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. 

Tl;dr

1. Why: If you’re a healthcare provider (doctor, nurse, physician assistant, etc.) and you want to get paid by a patient’s insurance, you need to be credentialed and get enrolled with the payer. 
2. Credentialing: Credentialing is the process of verifying that a healthcare provider is a legitimate, licensed, active and good standing healthcare provider.
3. Enrollment: Payer enrollment (also known as provider enrollment) credentials are specifically used for applying to an insurance panel. You will be using the repository of verified “Credentials” to enroll. 
4. Timeline: The process for brand new providers can take up to 6 months and for established providers, could take as little as 2 months.  

Defining Payer Enrollment

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.

Defining Medical Credentialing

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:

• The credentialing physician will need three letters of recommendation from providers who have observed the physician’s practice. 
• Current hospital affiliations must be presented. 
• Information 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 medical credentialing and payer enrollment?

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.

Types of payer enrollment

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 typical steps of payer enrollment

The National Association of Medical Staff Services provides thorough documentation on payer enrollment’s typical steps in an ideal setting are as follows:

• Requesting enrollment
• Completing the plan’s credentialing
• Submit copies of licenses
• Sign contract
• Steps unique to the contractor. These include additional requirements the individual payer has amended to their enrollment plan.

Types of medical credentialing

Medical credentialing requirements:

• 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. 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.

Outsourcing Enrollment and Credentialing to a Credentialing Specialist?

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.

Your Credentialing Specialist’s Job

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.

Duties and Responsibilities of the Credentialing Specialist

1. Leads, creates, coordinates timely filing, and monitors the review, analysis and accuracy of provider credentialing and re-credentialing applications as-well-as accompanying documents, ensuring consistent applicant eligibility.
2. Conducts thorough periodic background investigation, research and primary source verification of all components of the application file.

3. Identifies issues that require additional investigation and evaluation, validates discrepancies and ensures appropriate follow up.

4. Tracks license and certification expirations for all providers to ensure timely renewals.

5. Maintains copies of current state licenses, certificates, malpractice coverage and any other required credentialing documents for all providers.

6. Responds to inquiries from other healthcare organizations, interfaces with internal and external customers on day-to-day credentialing issues as they arise.

7. Assists with managed care delegated credentialing audits; conducts internal file audits.

8. Utilizes software and credentialing databases like Modio credentialing database, optimizing efficiency, and performs query, report and document generation; submits and retrieves National Practitioner Database reports in accordance with Health Care Quality Improvement Act.

9. Monitors the initial, reappointment and expirables process for all Neurocore clinical staff ensuring compliance with regulatory bodies (Joint Commission, NCQA, URAC, CMS, federal and state, as well as Neurocore policies and procedures, and health payer contracts.)

10. Maintains corporate provider contract files as-well-as the confidentiality of this information.

11. Maintains knowledge of current health plan and agency requirements for credentialing providers.

12. The Credentialing Specialist assists in the creation of provider profiles, submits to insurance payers and audits health plan directories for current and accurate provider information. 

13. Maintain a program for limited licensed providers to obtain full license that is in accordance with state and federal requirements.

Next Steps

If your practice needs help with credentialing, enrollment, or contracting, please  reach out to the Enter Enrollment Team anytime.