Every healthcare organization faces the challenge of keeping its network of providers up to date. When a practitioner leaves or joins an organization, it can take an average of 219 days to verify their credentials and enroll them with payers, according to the American Academy of Family Physicians.
This period of vulnerability can leave a healthcare organization open to costly audit findings and gaps in care. This guide will provide valuable insights about provider enrollment and credentialing to help organizations reduce the time required to complete this process and mitigate the associated risks.
Azulity’s provider credentialing services can help healthcare organizations achieve their goals by allowing them to use innovative data management to reduce the time it takes to verify and enroll providers.
What is Provider Enrollment?
Provider enrollment is joining a health insurance plan or network as a participating provider. Healthcare professionals, including doctors, nurses, and other medical personnel, must complete enrollment to treat patients with insurance coverage. Though the specifics of enrolling may differ from one insurance plan to another, the process generally involves filling out an application, submitting proof of credentials and licensure, and agreeing to the network’s terms and conditions.
Why Should Providers Enroll?
Providers have many reasons to enroll in a health insurance plan or network. One of the main motivations is that enrolling increases patient access to care. When providers become participating providers, they can offer their services to a larger pool of patients with insurance coverage. This can increase the provider’s patient base and improve their financial stability.
Another reason for enrolling is that it ensures providers are reimbursed for their services. When a provider treats a patient with insurance coverage, they submit a claim to the insurance company for reimbursement. However, they must be enrolled in the insurance plan or network to receive this reimbursement.
The Enrollment Process
The provider enrollment process can be daunting and time-consuming. To start, healthcare providers must complete various forms and submit documentation. Typically, they must provide proof of their credentials, such as their medical license and certification, and evidence of their education and training. They may also need to supply information about their practice, including their services and locations where they provide care.
Recredentialing
Once enrolled in a health insurance plan or network, healthcare providers may need to participate in ongoing requirements, such as meeting quality standards or engaging in continuing education programs. These requirements may vary depending on the specific plan or network but are typically designed to ensure that participating providers meet the highest standards of care.
Related Reading
- Best Credentialing Software
- CVO Credentialing
- How to Credential a Provider
- Credentialing in Healthcare
- How Long Does Credentialing Take
What is Provider Credentialing?
Credentialing verifies the qualifications of healthcare professionals. This process is crucial in establishing a healthcare practice’s authenticity and ensuring patient safety. For example, when a clinic or hospital applies for insurance reimbursement, the provider’s credentials will be assessed to determine their eligibility for payment.
If the provider’s credentials are out of date or if they have been flagged for disciplinary action, the claim could be denied, leaving the practice to absorb the costs. Ultimately, credentialing ensures that patients receive care from qualified, competent professionals.
The Credentialing Process: What to Expect
Credentialing can be time-consuming, taking 30 to 180 days to complete. The following steps can help you understand what to expect as you embark on the credentialing process:
1. Verify the Clinic
The first step in the credentialing process is to verify the clinic or organization that employs the healthcare provider. Insurance companies will evaluate the individual provider based on the facility’s training, certifications, reputation, and efficiency.
2. Provider Eligibility for Healthcare Services
Next, the credentialing process will determine if the healthcare provider meets eligibility requirements to deliver care within the specific facility or practice.
3. Set Basic Rules
Each facility will establish ground rules to deny professional verification based on the pre-application process.
4. Create a Process to Reapply
If a healthcare worker is initially denied credentialing, it’s essential to have a procedure that allows them to reapply after the initial rejection.
5. Mechanism for Rapid Credentialing
There should be a mechanism for rapid credentialing of emergency personnel and short-term staff in a medical emergency.
6. Limit Providers Who Don’t Follow Guidelines
Finally, individual healthcare workers who do not comply with guidelines or health requirements should be limited to ensure patient safety.
Organizations like Azulity can facilitate credentialing, ensuring it runs smoothly and efficiently.
Difference Between Provider Enrollment and Credentialing
Provider Credentialing vs. Enrollment: What’s the Difference?
Credentialing and provider enrollment are interrelated because you can’t complete the provider enrollment process without medical credentialing. If an interested practitioner applies to be part of a network under a specific payer, credentialing ensures claims don’t get denied. For example, say a dentist applies to enroll with Medicaid as a provider.
However, they don’t go through the credentialing process. They begin sending in medical billing claims. The claims are concurrently denied because the provider has not been adequately credentialed, and the contract between the provider and network is invalid. Therefore, you cannot have a successful provider enrollment without completing the medical credentialing process.
The Difference Between Provider Credentialing and Provider Enrollment
Now that we’ve explored provider credentialing and provider enrollment, let’s take a closer look at the differences between these two processes. While both are essential steps in becoming a participating healthcare provider in an insurance network, there are several key distinctions between the two.
Purpose
The primary purpose of provider credentialing is to verify a healthcare provider’s qualifications and eligibility to participate in an insurance network. The primary purpose of provider enrollment is to register with an insurance network and become an approved provider to receive reimbursement for services provided to patients covered by that network.
Timing
Provider credentialing is typically done before a healthcare provider can participate in an insurance network. At the same time, provider enrollment is done after a healthcare provider has been approved to participate in an insurance network.
Requirements
Provider credentialing typically involves verifying a healthcare provider’s education, training, licensure, and professional history, among other things. Provider enrollment typically involves submitting documentation of a healthcare provider’s licensure, malpractice insurance, and education and training credentials.
Entities Involved
Provider credentialing is typically done by insurance companies, healthcare organizations, and other entities that contract with healthcare providers to provide services to their members. Provider enrollment is generally done by healthcare providers who wish to participate in insurance networks, such as Medicare, Medicaid, or private insurance companies.
Timeframe
Provider credentialing can take several weeks to months, depending on the complexity of the provider’s application and the credentialing organization’s requirements. Provider enrollment can also take several weeks to several months, depending on the completeness of the provider’s application and any additional documentation that may be required.
13 Tips for Efficient Provider Enrollment and Credentialing
1. Use Azulity for Efficient Provider Enrollment and Credentialing
Azulity specializes in healthcare master data management and provider credentialing services, bringing proven expertise in implementing healthcare data solutions and credentialing across the US. Our comprehensive platform ensures consistent patient, provider, location, and claims data synchronization across all systems and departments.
Key features include healthcare MDM, provider MDM, reference data management, credentialing, and provider enrollment. We serve healthcare technology leaders – from CIOs and CDOs to VPs of data platforms and credentialing – helping them eliminate the costly problems of fragmented data systems. Book a call to learn more about our healthcare master data management services today!
2. Start the Licensing Process Early
For new practitioners, starting the licensing process as soon as possible is critical for a flawless transition from educational programs to practicing. Different licensing processes apply to other providers, and each can take a different time to complete. For example, PAs (Physician’s Assistants) must obtain certification from the National Commission on Certificate of Physician’s Assistants. This certification process can involve several steps, including verifying education and citizenship, and may require peer references.
3. Keep All Physician Contact Information Up to Date
Something as simple as a wrong address for a provider or peer reference can cause problems with medical credentialing. Therefore, ensure that all contact information for physicians or other providers is updated periodically. If clear lines of communication are not available for any given provider, this can slow down processes when a provider’s credentials are up for question by a payer.
4. Outsource Medical Credentialing Services
Medical credentialing can be a time-consuming process. Additionally, slight missteps in the process lead to frustrating issues later. Therefore, working with a medical credentialing service provider like PrognoCIS may be one of the best credentialing tips you can follow. When you outsource provider credentialing with a service like PrognoCIS, a medical credentialing specialist assesses credentials on file for providers within the organization and ensures everything is recorded as it should be.
5. Know Your State’s Regulations
State regulations for medical professionals can vary in terms of credentialing. This is especially important if your organization has providers transitioning from one state to another to provide services. If credentials for that specific state are not updated, this can lead to problems once claims are filed to receive payments from payers for services rendered.
6. Track Credentialing Applications
Once credentialing applications are submitted to an insurance company or organization, be sure to track the progress of that application. Don’t hesitate to check in with an insurance company to find out where an application is in the acceptance process. It is not uncommon for payers to set aside applications that are missing information and delay alerting providers promptly.
7. Avoid Common Errors
As simple as it sounds, an essential medical credentialing best practice tip is to be mindful of common errors. Standard errors are most likely to disrupt the credentialing process with a provider. Physician’s Practice states that as many as 85 percent of credentialing applications are missing must-have information the payer has to have to process the application. This can include:
- Lack of peer reference contacts or contact information for those contacts
- Improperly filled-out credential forms or missing information
- Submitting an expired NPI or DEA number
- Missing gaps in malpractice history
- Lack of clinical history documentation
- Data entry typos or mistakes
8. Keep Digital Files
Hard copies of credentialing files are essential, but keeping at least one digital file where all credentialing documents can be stored is just as vital. This is a crucial medical credentialing best practice to remember because it can save time later. When a payer requests credentials, you will have one transparent file where everything is digitally available. Be sure to include diplomas, state licenses, DEA documents, passports, driver’s licenses, and anything else used for credentialing experience or identity.
9. Obtain a Dedicated DEA Number
DEA (Drug Enforcement Administration) numbers are mandated for providers to prescribe medication. Providers typically need a number for each state where they intend to provide services, but requirements vary. It can take several weeks for applications for DEA numbers to be processed after applying through the DEA website.
10. Get an NPI Number
National Provider Identifiers (NPIs) are assigned to care providers, but the provider must also keep NPI information current. If a provider does not have an NPI or their information is not accurate, this is a common reason for the claim to be denied by payers. Therefore, any time a practitioner’s status changes, the National Plan and Provider Enumeration System (NPPES) must be updated through the NPPES website.
11. Request Procedure Logs & Clinical History
Clinical history is a common requirement for proof of work history in healthcare. To prove clinical history for any provider, request procedure or activity logs and keep them on file. Whichever department is responsible for billing for a provider’s services can usually offer an activity log that can be used for clinical history documentation.
12. Examine Malpractice Claims
An extensive record of previous claims filed, records of insurers, and policy numbers for malpractice insurance should be kept on file with credentialing information. Make sure new providers have a certificate of insurance on file as well.
13. Track Progress Using Advanced Software for Monitoring
A provider’s credential file can involve licenses, numeric identifiers, and forms of identification that face expiration dates. If these documents expire without notice, this can generate problems with credentialing. Be sure to track expiration dates on each provider’s credentials in the organization. This ensures that documents soon to be out of date are updated promptly without disruptions.
Related Reading
- Credentialing and Privileging
- How Much Does Credentialing Cost
- Types of Credentialing in Healthcare
- Hospital Credentialing Requirements
- Primary Source Verification Credentialing
- Benefits of Digital Collaboration
- Benefits of Influencer Marketing
- YouTube Brand Connect
- Best Influencer Brand Collaborations
Book a Call to Learn More About Our Provider Credentialing Services
Azulity specializes in healthcare master data management and provider credentialing services, bringing proven expertise in implementing healthcare data solutions and credentialing across the US. We serve healthcare technology leaders – from CIOs and CDOs to VPs of data platforms and credentialing – helping them eliminate the costly problems of fragmented data systems. Book a call to learn more about our healthcare master data management services today!
What Is Provider Credentialing?
Provider credentialing verifies the qualifications of a healthcare practitioner before they can deliver care to patients. Credentialing identifies a provider’s education, training, residency, licenses, certifications, and any specialties or areas of expertise. This process helps to ensure patients receive care from qualified practitioners. Credentialing is vital for individual practitioners and group practices, as it establishes the clinical reputation of providers within the healthcare community. While the process may differ depending on the organization, provider credentialing typically involves a thorough application, background checks, and ongoing monitoring.
What Is Provider Enrollment?
While credentialing verifies a provider’s qualifications, enrollment is the process that establishes their participation in insurance networks. After completing the credentialing process, a practitioner must apply for enrollment with each insurance company or network they wish to bill for services. This process can take weeks or months and often requires separate applications for each payer, with no guarantee of acceptance. The more thorough the initial application, the less likely the payer will have additional requests for information, which can delay the process further.
Why Are Provider Enrollment and Credentialing Important?
Credentialing and enrollment help ensure that providers are qualified to deliver safe, effective care and establish their ability to bill for services. The processes protect patients and help maintain a standard of care within the healthcare industry. Credentialing and enrollment also benefit providers by assisting them in quickly establishing their clinical reputation and receiving payment for their services.