A decade ago, a small practice could hire a physician in the spring, push paperwork through over the summer, and have that clinician billing in-network by early fall. Payer rosters were smaller, forms were shorter, and a determined office manager could shove an application across the finish line with a few phone calls. The same hire now routinely sits in enrollment limbo for four to six months, unable to bill most commercial plans, while the practice keeps paying salary, benefits, and overhead against zero collectible revenue.
For a growing group, that lag is more than a back-office annoyance. It’s the single biggest variable in whether the next hire lands profitable, breakeven, or as a hole in the P&L. And the decisions that shape it get made months before the offer letter goes out.
Decide When to Start Enrollment, Not When to Start the Job
Timing is the first decision, and most practices get it wrong by anchoring on the start date instead of the enrollment clock. Commercial payer credentialing commonly runs 90 to 150 days in 2026. Medicare sits closer to 60 to 90 days through PECOS, and Medicaid runs anywhere from a month to well over six, depending on the state. If you sign an offer for a July start and begin enrollment in June, the summer is already lost.
A better move is to make the signed offer the starting gun for paperwork, not for the clinical calendar. Some practices go further and open a CAQH profile and gather primary-source documents before the candidate has even accepted, so the packet can be submitted the day the ink dries. Aggressive, sure. Still cheaper than a clinician sitting idle in September.
Whichever path you pick, the underlying data has to live somewhere clean and current. Purpose-built credentialing software that keeps licenses, DEA registrations, board certifications, and CAQH attestations in one place lets packets be generated on demand instead of rebuilt from folders every time a payer asks.
Decide How Many Payers Are Worth the Fight
New groups often try to enroll every provider with every payer in the market. It sounds thorough. In practice, it multiplies the workload without matching it to revenue.
Pull your payer mix before you start. If three plans account for eighty percent of your collections, those applications get submitted first, tracked weekly, and escalated the moment they stall. Smaller plans can wait, or in some cases be skipped entirely if the volume doesn’t justify the ongoing revalidation burden. A BDO analysis on payer credentialing points out that most delays trace to handoff breakdowns and incomplete information rather than payer intransigence, which means a focused packet on your top plans moves faster than a scattered push at all of them.
Decide What the Provider Does While Enrollment Runs
The last decision is the most uncomfortable one: what does the new clinician actually do during those months of limbo? A handful of options exist, and none of them are perfect:
- Cash and self-pay work. Wellness visits, cosmetic services, or direct-pay specialty consults that don’t route through commercial plans and can start on day one.
- Bill under a supervising provider where rules allow. Locum tenens arrangements and certain incident-to scenarios can generate revenue during the wait, though the rules are payer- and state-specific and easy to get wrong.
- Load the clinician with non-billable value. Chart prep, protocol development, staff training, and patient onboarding won’t fund the salary, but they compress ramp-up time once enrollment closes.
None of these fully closes the revenue hole. What they do is turn a passive wait into a managed one, and that’s the difference between hiring plans that survive contact with reality and hiring plans that don’t.
