Difference Between Provider Enrollment And Credentialing

Provider-Enrollment-Credentialing
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Overview

According to numbers released by the Kaiser Family Foundation, one in every five in-network medical claims sent to marketplace insurers got denied in 2020. Medical claims denials cost providers both time and profit. In an effort to improve medical billing processes and cash flow, it is important to look at every affecting factor. Medical credentialing and provider enrollment are two influencing factors that are easily overlooked.

What is Provider Enrollment?

Also referred to as payer enrollment, provider enrollment is a process that involves adding providers to different payer plans to make sure those providers can be paid for their services. For example, providers need to be enrolled with certain health plan providers to be considered as “in-network” providers. Providers can also opt to enroll with state and federal insurance payers like Medicaid and Medicare.

What is Physician Credentialing?

Sometimes called “getting included on an insurance panel,” provider credentialing is a process that gets the provider properly credentialed with an insurance company. This process takes place after a provider requests to join a particular payer or network as a provider. Credentialing a provider involves a lengthy process of providing documents and information to the payer to verify things like education, malpractice insurance coverage, and licensure.

How Are Provider Enrollment and Credentialing Services Interrelated?

Credentialing and provider enrollment are interrelated because you can’t successfully complete the provider enrollment process without medical credentialing. If an interested practitioner submits an application to be part of a network under a certain payer, credentialing ensures claims don’t get denied.

For example, say a dentist applies to enroll with Medicaid as a provider. However, they don’t go through the credentialing process. They begin sending in medical billing claims. The claims are concurrently denied because the provider has not been properly credentialed, and the contract between the provider and network is not valid. Therefore, you essentially cannot have a successful provider enrollment without also completing the medical credentialing process.

How Does the Provider Enrollment and Credentialing Process Work?

The first steps in the provider enrollment process are relatively straightforward. The provider simply submits a request to a payer or health insurance network to enroll in that network as a provider. From here, several steps take place to complete the full process:

  • The provider completes the credentialing process
  • The provider submits the necessary documents to verify credentials
  • The provider signs a contract with the payer

While these steps sound simple, the credentialing process can get pretty complex. There are a few ways credentialing can be done. One, the provider can use the credentialing application provided by the payer. Two, the provider can utilize data from the Center for Affordable Quality Healthcare (CAQH). Or, three, the provider can complete a standardized state-level credentialing application.

To further complicate the credentialing and provider enrollment process, different organizations have unique requirements. For example, there can be extra steps when working with government healthcare programs than there are with networks that have a commercial insurance designation.

Whichever route is taken, the provider must be extremely meticulous about the process and make sure all required information is both recorded and submitted. Once all information has been supplied, the payer usually sends the information to its contracted or in-house credentialing committee to get the final approval.

How Long Does the provider Enrollment and Credentialing Process Take?

Timelines vary depending on which payer a provider is enrolling with. However, the general timeline can be anywhere from three to six months. Additionally, any mistakes along the way—such as not providing documentation to prove domestic education—can prolong the process.

Why is Provider Enrollment a Necessary Part of Healthcare? As of 2021, research indicated that more than 300 million individuals in the United States had some type of health insurance. With the population at around 334 million, this means almost every patient that sees a provider for care likely uses insurance to cover some of the cost. Provider enrollment is the foundational step that must be taken in order to work with a payer to be paid for the services provided to insured patients.

Credentialing is also an important step, but it is more important for other reasons. In short, if a provider is not properly credentialed, this could mean the quality of care a payer is helping a patient cover may not be up to the expected standards. For example, if a provider that has not been properly educated or licensed enrolls in a network, the network shares some responsibility if something goes wrong during patient treatment. Credentialing is a bit like a checks and balances process that upholds the quality of care provided to the average patient.

Can You Get Enrollment and Credentialing Services from a Single Point of Contact?

Yes. It is possible to work with a third party for provider enrollment and credentialing services to get enrolled. For many practitioners, this is actually preferred because it saves them time and the risk of having their application rejected. The full process is more streamlined and simple, and the service provider is already familiar with what is required with different payers for the process.

Tips for Improving the Process of Provider Credentialing and Provider Enrollment

Improving the Process of Provider Credentialing

To improve the provider credentialing and enrollment process, be sure to remember these tips:

  • Research each payer to know what is expected before beginning the process
  • Be meticulous about supplying information and documents the payer requests
  • Be patient – the credentialing process can take months to be fully complete and ready for contracting
  • Don’t hesitate to work with a credentialing and provider enrollment service if you feel overwhelmed

Let PrognoCIS Take the Stress Out of Provider Enrollment and Medical Credentialing

If you are a care provider looking to enroll in a new network but feel intimidated by the time and requirements, PrognoCIS can help. Our Medical Credentialing Services offer a quick and easy solution that requires only a few short steps. Reach out to get the process started or discuss your needs as a provider.

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