A credentialing business does one thing for its clients: it gets their providers able to see patients and get paid, and keeps them that way. Everything else, from software to pricing, follows from doing that reliably for many clients at once.
What a credentialing company sells
Practices hire a credentialing company because enrollment work is detailed, slow and easy to get wrong, and because a missed deadline costs them revenue. Most agencies offer some mix of these services:
- Initial payer enrollment for new providers and new practices: Medicare, the state Medicaid program, and commercial and managed care plans.
- CAQH ProView setup and maintenance, including regular re-attestation. CAQH asks providers to re-attest every 120 days (CAQH ProView FAQs).
- Recredentialing and revalidation with commercial payers, Medicare and each state Medicaid program, on their own schedules.
- Ongoing monitoring: license, DEA, board certification and malpractice expirations, and monthly exclusion screening.
- Demographic and group updates: new locations, address changes, a provider joining or leaving a group.
- Primary source verification for groups or health plans that need verified files, if you choose to offer it.
You do not need to offer everything on day one. Many successful agencies start with enrollment and CAQH maintenance for one specialty or one state, then add services as clients ask.
Skills and certifications
The work rewards people who are organized, persistent on the phone and comfortable with forms that do not forgive mistakes. Most founders come from a practice’s billing or credentialing office, a hospital medical staff office, or a billing company.
The National Association Medical Staff Services (NAMSS) offers three certifications: CPCS (Certified Professional Credentialing Specialist), CPMSM (Certified Professional Medical Services Manager) and CPES (Certified Provider Enrollment Specialist). They are not legally required, but they give you a structured body of knowledge and something concrete to show clients.
Know the systems you will use every week: CMS PECOS for Medicare enrollment, your clients’ state Medicaid provider portals, CAQH ProView, and each major payer’s enrollment process.
Legal and business setup
This is general information, not legal or tax advice. Talk to an attorney and an accountant before you sign your first client.
- Business entity. Many service businesses form an LLC or corporation to separate business and personal liability, and get an EIN for taxes and banking.
- Insurance. Ask a broker about professional liability (errors and omissions) coverage and cyber coverage. A missed filing can cost a client real money.
- Client agreement. Define the scope (which payers, which providers, which services), what the client must provide and by when, your fees and payment terms, and what happens when the client is slow to respond.
- HIPAA. If you handle protected health information on a client’s behalf, you are likely a business associate and need a Business Associate Agreement. HHS publishes sample BAA provisions. Any software you use to store that information should also be covered by a BAA.
- Authorizations. Payers require the provider (or an authorized official of the group) to sign applications and attestations. Your agreement should make clear that you prepare and submit, and the provider attests.
Tools you will need
At minimum: secure document storage, a way to track every application and its follow-ups, a calendar of every expiration and recredentialing date, and a way to communicate with clients that is not your personal inbox.
Many people start with a spreadsheet and a shared drive. That works for a handful of providers. It breaks when you have several clients, a teammate, or dates in more than one state. Our guide to spreadsheets vs credentialing software covers where the line usually falls.
If you choose software, look for something built for agencies rather than single practices: separate client records, a portal per client, reminders that run on their own, recredentialing tracking, and a BAA.
Pricing your services
Common models include a fee per payer application, a package per provider, a monthly maintenance fee per provider, and hourly or project pricing for clean-up work. Whatever you choose, write down exactly what each fee includes. Our guide on how to price credentialing services walks through the trade-offs.
Finding your first clients
- Your network. Practices and colleagues you have worked with already know your work.
- Billing companies. Many billing companies need a credentialing partner and see the cost of enrollment problems every day.
- New practices and new providers. A practice that is opening, adding a location or hiring needs enrollment done before it can bill.
- A niche. Specializing in a specialty (for example behavioral health) or a region lets you learn its payers deeply and makes referrals easier.
Your first 90 days
- Write your service menu, prices and a standard client agreement.
- Build a standard intake: the information and documents you need from every practice and provider. Our client onboarding checklist is a starting point.
- Set up one system of record for applications, deadlines and documents before your second client, not after your tenth.
- Decide how you will report progress to clients, and how often.
- Track how long each payer actually takes for you. That history becomes your best sales and planning tool.
How Credentik helps a new agency
Credentik is built for credentialing and billing agencies serving many practices. The Solo plan is $79 a month and includes credentialing checklists and primary source verification, document requests and e-signature, recredentialing tracking, exclusion monitoring and CAQH; the Agency plan adds white-label client portals, billing and automation as you grow. Every plan has a 14-day free trial and no credit card. See Credentik for solo specialists and growing agencies.