All you need to know about Credentialing and Enrollment in Healthcare

CMS (Centers for Medicare and Medicaid Services) offers two ways for healthcare providers to get recognized and participate in the Medicaid and Medicare programs – these are provider enrollment, and provider credentialing services. The significant difference in enrollment and credentialing is the application process to become a Medicare or Medicaid provider. Enrollment in healthcare is the first step for all providers who wish to partake in Medicare and Medicaid programs. While credentialing is a secondary process that some providers need, not all. Credentialing entails verification of providers – whether or not they meet specific qualifications to participate in the programs.
Let’s dive deep to fully understand the differences between credentialing in medical billing and enrollment in healthcare.

Defining Payer Enrollment in Healthcare

Payer enrollment is requesting enrollment in healthcare insurance panels and medical billing plans. If you are a medical practitioner and want quick payments from your patient’s insurance, you must enroll with the payers. The process requires many application documents and necessitates organization on applicant’s end – since the enrollment process in healthcare is detail-rich.
Once the applications get submitted to the payers – a healthcare provider’s medical credentials must be submitted, along with the supporting documentation. Furthermore, it is also essential that a provider’s credentials are verified before a practice is accepted by payers. If all goes smoothly, a contract will be made and signed.

Types of Payer Enrollment in Healthcare

The enrollment processes for different payers vary. Furthermore, different enrollment processes can be put to use for the new medical staff and when medical practices are applying for staff members to Medicare.
Different types of enrollment have varying institutional references. For instance, CMS is the typical go-to resource for enrolling a practice into a Medicare program – the same as commercial payer enrollments.

Classic Steps of Payer Enrollment in Healthcare

The National Association of Medical Staff Services offers thorough documentation on a payer’s enrollment steps in an ideal setting – the steps are as follows:

Requesting for enrollment
Completing the plan’s credentialing
Submitting copies of licenses
Signing contracts
Steps unique to contractors will include additional requirements where the individual payer has adjusted to their enrollment plan.

Defining Provider Credentialing in Medical Billing

Credentialing is one of the most exhaustive processes for healthcare practitioners – verifying their:

Background
Education
Identity
Residency
Licensing and other additional criteria

Medical credentialing and physician credentialing can oftentimes be used interchangeably. To avoid confusion, medical credentialing applies to professionals who administer care, including:

Physicians
Nurses
Therapists
Radiologists, etc.

Secondly, the individual physician credentialing is also exhaustive – taking over 4 months to complete. Physicians must submit credentialing data, including:

Street addresses
Recent photograph
Copy of NPI (National Provider Identifier), and more.

However, this basic information must accompany with additional and extensive details, including:

The credentialing physician must provide three letters of recommendation from providers who have observed the said physician’s practice.
Current hospital affiliations – all that apply must be presented.
Information about a physician’s legal status – including their:

Military personnel records
Proof of Green Card and/or labor visa status
Locum Tenens Practice Experience form

Types of Provider’s Medical Credentialing

The requirements of medical credentialing include:

Proof of identity
Educational and training certificates
Professional Licensure
Military service – if and when applicable
Board certification
DEA Registration, CDS Certifications, State DPS
Affiliations and Work History
Sanctions disclosure reports
Criminal background disclosure reports
Health status
Malpractice insurance
NPDB
Professional references

All of these items come in handy when a medical practice applies. The enrollment and credentialing specialists file this information in their databases to verify and format the submissions. Here, the final verification report is archived automatically.

Key Differences between Medical Credentialing and Payer Enrollment

The payer enrollment or provider enrollment credentials apply to an insurance panel. On the other hand, medical credentialing is a repository of information for verifying the valid status of a healthcare practice and all of its members. The medical credentialing process must be completed before an organization or provider can enroll with or bill an insurance carrier.

Interrelation of Credentialing and Provider Enrollment in Healthcare

Physician credentialing and provider enrollment in healthcare are two critical processes for every healthcare organization. While both seem unrelated, the two processes are interrelated. Provider enrollment is enrollment of healthcare providers with private health and government insurers. On the other hand, physician credentialing is a process of verifying a physician’s credentials and privileges for being able to practice at a healthcare facility.
One essential requirement for a provider’s enrollment in healthcare is proof of physician credentialing. In other words, a healthcare practitioner cannot enroll with an insurer until and unless they undergo credentialing. Insurers must verify that a particular provider is qualified to offer care before they can start billing them for care services.
Similarly, most healthcare facilities will not grant physician privileges unless they properly enroll with the facility. The provider typically does enrollments; however, credentialing is usually done by the health insurance company. Again, there are some cases where different parties complete the two processes. For instance, if a provider is credentialed through CMS, they must submit an enrollment application to CMS.

Classic Steps for Credentialing a Healthcare Provider

1- First off, make a list of everything you will need for provider credentialing applications, including:

Medical licenses
Employment history
Résumé or curriculum vitae
Certificates
Medical malpractice certificates
Recommendations
Clinic ownership data
W-9
Criminal records
Bank records, and more.

2- Collect the provider’s National Provider Identifier (NPI), Federal Income tax ID, and Clinic EIN; all of this information must be with information on the W-9 application.
3- Get a provider’s CAQH ID after registering them with CAQH. Verifying that CAQH has an updated W-9 and liability certification for the provider is important.
4- Ensure your work and graduation dates are in month/year format. CAQH might reject your application if it is not provided with accurate dates.
5- CAQH shall email the healthcare provider each quarter to re-attest that the information in the portfolio is up-to-date for taking prompt actions.
6- It is always specified if there is a requirement for a provider’s authentic written signature for processing the healthcare credentialing.
7- Filling out and submitting a set of applications to every health insurance provider
8-It is important to follow up on the provider’s credentialing application with health insurance providers, as they are notorious for not returning calls if anything is missing from the application. Throughout the credentialing process – keep track of all calls and online discussions.

9- It is important to follow up on the provider’s credentialing application with health insurance providers, as they are known for not returning calls if anything is missing from the application. Throughout the credentialing process – keep track of all calls and online discussions.
10- Lastly, maintain copies of all/any healthcare applications and contracts you send out and the health insurance payer’s credentialing and enrollment letters.

Advantages of Credentialing and Enrollment

Both credentialing and enrollment in healthcare ensure:

Payers have complete data on your medical specialty or practice.
More patient referrals, getting fast-track payments from payers.
Reduction in chances of revenue losses in forms of claim denials.
Getting rid of manual paperwork and submitting piles of application forms quickly.
Building relationships with different payers for increasing revenue.
Attaining real-time insights on provider credentialing and enrollment transactions.

The Wrap Up

Provider credentialing is an essential requirement for providing care services to patients. Moreover, providers can also grow their networks and bring in more patients for their practice. Physicians Revenue Group, Inc. offers credentialing services and enrollment in healthcare for medical practices in the USA. Our team of credentialing experts handles the entire documentation process. Consequently, our partner medical providers can begin practicing and working with more insurance payers. Let our enrollment and credentialing teams handle the process – why you take care of your patients.

Frequently Asked Questions

What is credentialing in healthcare?

Credentialing is a process to check a medical professional’s ability to offer patients with top-quality healthcare services. It is helpful for medical billing systems and the RCM process, as the reimbursements can be issued promptly without any issues.

What is enrollment and credentialing?

Medical credentialing is an essential process for certifying a healthcare provider’s qualifications. Meanwhile, payer enrollment requests participation in a health insurance network to function as a medical provider.

What is provider credentialing flow?

Provider credentialing is an essential process in the healthcare industry. It involves verifying a healthcare provider’s credentials, experience, and qualifications to ensure they meet specific standards set forth by insurance companies.