What is the Difference Between Payer Enrollment and Credentialing?

Nov 19, 2021 | Credentialing, Enrollment | 0 comments

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Among healthcare practitioners, there is sometimes confusion between the concepts of “payer enrollment” and “medical credentialing.” The process of payer enrollment and credentials verification is intricate, and it becomes more so with each passing year. It’s important for your business to understand the difference and find a way to navigate the intricacies.

Find a CVO Partner

First off, your organization should consider finding a partner in this process. Without the proper verification services, small practitioners – and large ones too – lose money drowning in paperwork. This is where outsourcing to a Credentials Verification Organization (CVO) is a sound investment. A CVO can handle medical credentialing and payer enrollment processes simultaneously. They do all the heavy lifting so practitioners can focus on patient treatment and staff can focus on more critical tasks.

A service that handles credentialing and insurance enrollment is a lifesaver when paperwork becomes tedious and complicated. This is especially true in payer enrollment and credentialing.

Defining Payer Enrollment

Payer enrollment (aka provider enrollment) is the process of requesting enrollment in a healthcare insurance panel and plan. The process requires a plethora of application documents. Then, once those applications are submitted, medical credentials must be submitted. The credentials must be verified before the practice is accepted by the provider. If all goes well, a contract will be created and signed.

Once enrolled, providers are then considered “in-network” or “participating.” Becoming listed as such is crucial, as most patients will not pay the higher copay to be seen out-of-network.

The high costs of health insurance already burden most people. Since 2015, healthcare costs have skyrocketed. Patients today pay an average of 30% more for health coverage in the form of deductibles and out-of-pocket expenses. Patients don’t want to pay more to see non-participating providers.

Defining Medical Credentialing

The process of medical credentialing began as far back as 1,000 BC when the Cult of Zoroaster mandated that physicians treat three heretics. If all three lived, the doctor would be qualified to treat patients until the end of his or her career. Today, medical credentialing is the exhaustive process by which background, education, identity, residency, licensing, and other criteria are verified against primary sources.

Medical credentialing and physician credentialing are terms that are sometimes used interchangeably, but medical credentialing applies to any professional who administers care including physicians along with therapists, nurses, radiologists, and more.

Because individual credentialing is exhaustive, it takes roughly four months to complete. Required credentialing data includes street addresses, a recent photograph, a copy of a National Provider Identifier (NPI), and much more.

This basic information must then be coupled with more extensive information. Most of this information is a logical follow-up to the initial credentialing requirements:

  • Three letters of recommendation are required from providers who have observed the physician’s practice.
  • Current hospital affiliations must be presented.
  • Some additional information can be unique to the physician’s legal status – such as military personnel records, proof of Green Card or labor visa status, or Locum Tenens Practice Experience form.

What Are the Differences Between Payer Enrollment and Medical Credentialing?

Payer 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.

Types of Payer Enrollment

Payer enrollment processes vary. New hires will undergo a different process than those used when applying staff members to Medicare. Different types of enrollment have various institutional references. For example, Centers for Medicare & Medicaid Services (CMS), is the typical resource when enrolling a practice into a Medicare program.

The Typical Steps of Payer Enrollment

The National Association of Medical Staff Services says, in an ideal setting, there are five typical steps in payer enrollment:

  • Request enrollment
  • Complete the plan’s credentialing
  • Submit copies of licenses
  • Sign the contract
  • Complete steps unique to the contractor (these include additional requirements the individual payer has amended to their enrollment plan)

If your organization is applying for Medicare specifically, it’s important to remember the following:

  • You must have a primary place of service in operation
  • You need banking information to set up EFT payment for reimbursement
  • You must provide personal details of every individual who has ownership of the practice
  • Documents will vary with the type of provider enrolling
  • Citizenship documents are required for providers born outside the U.S.
  • ECFMG certificate is required for providers educated outside the U.S.
  • Sign your application forms in every signature location

Types of Medical Credentialing

We described some of the information that is required for medical credentialing, but here is a short summary of some of the required paperwork:

  • Proof of identity
  • Education and training certificates
  • Military service (if applicable)
  • Professional licensure
  • DEA Registration, State DPS, and CDS Certifications
  • Board Certification
  • Affiliation and Work History
  • Criminal background disclosure reports
  • Sanctions disclosure reports
  • Health status
  • NPDB
  • Malpractice insurance
  • Professional references

These items are used when a medical practice files an application with a CVO like Verisys. From there, the CVO will file this information in their databases to verify and format the submission. The final verification report is automatically archived.

By submitting your medical and physician credentialing data to a CVO, you can eliminate errors and streamline the payer enrollment process. Fewer errors result in fewer resubmissions and save the practice both money and time. Contact Verisys today to learn more.

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