real-world consequences of delays, and how to build a process that protects every dollar. Their stories and insights reveal that credentialing isn’t just paperwork—it’s the foundation of your ability to bill and get paid.
Credentialing vs. Provider Enrollment
Many use “credentialing” and “provider enrollment” interchangeably, but they’re distinct steps in the same revenue-critical process. Credentialing verifies a provider’s qualifications, licenses, and work history—often linked to hospital board approvals. Provider enrollment is about connecting those providers to the right payer networks and tax IDs so claims can be paid. For hospital-based providers like radiologists, payers may skip full credentialing, but enrollment is still essential for correct routing and payment.
The Hidden Risk of Treating Credentialing as a Checkbox
Credentialing work happens before a claim is even submitted, which is why it’s often overlooked. But if it’s done incorrectly, every downstream step—from reimbursement to audit compliance—can be compromised. When credentialing runs smoothly, it’s invisible. When it fails, the ripple effect is immediate and expensive. As Barnes put it, “It’s the first step of getting paid.”
Payer Delays: The Unseen Bottleneck
Many credentialing stalls aren’t caused by internal inefficiencies but by payer-driven delays. Payers may sit on applications for weeks, request missing documents that were already submitted, or close network access altogether. Large groups may need to submit thousands of applications, multiplying the risk of slowdowns. Clients often misplace blame internally, not realizing the sheer volume and manual follow-up these processes require.
The Complexity of Multi-State Expansion
Large radiology groups with hundreds or thousands of providers across multiple states face an exponential increase in complexity. Each state has its own payer landscape, Medicaid rules, and credentialing requirements—down to fingerprinting mandates or county-specific Medicaid plan access. Without strong planning, one missing document or delayed signature can derail start dates and jeopardize revenue.
The Tax ID “Workaround” Dilemma
Some groups try to route claims through whichever tax ID has the strongest contract, but without proper credentialing and compliance checks, this can create serious risk. While strategic mapping is possible, it must align with contracts, payer rules, and the architecture of billing systems—especially with the No Surprises Act adding compliance pressure.
Technology’s Promise and Limitations
Credentialing software can help organize documents, flag expirations, and store data—but most systems are built for hospital verification processes, not the nuanced workflows of payer enrollment. Common gaps include lack of CAQH integration, limited onboarding tools, and incomplete form mapping. True efficiency comes from combining technology with experienced specialists who actively manage follow-ups and troubleshooting.
State-Specific Hurdles and Medicaid Challenges
Credentialing rules vary dramatically by state. Some Medicaid programs require annual license updates, while others disenroll providers for inactivity within months. The key to staying ahead is thorough pre-expansion research and maintaining up-to-date payer and state requirement tracking. Strong client communication is essential to set realistic timelines.
Telehealth and Teleradiology: A New Layer of Complexity
The pandemic accelerated telehealth adoption, and teleradiology has become essential in addressing radiologist shortages. But evolving rules—like the potential expiration of CMS telehealth waivers—could require listing providers’ home addresses on claims, raising privacy concerns. While reimbursement models may shift, the consensus is that telehealth in radiology is here to stay.
KPIs for Measuring Credentialing Success
Key performance indicators can help leaders see if their credentialing function is truly effective:
- Time to complete enrollment (packet receipt to approval letter)
- First-pass approval rate (no kickbacks or additional documentation requests)
- Recredentialing compliance rate (avoiding network lapses)
- Payer lag time (submission to approval) tracked by state and payer
Conclusion
Credentialing isn’t a back-office task—it’s the revenue cycle’s launch pad. For radiology groups, getting it wrong can mean millions lost, delayed start dates, and compliance risks. Barnes and Kelly’s message is clear: invest in the right processes, technology, and expertise, and treat credentialing as the core business function it truly is. To hear their full insights and real-world examples, watch the webinar on demand.