As with many processes and systems in the universe of healthcare, a confusing duo exists between “payer enrollment” and “medical credentialing”. The process of payer enrollment and credentials verification is intricate and it becomes more so with each passing year.
Without proper enrollments and credentialing, your cash flow will be negatively impacted and Enter’s revenue cycle management platform will not function properly.
Payer enrollment is the process of requesting enrollment in a healthcare insurance panel and plan. If you are a provider and you would like to be able to get paid by your patient’s insurance, you will need to be enrolled with the payers. This process requires a substantial amount of application documents and will certainly require the applicant to be extremely organized since the process is so document and detail rich.
Once applications are submitted to the payer, the provider’s medical credentials must be submitted. With supporting documentation attached. It is important that the credentials are verified before the practice is accepted by the payer. If all goes well, a contract will be created and signed.
Medical Credentialing is the exhaustive verification process for healthcare providers of background, education, identity, residency, licensing and other criteria. Medical credentialing and physician credentialing can sometimes be used interchangeably. To avoid confusion, medical credentialing applies to any professional who administers care: physicians, therapists, nurses, radiologists, etc.
For the individual physician credentialing is exhaustive, it takes roughly 4 months to complete. Physicians will need to submit credentialing data like street addresses, a recent photograph, a copy of a National Provider Identifier (NPI), and more.
This basic information must then be coupled with even more extensive information, such as:
Payer enrollment (also known as provider enrollment) credentials are specifically used for applying to an insurance panel. Medical credentialing is a repository of information to verify the valid status of a healthcare practice and each of its members. Medical credentialing must be completed before a provider or organization can enroll with or bill an insurance carrier.
Payer enrollment processes vary. Different enrollment processes are used for new medical staff vs when practices are applying staff members to MediCare.
Different types of enrollment have various institutional references. For example, Centers for Medicare & Medicaid Services (CMS), are the typical resource when enrolling a practice into a Medicare program. Likewise with commercial payer enrollments.
The National Association of Medical Staff Services provides thorough documentation on payer enrollment’s typical steps in an ideal setting are as follows:
Medical credentialing requirements:
Criminal background disclosure reports
These items are used when a medical practice files an application. From there, the credentialing and enrollment specialists will file this information in their databases to verify and format the submission. The final verification report is automatically archived.
This process is paperwork intensive and requires serious organization. Most medical professionals are typically ridiculously busy and require some extra help managing credentialing and enrollments.
At Enter, we typically recommend folks work with enrollment and credentialing specialists to manage both processes (medical credentialing and payer enrollment) simultaneously. They will be doing all the heavy lifting so practitioners can focus on patient treatment and staff can focus on more critical tasks.
One very important note - we can’t stress enough the importance of great organization. We are huge fans of the team at Modio Health. Built by a team of medical providers and credentialing experts - Modio's innovative platform transforms slow and tedious credentialing processes like license renewals, re-credentialing, and payor applications into a seamless, hassle-free experience. Modio's OneView links the gap between billing and credentialing departments to ensure clients minimize credentialing-related billing denials and expedite new payor enrollment.
A platform that manages credentialing and insurance enrollment is a lifesaver when paperwork becomes tedious and complicated. Such as is the case with the difference between payer enrollment and credentialing.
The primary goal of a Credentialing Specialist is to ensure clinical staff and services meet all established contractual, federal and state standards.
The Credentialing Specialist will verify and maintain databases regarding the licensing including any limited licensed staff meeting requirements for obtaining a full license, credentialing, training, education, timely continuing education, re-certifications and re-credentialing of the professional clinical staff as mandated by state and federal regulations. They will also review applications, verify both individual and clinic accreditation, maintain records of verification, conduct internal audits and work with external auditors as needed.
The Credentialing Specialist will ensure interpretation and compliance with the appropriate accrediting and regulatory agencies, while developing and maintaining a working knowledge of the statues and laws relating to credentialing. They are responsible for the accuracy and integrity of the credentialing database system and related applications.
If your practice needs help with credentialing, enrollment, or contracting, please reach out to the Enter Enrollment Team anytime.
The definitive guide on credentialing and enrollments. What is the difference? Why is it necessary? How to do it perfectly, the first time.