Payer Timelines: Why "Averages" Mislead (And How to Beat the Clock)

"How long until I can start billing?"

It is the question every Credentialing Specialist and Practice Manager dreads. The standard industry answer is usually a safe, rehearsed range: "Expect 90 to 120 days."

But in reality, that "average" is a dangerous metric. It flatters the slow payers, penalizes the fast ones, and completely ignores the nuances of specific channels. For a new provider joining a practice, "average" doesn't pay the bills, specific dates do.

Relying on broad averages leads to revenue forecasting errors and frustrated stakeholders. To manage expectations and accelerate revenue, we need to deconstruct the timeline by channel and understand where the bottlenecks truly lie.

The Problem with "The Average"

The concept of a "90-day turnaround" is a statistical aggregate that lumps together efficient electronic submissions with messy paper trails.

If you submit a clean web application to a responsive Medicare Administrative Contractor (MAC), you might see approval in 30-45 days. If you submit a complex application to a smaller Medicaid HMO with a backlog, it could take 180 days.

Averaging these two scenarios gives you a number that applies to neither. The "Average" hides the outliers, and unfortunately, the outliers are where the most revenue is lost.

Deconstructing the Channels

To predict timelines accurately, you must look at the specific mechanism - the channel of enrollment.

1. Medicare (PECOS vs. Paper)

· The Channel: The Provider Enrollment, Chain, and Ownership System (PECOS).

· The Reality: Medicare is surprisingly transparent compared to commercial payers.

· The Timeline Factor: Electronic PECOS applications are generally processed within 45–60 days. Paper applications (CMS-855 forms) automatically double that timeline.

· The "Gotcha": The clock stops the moment they find an error. Medicare does not "fix" mistakes; they send a development letter. If you miss the response deadline (usually 30 days), the application is rejected, and the clock resets to day zero.

2. Commercial Payers (The CAQH Dependency)

· The Channel: Direct portals or via CAQH ProView.

· The Reality: Commercial payers (Aetna, Cigna, UHC, etc.) are often "black boxes."

· The Timeline Factor: While they quote 90-120 days, the real variable here is your CAQH profile. Many commercial payers scrape data from CAQH.

· The "Gotcha": If your CAQH profile hasn't been re-attested in the last 120 days, or if a document is illegible, the payer simply pauses the application - often without notifying you. The "average" timeline assumes your CAQH is perfect. If it’s not, add 4 weeks.

3. Medicaid (The State Variable)

· The Channel: State-specific web portals.

· The Reality: This is the Wild West.

· The Timeline Factor: Some states have modernized, streamlined portals. Others are dealing with massive staffing shortages and backlogs.

· The "Gotcha": Medicaid revalidation cycles. If a state is in the middle of a massive revalidation push for existing providers, new enrollment applications often get pushed to the bottom of the pile.

How to Beat the "Average"

You cannot control the payer’s internal workload, but you can control the quality of your submission. Here is how to move from the "slow track" to the "fast track."

1. Aim for "First-Pass Acceptance"

The biggest killer of timelines is the RFI (Request for Information). Every time a payer has to ask you for a missing NPI, a clearer copy of a malpractice face sheet, or an explanation of a gap in work history, your application goes to the back of the queue.

· The Fix: Use a centralized platform like CredyApp to store and validate documents before you apply. Ensure no data fields are left blank.

2. The "Squeaky Wheel" Strategy

Do not wait for the 90-day mark to follow up.

· The Fix: Implement a follow-up cadence. Check status at Day 15 (receipt confirmation), Day 30 (in process), and Day 60. Document every reference number and the name of the representative you spoke with.

3. Delegated Credentialing (The Ultimate Shortcut)

If your group is large enough, pursuing delegated credentialing takes the timeline out of the payer's hands entirely.

· The Reality: You perform the credentialing in-house, and the payer accepts your roster. This creates a "notification" timeline rather than an "approval" timeline, often cutting the wait to 30 days or less.

Stop telling your providers "90 to 120 days." Instead, tell them: "It depends on the quality of our data and the specific payer channel."

In the race for reimbursement, precision beats averages every time. By centralizing your data and automating your document management, you don't just track the timeline—you shorten it.

Is your team spending too much time chasing applications? CredyApp gives you a unified dashboard to manage provider data, track expiries, and streamline the enrollment process. Stop guessing and start managing.

Read more articles