What is the Difference Between Provider Credentialing and Provider Enrollment?
Posted on Friday, June 12, 2020
Many healthcare professionals experience confusion over the terms provider credentialing and provider enrollment, and justifiably so – there is plenty of overlap between them. However, understanding the differences will help you better navigate the complex credentialing process.
What is Credentialing?
Credentialing is the process of verifying a provider’s qualifications for practicing medicine. The provider’s education, licenses, certifications, work history, references, and more are validated through primary source verification (checking with the original source that issued each credential). Additionally, background checks of the provider’s financial, criminal, and/or social media history may be conducted.
Credentialing is completed as part of the hiring process, in order to obtain hospital privileges, and as a key step in provider enrollment.
What is Provider Enrollment?
Provider enrollment is the process of adding a provider to commercial and/or government health plans so that the provider/practice can be reimbursed for services provided to patients.
To join a commercial health plan, the provider must follow the payer’s specific application and credentialing process. If the provider is approved and signs a contract with the health plan, the provider will be considered “in-network.” This is very exhaustive work, yet the credentialing process is even more strict and detailed for enrollment with government health plans like Medicare and Medicaid.
Most patients will not seek care from an out-of-network provider. Provider enrollment is therefore not only essential to getting paid but also for attracting patients.
Provider Credentialing Vs. Enrollment – What’s the Difference?
Credentialing and enrollment both entail similar tasks related to the verification of a provider’s credentials, and credentialing is a part of provider enrollment. You can think of credentialing as an umbrella term used to encompass all instances where validating a provider’s qualifications is necessary – for the purpose of attaining employment, hospital appointment, and/or participation in health plans.
Because credentialing is a condition of hiring, granting hospital privileges, and contracting with payers, the work involved becomes very repetitive and laborious as each entity (the practice, hospital(s), and payers), must ensure the provider is qualified.
There is even more redundancy when you factor in the lack of standardization among health plans. Each payer has its own unique credentialing requirements and most providers will enroll in a dozen or more different health plans in order to remain competitive. This equates to a lot of time and paperwork – the average time it takes to credential one provider with one payer is 8 to 10 hours per application.
The repetition only continues as providers must renew their appointment with a hospital (usually every two years) and complete periodic recredentialing with commercial insurance companies and revalidation with government payers.
Outsourcing Credentialing and Enrollment
EligibilityAdvocates handles all provider credentialing and provider enrollment work for you.
EligibilityAdvocates can take care of this redundant and time-consuming work for you.
We handle everything – from completing documentation and submitting applications, to following up on them until each provider has an effective start date with each payer, to the ongoing credentialing maintenance needed to keep payers and practices compliant with health plans.
Our services include credentialing for all provider types and new/existing practices of any size, provider enrollment in commercial and government health plans, recredentialing/revalidation, hospital appointment and reappointment, and much more.
Additionally, we provide monthly monitoring and maintenance of documents, certifications, CE, and malpractice insurance, as well as automated alerts to ensure you never become inactive with a payer as a result of credentialing noncompliance.
To schedule a complimentary consultation on how we can help you with provider credentialing and provider enrollment, contact us today.
By Stephanie Salmich