Master the Differences Between Credentialing & Enrollment

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Master the Differences Between Credentialing & Enrollment

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credentialing and enrollment

Interchanging the terms credentialing and enrollment is a surefire way for your provider reimbursement to take a serious hit. The problem is that there is definitely overlap between them. Ultimately, however, having a solid  understanding of each process is the only way to more efficiently and accurately manager your payor approval process and to get your claims paid.

What Is Provider Credentialing?

The American Medical Association (AMA) defines credentialing as follows:
The process of obtaining, verifying, and assessing the qualifications of a [clinician so that he/she may] provide care or services in or for a health organization.

There are a variety of reasons you may be required to manage the credentialing process for your provider. Some of these include employment, hospital privileges, accepting insurance, etc.

Basically, credentialing is the process by which your provider’s qualifications are double checked and confirmed.  Depending on what type of organization is doing the verifying, the information you are required to provide can change.  Some typical items requested during the credentialing process include:

  • Education
  • Licenses
  • Diplomas
  • Certifications
  • Work History
  • References
  • etc.

When supplying the above items, they are normally required to be primary source verified. This means you must check with the original source or entity that issued each individual credential to confirm its accuracy. Your provider may also be required to get background checks of their financial, criminal, and possibly even social media history. credentialing and enrollment.

What is Provider Enrollment?

Just like credentialing, the enrollment process can be time-consuming and require a significant amount of tracking and follow up.  So, if it is such a pain, why even bother.  Because this is how your practice gets access to patients and gets reimbursed. credentialing and enrollment.

The AMA defines enrollment as follows: The process of applying to health insurance plans/networks for inclusion into provider panels to bill and be paid for services rendered.

Enrollment occurs when your provider is applying to partake in any number of programs (i.e. insurance plan/network, hospital privileges, specialty society membership, government program, etc.).  This is where credentialing comes in. During this process, your provider will be asked to supply items that prove he/she has the experience, training, education, and/or background to qualify for acceptance.

Each health insurance plan/network applied to will likely have a separate enrollment application and process. Every detail must be correct for your provider to have any hope of being approved. This is especially true for government health plans like Medicare and Medicaid. Government plans typically are more detailed and are accompanied by even stricter rules and regulations.

Once your enrollment application has been completed and submitted, it will be reviewed for accuracy and possible acceptance. When a determination has been made, you will be notified. If your application is approved, you may be asked to sign a contract with the specific terms of the relationship. Once the contract is signed, your provider will be considered “in-network.”

Repetition Anyone? credentialing and enrollment.

To be competitive, your provider will most likely enroll in a dozen or more health plans. Each enrollment application will most likely be accompanied by a variety of required verification documents. This process takes between 8 to 10 hours to set up, and then another 3 to 5 hours each time the information must be updated. credentialing and enrollment.

Note: Other terms for this updating process include re-credentialing and re-attestation.

So, it’s all up to you. Yes, your provider must have the correct experience and training to be approved, but if you don’t submit the enrollment application and supporting credentialing documents correctly, it may never happen. It is essential that you manage this process correctly each and every time – especially when it comes to Medicare.

To help you save time, reduce headaches and speed up your reimbursement, credentialing expert, Yesenia Servin, CPMSM, PESC, is presenting a 60-minute online training specific to the Medicare credentialing portal entitled, Cut Through CAQH Credentialing Portal Confusion to Get Paid Faster. Access to this online training is limited. To ensure your access, register today.

Source: AMA enrollment and credentialing definitions were taken from the following credentialing, privileging and enrollment 2019 presentation:

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Meet Your Writer

Samantha (Sam) Saldukas

President, Healthcare Training Leader

Samantha (Sam) Saldukas started Healthcare Training Leader in 2012 after working as a leader in healthcare information for 20+ years. She wakes up every morning striving to help physician and dental offices improve the business-side of their practices. Her background in nursing and running her husband’s practice makes her passionate about figuring out how to help your practice succeed. More than 5 years later, thousands of practices have turned to Healthcare Training Leader for affordable, easy-access solutions to their most challenging business and regulatory issues. Some of the key topics include coding, billing, compliance, credentialing and practice management. Healthcare Training Leader guarantees the quality of every single training it offers.  Each session is backed by a money-back  guarantee of satisfaction to ensure you get when you need.