Provider Credentialing v/s Enrollment: What is the difference?

Did you know that the job rate of provider credentialing specialists is growing by the day in the USA due to the sheer volume of the work pattern and the complexities involved? But you’ll be shocked to know that half of the lot is still confused about the basics of the job. And one of the most common questions asked by beginners is the difference between provider credentialing and provider enrollment. If you are one of them, this article will help you navigate through the details of the procedure and explain what exactly you need to know about the different systems.

Here is the list of differences you need to know between provider credentialing and enrollment before you start working:

1.What do you mean by provider enrollment?

• There are several health insurance plans in the USA offered by a host of insurance companies, big and small.
• An insured individual has a health plan under one or more of these insurance companies.
• The health plan covers a range of facilities or providers, which the patient usually looks up if they want to get medical services.
• The provider needs to be “enrolled” in one or more of such health plans to receive reimbursements for the medical services they provide.

What is provider credentialing?

• The provider needs to apply with the concerned insurance network to get enrolled in any health plan.
• The first step of the application is the provider credentialing process.
• During this step, the insurance staff notes all your details, from your demographic data to the latest professional training you have taken.
• The collected data then goes through a primary verification process to get approved.

2.What are the steps of provider enrollment?

• The steps of provider enrollment can vary between different payer networks. The steps are often unclear and difficult to understand.
• The first step, however, is credentialing the concerned provider after the collection of documents.
• Once the credentialing process is over, the provider can expect further questions regarding their education details or any previous work history, depending on the payer network vacancy.
• The provider enrollment specialist helps the provider to navigate through these critical steps to get started.

What are the steps of provider credentialing?

Provider credentialing aims to determine the healthcare specialist’s competence and verify if all the documentation provided is genuine. Here are some basic steps followed in most cases:

• The payer network asks for a set of documentation regarding the details of the provider.
• However, the documentation required can vary from payer to payer.
• Standard details include name, address, contact information, educational certificates, medical residency certificates and training certificates.
• In the case of specialization, board certification is required.
• Sometimes the role might also need to be backed up by any research that the provider might have done during their training period.
• The credentialing committee then sends this information for verification by primary sources.
• In case any discrepancy occurs, the provider might have to produce certain additional documents too.

3.What is the scope of a provider enrollment specialist?

• The provider enrollment takes note of the different health plan applications on behalf of the healthcare professional.
• Since the application is a lengthy process with several deadlines, the specialist sets up priority lists concerning which application needs your attention at the moment.
• It is best to make sure that you submit all the due paperwork and any additional answers well before the deadline for the process to run smoothly. The enrollment specialist takes care of that as well.
• In the case of Government payer plans like Medicare and Medicaid, the specialist can guide the provider about the kind of plans that come into effect retrospectively. These plans can be beneficial for the provider’s cash flow.
• Apart from all generic work, the specialist takes care of any other job required by the provider to complete the final step of enrollment in the payer networks.

What is the scope of a provider credentialing specialist?

• A credentialing specialist focuses on the provider data collection required by the payer network and verification of the same.
• The provider submits all the information as mentioned in the credentialing packet to the credentialing specialist.
• The specialist runs all the data through the primary source verification process to identify any missing information or discrepancies in the data.
• The process, though lengthy, is streamlined and is less complicated than the enrollment process, which does not always have defined requirements.

4.How long do the processes take?

• Both provider credentialing and enrollment take up a long time. It can range from a few days to as long as a year.
• On average, the credentialing procedure takes about 90 to 120 days to get finished.
• After the credentialing process is completed, the rest of the enrollment process can be quick if all the data is provided or the provider had a previous contract with the payer network.
• If the information with supporting documents takes too long for the provider to submit, the enrollment procedure can get unnecessarily delayed.
• So it is advisable to keep all your documents in place before applying to the different insurance networks.

5.Can you get enrollment and credentialing services from a single point of contact?

• Enrollment and credentialing need not be too complicated if you have the right service provider to help you.
• Leading revenue cycle management companies provide complete end-to-end support for the entire procedure.
• With a single point of contact under an established vendor, the providers can dedicate their time to patient care while the assigned specialists take care of the administrative burden.
• They also offer software solutions where you can upload your information and track your deadlines.
• The professionals also specialize in renewing and upgrading existing payer contracts to maximize the providers’ benefit.

Get in touch with a specialized service or schedule a free consultation to understand your pain points and prepare a complete map for getting them corrected.

We hope this article helped you understand the comparison between provider enrollment and provider credentialing. If you have any queries, please write them to us in the comment section below. We truly value your opinion. For more such articles on medical services and technology, please subscribe to our blog. Do not forget to subscribe to our Facebook, Instagram, LinkedIn, and Twitter pages to get regular updates.