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Physician credentialing and provider enrollment are two terms that are often used interchangeably, however, there are distinct differences between the two. Let's clarify the differences and understand what each one is and when they are required.
Think of physician credentialing or medical credentialing as a background check. It’s the process of verifying the qualifications of licensed professionals and assessing their background and legitimacy. This includes Primary Source Verification (PSV) of education, training, residency, malpractice history, and other requirements.
There are several situations where physician credentialing might be required, including:
Provider enrollment, also known as payer enrollment, is how you get paid with government and commercial payers. It is the process of requesting participation in a health plan network. Once you are approved you are considered “In-Network” for that payer. By offering a variety of In-Network payer options to your patients, you can expand you network and grow your practice.
There are two situations where you would need provider enrollment:
Physician credentialing and provider enrollment is paper-intensive. You will be asked to provide a variety of information including, but not limited to:
To help cut down on the paperwork, establishing a CAQH profile for your providers will help. CAQH enables the provider to enter their information into a secure database and authorize payers to access that information, cutting down on the manual completion of paper applications.
Benefits of a CAQH profile include:
The credentialing process is a labor-intensive processes. You need people to manage the workflow, enter the data, fact-check the reporting, and the list goes on. Not having the appropriate allocation of staff can lead to mistakes. This is one of the most common pitfalls practices encounter.
Another pitfall is letting CAQH lapse. Once established, CAQH profiles need to be re-attested and updated. You must also keep your credentialing contacts current. By being proactive and updating CAQH right when you receive an updated insurance, license, or DEA document, you can avoid issues.
Not creating a sustainable and scalable process is another common pitfall. Practices that are managing their own credentialing and enrollment efforts should develop policies and procedures to help manage the workflow. They should address the “who, what, when, and where” of commercial and government payer enrollment and credentialing.
More importantly, you want to make sure your process is clearly understood by staff and repeatable every time credentials need updating or an enrollment is required.
Ultimately, you can avoid these pitfalls by dedicating a resource to submitting, monitoring, and maintaining provider credentials, centralize the credentialing function for your organization, and create a repeatable, scalable workflow.
Credentialing and enrollment are the starting point of your practice’s revenue cycle. You need to be credentialed (approved) to practice, and you need to be enrolled to get paid. Any delays or lapses with either process can have a significant impact on your cash flow.