Provider Enrollment and Credentialing – Let’s Clear the Confusion

In the medical billing process, every step you take brings you closer to revenue – either you get it, or you lose it. There are multiple steps throughout the process, such as medical coding, patient demographics, charge entry, and claim submission, and even a small mistake at any of these steps could cause denials. Behind that, one reason might be “Provider Enrollment and Credentialing”. Because these two terms are related, they also confuse healthcare experts, billers, and patients.

And that’s the reason we’re here to come up with this blog. It will help you understand the difference between provider enrollment and credentialing, and why they both are important for your revenue cycle. Moreover, you will also know about the medical credentialing and enrollment process. So, keep reading if you don’t want to lose revenue again, just because of your confusion!

What is Provider Enrollment & Why Does it Matter

Provider enrollment means getting in-network with the insurance plans (Medicare, Medicaid, and commercial plans). It helps you bill insurance companies for the services you have rendered.

Whether you’re a solo practitioner, a small clinic, or own a large healthcare organization, you need payer enrollment services, as they allow you to work with the insurance companies. Moreover, it helps you access more patients because many patients prefer treatments from in-network doctors.

Here’s why it matters:

First, Provider enrollment helps you access more insured patients through commercial and government plans, ultimately growing your cash flow.

Second, if you’re enrolled with the government or commercial plans, then the patient becomes satisfied, as it signals that you’re a legitimate healthcare professional.

What is Credentialing & Its Importance in Medical Billing

Provider credentialing is the verification of the healthcare professional’s educational and medical background, ensuring they’re ready to deliver patient care.

Here’s why it’s important

Unless your credentials are verified, you can’t apply for enrollment, which means you can’t get reimbursed for your services.
Secondly, the provider credentialing means you’re a certified and verified doctor, so you can see your patients stress-free.
Moreover, it increases patient volume and helps you stay compliant and competent in the healthcare industry, ensuring you receive payments without delay.

Provider Enrollment Vs Credentialing: Which Helps in Faster Reimbursements

Honestly, they are both essential and work together to help you get faster reimbursements. Because without credentialing, you can’t get enrolled in a payer network, and without enrollment, you can’t submit claims.

Hence, to optimize your revenue, you must have both, which helps you submit claims electronically, speed up your revenue cycle, reduce denials and boost cash flow.

Remember that credentialing doesn’t directly impact your cash flow, but it’s important before provider enrollment.

Simplifying the Provider Enrollment and Credentialing Process

To receive payments on time, every practice and facility provider needs to obtain provider enrollment and credentialing services. Mostly, doctors, nurse practitioners and even healthcare organizations seem to find both processes complicated, not because they really are, but because they misinterpret the steps.

Let’s simplify the provider credentialing process in just four steps.

Step 1 – Data Collection

The first step when applying for credentialing is to gather all necessary documents. It involves your medical license, malpractice insurance, work history documents, and all educational documents. Make sure that your licenses are valid to avoid rejection.

Step 2 – Primary Source Verification (PSV)

Once you submit a credentialing application, it goes through the primary source verification process. Throughout this process, a healthcare payer verifies all your documents to ensure you’re eligible to provide patient care.

Step 3 – Payer Review & Approval

Then an organization matches a practitioner’s data with the verified documents. If it matches, they approve your application. Now, you’re eligible to deliver patient treatments at a clinic or hospital.

Step 4 – Ongoing Maintenance

It is the most essential step that healthcare professionals often overlook: maintaining their credentials in accordance with payer requirements, known as recredentialing. So, your revenue is never disrupted, and you can provide patient care without any stress.

Provider Enrollment Process in 4 Steps

Once you get your credentials, you need to become in-network with the payer. For that, you need to go through the provider enrollment process. Here are the steps you should follow to get enrolled with healthcare insurance companies;

Step 1 – Document Preparation

When you apply for provider enrollment, ensure you gather all necessary documents, including malpractice insurance, credentialing training, medical board licenses, and educational records.

Step 2 – Submit Application to Insurance Payer

Once you have compiled all important documents, then apply through the payer portals. It depends on which payer you want to enroll with, as each payer has its own portal.

Step 3 – Review, Verification & Contracting

When you apply, the payer reviews and verifies it in accordance with healthcare regulations. If you meet the insurance company’s requirements, you can start your practice and get reimbursed for insured patients.

Step 4 – Enrollment Approval & Payer ID Activation

As you start your practice as an enrolled participant with an insurance company, you can now easily bill for the services and get paid based on the payer’s billing rates and rules. So, you can’t receive insurance claim denials due to the provider enrollment issues.

Mistakes You Should Avoid During Provider Credentialing & Enrollment

As we have clearly mentioned above, provider and credentialing enrollment either help you earn dollars or cost you money! Avoid these mistakes during credentialing and enrollment to ensure faster claim submissions. However, your revenue depends not only on these two terms but also on medical coding, prior authorization checks, eligibility criteria, and much more.

Missing or Outdated Documents

The most common mistake healthcare providers make is submitting outdated documents or forgetting to add an important one, leading to rejections. Therefore, always ensure to hand in the proper and valid documents.

Delays in Submit Credentialing Application

Another mistake you should avoid during the process is to submit applications late. It seriously hurts your revenue and reputation that you’re not serious about your profession. Hence, make sure to submit the credentialing application on time based on payer requirements.

Incorrect NPI Linking

Your National Provider Identifier (NPI) is the most critical step of your credentialing and enrollment process, as it allows you to onboard with the insurance companies. Make sure to connect the right NPI link. So, if you’re an individual link NPI type I, and if you’re a clinic or organization, link to NPI type II.

Forgot to Update or Attest the CAQH Profile

Another mistake that healthcare professionals often make is forgetting to update their CAQH profile, which leads to rejections.

Conclusion

In short, medical credentialing and enrollment are interlinked, which ultimately impact your revenue cycle and boost cash flow. Many healthcare professionals often confuse the two, leading to payment delays, compliance issues, and more.

We hope this guide helps you clear the confusion between enrollment and credentialing. Moreover, we guide you on how to enroll, the credentials that verify you as a physician, and how to improve your cash flow, which can increase your patient volume.

Moreover, credentialing and provider enrollment are both critical processes, and even minor errors can lead to payment delays. You should consult with a healthcare billing professional, such as eClaim Solution, who knows how to handle credentialing and enrollment with the payer as soon as possible.

If you want to get credentials as fast as you see your patients, contact us now!

Frequently Asked Questions

What is the difference between provider enrollment and credentialing?

Provider enrollment and credentialing are distinct processes, terms, and aspects, but they interconnect. Credentialing means you’re verified to apply for payer enrollment services. On the other hand, provider enrollment directly impacts your cash flow by allowing you to treat insured patients and bill according to the payer’s policies and rates for rendered services.

Why is provider data management necessary?

Provider data management is necessary to ensure accuracy in credential and enrollment details. Such as NPI credentials, malpractice insurance, certifications and training are updated through the portals to meet the healthcare and HIPAA regulations.

What are the three steps of credentialing?

Credentialing is a lengthy process, but you can understand it through three essential steps. First, gather all necessary documents and submit them to healthcare organizations. Then wait for the processing and verification, and follow up consistently if any changes are required or if clarification is needed regarding your application. Once everything is verified, you can easily apply for enrollment and contracting with insurance companies or payers (Medicare, Medicaid or a commercial one) to bill for the rendered services.

Which company offers the best provider enrollment and credentialing services?

Various companies offer the best provider enrollment and credentialing services, including RCM Matter, BellMedex, MediBill MD, CureMd, MedTrainer, and eClaim Solution, which help you get enrolled with any payer (government or commercial) efficiently and effectively without making you wait long.

What documents should I submit during the credentialing process?

During the credential process, you must have the following documents;

Medical licenses and training certificates
Malpractice insurance
Educational documents
Work history
Employment gap reason and proof (if any)

Which documents should I need for the payer enrollment process?

For the payer enrollment process, you must have;

National Provider Identity (NPI)
Medical Board Verification
CAQH profile
DEA Certificates
Medical Licenses

What is the difference between credentialing and privileging in healthcare?

Credentialing refers to the verification of a healthcare provider’s medical license, certifications, training, and work history to ensure they meet healthcare standards to practice. On the other hand, privileging enables providers they perform specific treatment or services for patients within the facility.

How does medical credentialing and enrollment impact my revenue cycle?

Medical credentialing and enrollment are both necessary because without these, your claims can’t be processed, which hurts your revenue.

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