Credentialing & Payer Enrollment

Credentialing and payer enrollment are two of the most important first steps to opening your practice. If you have decided to accept insurance you will need to submit applications for participation with your desired insurance plans before you can be reimbursed for your services. So what's the difference between credentialing and enrollment? Keep reading to find out!

The two terms are often used as one in the same, but credentialing is the vetting process of a medical provider and payer enrollment is submitting applications for participation. Payer enrollment cannot be done without credentialing as this is how the insurance companies decide if you meet the criteria to participate in their networks. And practices will want to verify a provider's credentials to make sure they are licensed to practice medicine before adding them to their roster. A provider will need to supply many pieces of information; medical license, malpractice insurance, work history along with education and training among others. Providers are encourages to register with CAQH, Council for Affordable Quality Healthcare, where all these required documents can be uploaded. Insurances utilize this during the enrollment process to verify providers credentials.

Credentialing & payer enrollment is a long and time consuming process. The rule of thumb is to allow 90-120 days, however it can sometimes take longer. Nothing can be done to speed up the process, but proper documentation and accurate applications can help avoid any delays. This is why it is a good idea to hire a Credentialing Specialist to do this for you and your practice. When you work with a Credentialing Specialist they will obtain the required documentation for you, submit all applications on your behalf and track their progress through completion. One incorrect box checked or a missing document can kick your application back and start the process from the beginning. It's also important for your credentialing specialist to obtain copies of your contracts, fee schedules and recredentialing or revalidation dates so you never have a lapse in your network status. Working with someone who has the knowledge and experience with provider enrollment will help make sure the process is done accurately and smoothly!

Communication and clear expectations are the foundation between a provider and their credentialing specialist. If you decide to hire someone to take on this responsibility for you be sure to ask questions! What experience do you have? What is your process for tracking each application? How often should I expect application status updates? Your credentialing specialist should be honest about the expected time frame since you should not see patients until your contracts are complete as we can never guarantee a backdated effective date. They should be willing to discuss their process with you so that you feel comfortable putting this important responsibility in their hands!