When this behavioral health group first contacted Medwave, its office manager was spending 25 to 30 hours a week on credentialing on top of her regular job. The practice had 10 providers seeing telehealth patients in six Southeastern states, roughly 45 payer plans to keep straight, and new hires who waited four to five months […]
IMLS, Interstate Medical Licensure Compact, Telehealth Credentialing, Telemedicine Credentialing
Value-based care (VBC) is a payment model in which providers are reimbursed based on patient health outcomes and cost efficiency rather than the volume of services delivered. Under the traditional fee-for-service model, a provider is paid a set rate for each procedure or visit regardless of whether the patient’s condition improves. Under value-based reimbursement, payment […]
Accountable Care Organizations, Bundled Payments, Capitation, Pay-for-Performance, Value-based Reimbursement
Three regulatory areas are generating the most immediate compliance and revenue impact for medical practices right now. No Surprises Act billing requirements for out-of-network services, the CMS Physician Fee Schedule updates that adjusted payment rates for dozens of common procedure codes, and Medicare Advantage plan policy changes that affect prior authorization timelines and coverage determinations. […]
Decoding Payment Changes, Fee Schedule, Medicare Advantage Payment, Regulatory Challenges
PECOS, the Provider Enrollment, Chain, and Ownership System, is the CMS web-based portal through which healthcare providers and suppliers enroll in Medicare, update their enrollment information, and manage their participation status. Any provider who wants to bill Medicare for services must have an active, accurate PECOS enrollment record. Billing Medicare without an active enrollment, or […]
CMS, Medicare, Medicare Enrollment, PECOS
In-house credentialing costs a medical practice $75,000 to $100,000 per year once salary, benefits, payroll taxes, software, and management oversight are fully accounted for. That figure surprises most practice administrators who assume handling credentialing internally is the lower-cost option. Outsourced credentialing services typically run $100 to $300 per application. That’s also per provider, per payer […]
Medical Credentialing, Outsourced Credentialing
Electronic Remittance Advice (ERAs) and real-time claim status checks are two distinct tools used to monitor claims in the medical billing process, and they are not interchangeable. An ERA is the electronic payment document a payer sends after adjudicating a claim, it contains the exact payment amount, adjustment codes, EFT or check number, and patient […]
Claim Status Check, ERAs, Real-Time Claim Status Check
Modifier 59 is appended to a CPT code to indicate that a procedure or service was distinct and independent from another service performed on the same day, and that the two services should not be bundled into a single payment. It is used when two procedures would normally be considered part of the same clinical […]
Modifier XE, Modifier XP, Modifier XS, Modifier XU, X Modifiers
The 2026 CPT coding updates took effect January 1, 2026, with the most significant changes affecting remote patient monitoring, telehealth billing, evaluation and management documentation, and interventional radiology. CMS published the full list of new, revised, and deleted codes in the annual update to the CPT/HCPCS code list, available directly from CMS.gov. Claims submitted with […]
CPT Code Modifiers, E/M coding, Interventional Radiology, Remote Patient Monitoring, Telehealth Billing
Average Revenue Per Encounter (ARE) is the total net revenue a medical practice collects divided by the total number of patient encounters over a given period. The formula is straightforward: Total Revenue Collected divided by Total Number of Patient Encounters equals ARE. A practice that collected $90,000 last month across 600 patient visits has an […]
ARE, Average Revenue Per Patient Encounter, Coding and Billing, Industry Benchmarks, Payer Mix, Point-of-Service Collection
The Merit-Based Incentive Payment System (MIPS) determines annual Medicare reimbursement adjustments for nearly 800,000 eligible clinicians through a four-category scoring framework. Quality performance accounts for 30% of the final score, Cost accounts for 30%, Promoting Interoperability accounts for 25%, and Improvement Activities accounts for the remaining 15%. Final scores translate directly into payment adjustments applied […]
Medicare Reimbursement, MIPS, Promoting Interoperability, Quality Reporting, Value Based Care
Allied health credentialing differs from physician credentialing in three significant ways: many allied health professions are not eligible for CAQH ProView profiles, payer panels for allied health providers are more restricted and specialty-specific than physician panels, and the licensing and certification requirements vary by profession and state in ways that require specialty-specific documentation for each […]
Allied Health Credentialing, OT Credentialing, PT Credentialing, SLP Credentialing
Provider credentialing is how insurance companies and hospitals confirm that a provider holds the qualifications they claim, then approve that provider to bill inside their network. Without it, there’s no Medicare or Medicaid billing and no commercial reimbursement, however well trained the provider is. Plan on 90 to 120 days with most commercial payers. It […]
CAQH, CPCS, Credentialing Lifecycle, CVOs, NPPES, PECOS
Medicare credentialing is the process through which CMS authorizes a healthcare provider to see Medicare beneficiaries and bill for covered services. Enrollment is managed through PECOS, the Provider Enrollment, Chain and Ownership System, and processed by regional Medicare Administrative Contractors (MACs) assigned to specific geographic areas. Processing typically takes 60 to 90 days from submission […]
Credentialing, Medicare, Medicare Credentialing, PECOS
Medical credentialing requirements vary significantly depending on the situation. A new physician joining an established group practice faces a different process than a solo practitioner opening a second location, a surgeon seeking hospital privileges, or a provider adding telehealth services to an existing credential. Each scenario has its own documentation requirements, payer-specific steps, and timeline […]
CAQH Profile Updates, Hospital Privileging, Locum Tenens, Multi-State Licensing, Telehealth
Relocating a medical practice requires restarting the credentialing process with most payers, regardless of how long the provider has been credentialed in their previous location. Insurance networks operate regionally, and a credentialing approval in one state does not transfer to another. A Blue Cross Blue Shield contract in Pennsylvania is held by a separate regional […]
Credentialing, Credentialing Challenges, Relocation Credentialing
Three medical billing trends are having the most immediate operational impact in 2026. AI-powered claim scrubbing and denial prediction becoming standard in billing departments of all sizes, electronic prior authorization reaching meaningful interoperability across major payers, and value-based payment arrangements tying a growing share of reimbursement to quality metrics rather than visit volume. Each trend […]
AI, Cybersecurity, Interoperability, Price Transparency, Prior Authorization, Telehealth Billing
Medicaid credentialing differs from Medicare enrollment in one fundamental way. There is no single federal process. Each state operates its own Medicaid program with its own application portal, documentation requirements, and processing timelines. In states that have expanded Medicaid through managed care, providers must credential separately with each managed care organization (MCO) operating in the […]
Credentialing, Medicaid, Medicaid Credentialing, Medicaid MCO Enrollment
The National Provider Identifier (NPI) is a unique 10-digit number assigned by CMS to identify healthcare providers on claims. There are two types, Type 1 NPI and Type 2 NPI. A Type 1 NPI belongs to an individual provider. A physician, nurse practitioner, physical therapist, or any licensed professional who delivers patient care. A Type […]
Billing Mistakes, CMS-1500, Group NPI, Individual NPI, Provider NPI
Getting credentialed with insurance companies should be straightforward, but for many healthcare providers, it turns into a months-long headache. You’ve spent years earning your medical degree, completing residencies, and building your practice. Yet somehow, filling out insurance forms becomes one of the most frustrating parts of starting or expanding your healthcare business. The credentialing process […]
CAQH, Credentialing Denials, DEA Registrations, Hospital Privileges, Malpractice History, NCQA
Provider credentialing serves as a fundamental quality assurance process in healthcare, ensuring patients receive care from qualified medical professionals. For healthcare providers seeking to join PacificSource’s network, mastering the credentialing process opens doors to serving one of the Pacific Northwest’s most established health insurance organizations. PacificSource operates as a not-for-profit health insurer serving Oregon, Washington, […]
Credentialing, Medical Credentialing, PacificSource, PacificSource Credentialing