Credentialing Challenges in the Era of Telemedicine

In this blog, we explore the credentialing challenges unique to telemedicine, highlight key data points, and offer insight into how healthcare providers can navigate this evolving environment.

What Is Credentialing and Why Does It Matter in Telehealth

Credentialing is a crucial medical assessment procedure in the healthcare industry that ensures the qualification of healthcare providers. It is a process through which healthcare organizations and insurance companies can verify the credentials of healthcare providers, which involves verifying a healthcare professional’s education, training, licensure, board certifications, work history, and eligibility with an insurance plan. It is a critical step that ensures the safety and effectiveness of healthcare and whether the healthcare providers are authorized and eligible to provide healthcare services to the patients. 

Credentialing in the classical care models is limited to one location or hospital. Telemedicine makes this more complicated with state lines, payers, and technology platforms crossing. When more than one insurance network requires enrollment and verification procedures of providers, with their own different rules, credentialing, and medical billing becomes even more challenging. Not completing credentialing properly on time may lead to delays in billing, service disruptions, or even compliance issues.

Key Credentialing Challenges in the Telemedicine Era:

As we have already talked about why credentialing in medical billing is important on time, let’s now talk about the challenges related to credentialing in telehealth. The following are a few of the challenges associated with it: 

1. Cross-State Licensing Barriers

The requirements to become licensed as a medical professional vary by state in the U.S., and most state laws do not permit working outside of their state via telehealth without further licenses in the U.S. Although the Interstate Medical Licensure Compact (IMLC) has aided in the streamlining of licensure in states, there are still gaps to be filled. Providers who offer services to patients in more than one state need to be licensed in every state. This increases time and administrative overhead.

2. Inconsistent Insurance Credentialing Requirements

Credentialing with insurance plans is another major hurdle. Each payer has its own guidelines; some payers require separate telemedicine enrollment forms, while others accept traditional credentials. There’s no single procedure.

For example, Medicare, under CMS guidelines, allows for credentialing by proxy in specific facility settings. But private payers may not necessarily accept this method, which can lead to a lot of confusion and ultimately increase administrative burden.

3. Delays in Provider Application Processing

It usually takes 60 to 180 days to complete the credentialing process with insurance companies. During this time, providers cannot bill for services they provided, which results in revenue loss.

According to the American Medical Association (AMA), most of the delays in credentialing are caused due to incomplete documentation, miscommunications with payers, or gaps in primary source verification.

4. Repetitive Credentialing Across Systems

The identical provider can also be performing continuous credentialing with multiple insurance panels or health systems, in which a unique application, documentation, and review schedule are needed. This leads to inefficiency and duplication of effort and chances of error.

5. Outdated Technology and Lack of Integration

There is a high likelihood of having disjointed credentialing systems- utilizing outdated spreadsheets, isolated databases, or paper-based credentialing forms. This does not go with the quick pace of telemedicine.

There is no integrated, cloud-based solution to track license expirations or payer statuses and/or provider enrollment efforts at scale.

Credentialing Delays: What the Data Really Shows

There is data about the issues in credentialing in telemedicine. According to MGMA Stat polls and industry research from 2021 to 2024, credentialing-related denials and delays are rising.

The chart below shows the most common causes of delays, and their percentages, as reported by healthcare administrators in national surveys:

Source: MGMA Stat Polls (2021–2024), as cited in the MGMA Insights Report on Credentialing-Related Denials

Why This Matters in Telehealth

Such delays are not only administrative. Telemedicine depends on weekly credentialing, and many virtual visits are missing when credentialing is delay. In the case of multi-state practices or even expanding telehealth networks, delays in one phase of credentialing may cause a spillover effect in terms of scheduling, compliance, and reimbursement.

Credentialing in medical billing is crucial for both healthcare providers and insurance companies, ensuring quality patient care and proper billing practices, including:

• Submission of applications of health care providers based on their education, training, licensure, and other requirements.
• The verification of professional education and licensure, board certifications, and DEA registration.
• Enrollment of healthcare practitioners and doctors joining a health insurance network.
• Choosing insurance partners that align with healthcare practice goals and license type, while also finalizing insurance panels based on practice location.
• CAQH application submissions, managing accounts, and keeping credentials current for smooth primary source verification.
• Signing of the contract and reviewing of data provided by the practitioners.
• Monitoring the provider’s credentials to remain in compliance with year standards.

Proactive steps can reduce credentialing time by weeks and eliminate preventable payer rejections.

Benefits of working with Medical Credentialing Companies:

Working with medical credentialing companies can be a game-changer to boost your revenue and standardize healthcare services. There are various benefits of choosing medical credentialing companies. After reading about them, you can get a clear idea of why you should choose a good credentialing service provider. Some of the key benefits of healthcare credentialing companies are:

• Effective medical credentialing leads to the most profitable and compliant.
• It offers streamlined scheduling and reduced waiting times, leading to improved patient experiences.
• The implementation of the rules and regulations by medical credentialing companies results in fewer cases of legal issues.
• Medical credentialing companies help boost financial stability and increase revenue.

Although much of this can be achieves in-house, to scale virtual care in an effective manner, significant expertise is needs in understanding the changing payer policies, licensure requirements, and digital infrastructure.

Final Thoughts

The problem of credentialing during the age of telemedicine is not unsolvable, although the issue is complex. Healthcare organizations need to ensure that their credentialing is modernizes as virtual care keeps expanding.

By cutting down on processing delays, better communicating with payers, and generally closing the gaps between the back office and practice, closing the listed gaps will enable providers to be more efficient and less likely to fall out of compliance in delivering care. Credentialing was once a bottleneck, but with the right systems and support, it will facilitate growth in contemporary healthcare delivery.