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Cover of The Credentialing & Billing Agency Playbook, 2026 edition, by the Credentik team
Ebook · 2026 edition

The Credentialing & Billing Agency Playbook

How to build, run and grow a profitable provider credentialing and medical billing agency

The operating manual we wish every agency owner had on day one: what to sell, how to price it, how to do the work payer by payer, how to stay compliant and how to grow from one person to ten.

$19.99PDF + EPUB · 209 pages

  • Instant download
  • Secure checkout by Stripe
  • Receipt + download link by email
  • 4parts
  • 27chapters
  • 9checklists
  • 8templates
  • 105glossary terms
  • 51primary sources
Who it’s for

Written for agency owners, and for the people about to become one

A small credentialing and billing agency, from a solo specialist working from home to a team of ten serving dozens of practices, is one of the most practical businesses in American healthcare. You don’t need a medical license or venture capital. You need process discipline, regulatory literacy and a way to keep hundreds of moving pieces from falling on the floor.

This is not a certification textbook and it is not a software manual. It is a field guide you can open at the problem in front of you.

You run a small agency

  • Price more profitably, including the legal limits on percentage-of-collections fees
  • Tighten tracking, follow-up and effective dates so applications stop stalling
  • Hire, write SOPs and scale without drowning

You are starting one

  • For experienced credentialing specialists, billers, coders and practice managers going out on their own
  • Entity, insurance, HIPAA foundations, contracts and your first services menu
  • A 90-day plan for your launch
What’s inside

Four parts that follow the life of an agency

Twenty-seven chapters, each ending with a key-takeaways checklist, plus four appendices you will reuse every week.

Part I

Start the Agency

The market, your services, the legal foundation, pricing that protects your margin, and contracts that protect everything else.

  1. The Opportunity
  2. Your Services Menu
  3. Setting Up the Business the Right Way
  4. Pricing Your Services
  5. Client Contracts and SLAs
Part II

Credentialing and Enrollment

From the first intake form to “you’re loaded and payable”, payer by payer, plus the maintenance that keeps providers in network.

  1. Credentialing 101: The Landscape
  2. Provider Intake and Document Collection
  3. NPPES and CAQH ProView
  4. Medicare Enrollment: PECOS and the CMS-855 Family
  5. Medicaid and Medicaid Managed Care
  6. Commercial Payers and Contracting
  7. Tracking, Follow-Up and Effective Dates
  8. Recredentialing, Expirables and Exclusion Monitoring
Part III

Medical Billing and Revenue Cycle Management

From the eligibility check to the final zero balance: clean claims, posting, denials, appeals, AR, patient balances and the numbers that prove it works.

  1. The Revenue Cycle and the Front End
  2. Coding, Charge Capture and Clean Claims
  3. Payment Posting, ERAs and Reconciliation
  4. Denial Management
  5. Appeals That Win
  6. AR Follow-Up and Patient Balances
  7. KPIs and Benchmarks
Part IV

Run and Grow

Compliance, people, technology, reporting, sales and scale: turning a capable practice into a durable business.

  1. HIPAA and a Compliance Program for Agencies
  2. Building the Team
  3. Tools and Technology
  4. Client Reporting and Retention
  5. Finding Clients
  6. Onboarding New Clients
  7. Scaling from One to Ten

Bonus: a complete business plan

New in Edition 1.2: Chapter 21, “How the Money Flows” — why payer and patient money goes to the practice, never your account; the Medicare and Medicaid billing-agent rules on percentage fees; matching ERAs to deposits; payer take-backs; refunds and credit balances; and a worked monthly fee statement with a sample contract clause.

New in Edition 1.1: a full, worked business plan for a fictional Florida credentialing and billing agency, from startup costs and pricing to a monthly P&L, 3-year projections, hiring plan and break-even. Use it as a template for your own.

9 checklists

Provider intake, enrollment tracker fields, monthly CAQH maintenance, change of information, new billing client onboarding, the daily and weekly billing routine, monthly close, AR follow-up per claim and a monthly compliance checklist.

8 templates

Engagement letter and BAA outlines, a payer authorization letter, credentialing follow-up and escalation scripts, a Medicare redetermination cover letter, an underpayment dispute letter, a pending-provider policy and a client monthly report.

Glossary and sources

105 plain-English definitions of the terms you hear every day, and the 51 primary sources the book relies on (CMS, HHS OIG and OCR, NCQA, CAQH and the CFR), checked October 2026.

Table of contents

A look at the contents

  1. Introduction6
  2. Part I — Start the Agency9
  3. 4. Pricing Your Services27
  4. 5. Client Contracts and SLAs34
  5. Part II — Credentialing and Enrollment39
  6. 9. Medicare Enrollment: PECOS and the CMS-855 Family55
  7. 12. Tracking, Follow-Up and Effective Dates68
  8. Part III — Medical Billing and Revenue Cycle Management78
  9. 16. Payment Posting, ERAs and Reconciliation90
  10. 17. Denial Management95
  11. 18. Appeals That Win99
  12. Part IV — Run and Grow114
  13. 21. HIPAA and a Compliance Program for Agencies115
  14. 27. Scaling from One to Ten142
  15. Conclusion: Your 90-Day Plan146
  16. Appendices: Checklists · Templates · Glossary · Sources149

Selected entries. Page numbers refer to the PDF edition.

Free sample

Read the opening of Chapter 4: Pricing Your Services

Chapter 4 · Pricing models, the legal limits on percentage-based fees, worked examples and the margin math that keeps a small agency alive.

Pricing is the single biggest lever you control. A ten percent price increase on work you are already doing goes straight to profit; a ten percent increase in clients brings ten percent more work with it. Yet most new agencies price by looking at a competitor’s website and charging a little less. This chapter gives you a better method: understand your cost per unit of work, choose a pricing model that matches the service, check the legal constraints and then set prices that leave room for the inevitable surprises.

Step 1: Know your fully loaded hourly cost

Every price should start from what an hour of your team’s time actually costs.

Fully loaded hourly cost = (annual wages + payroll taxes and benefits + allocated overhead) ÷ annual productive hours

Productive hours are not 2,080. Subtract holidays, vacation, sick time, training, internal meetings and the unbillable minutes between tasks. A realistic figure for a full-time specialist is 1,500–1,650 productive hours per year.

Example: calculating a loaded rate

Bright Path Credentialing employs a credentialing specialist at $52,000 a year. Payroll taxes, workers’ comp and a modest health stipend add 20% ($10,400). Bright Path’s annual overhead (software, insurance, phone, rent share, accounting and a share of the owner’s management time) is $36,000, split across two specialists ($18,000 each). The specialist delivers about 1,600 productive hours.

($52,000 + $10,400 + $18,000) ÷ 1,600 = $50.25 per productive hour.

Every hour of work Bright Path sells must recover at least $50 before it earns a dollar of profit.

The chapter continues with hours per unit of work for every common service, eight pricing models compared side by side, the legal limits on percentage-of-collections billing, worked price lists and the margin math.

Also from the Credentik team

The NP Practice Launch Consultancy Playbook

Thinking about helping nurse practitioners open their own practices? The new playbook covers state feasibility, discovery, packages and pricing, contracts, credentialing, billing readiness, compliance and launch management, with a 12-template toolkit.

See the NP Consultancy Playbook
Free download

Get the free Credentialing Checklist

The provider intake checklist from the Agency Playbook (Appendix A.1): every document and data point to collect before you start a provider’s payer applications. A printable two-page PDF, yours to adapt, sent to your inbox.

We'll email you the checklist and a few tips for running your agency — unsubscribe anytime.

Get the playbook for $19.99

PDF + EPUB, 209 pages. Download it right after checkout; the receipt email has your download link too.

Questions

Frequently asked

What format is the book in?
You get both a PDF (209 pages, designed for reading on screen and printing) and an EPUB for Kindle, Apple Books, Kobo and other e-readers. Both files are included in the one price.
How do I get it after I pay?
Instantly. After checkout you land on your download page with buttons for the PDF and the EPUB, and we email you a receipt with a link back to that page. The link works for 30 days, so save the files somewhere safe.
How do I pay?
Checkout is handled by Stripe, so you can pay by card and other methods Stripe offers in your country. Credentik never sees your card number. If you have a promotion code, enter it at checkout.
What is your refund policy?
14-day money-back guarantee: if the playbook isn’t useful to you, email support@credentik.com within 14 days of purchase and we’ll refund you in full.
Do I need to use Credentik software to use the book?
No. The playbook is vendor-neutral: the workflows, checklists and templates work with spreadsheets or any software. Chapter 23 includes a selection checklist for choosing tools.
Can I share the book with my team?
Your purchase is for you. You may copy and adapt the checklists and templates for internal use in your own agency. For a team license, email hello@credentik.com.
Is this legal or tax advice?
No. The book points out where rules vary by state, payer or contract, and lists the primary sources it relies on (CMS, HHS OIG, HHS OCR, NCQA, CAQH and the CFR, checked October 2026). For your entity, contracts and pricing model, talk to a qualified healthcare attorney or accountant.