Credentialing, Provider Contracting

Credentialing, Provider Enrollment, Privileging – isn’t it all the same?

Devonn Simmons
September 1, 2021
11:00 am

Not really. While these 3 terms are often used interchangeably, they actually have different meanings:

Credentialing, as defined by Joint Commission, is the process of obtaining, verifying, and assessing the qualifications of a practitioner to provide care or services in or for a health care organization. During this process, which hospitals and health plans use, a provider’s education, work history, licensing, malpractice history, and more are reviewed, assuring your patients that they are receiving quality healthcare.
Enrollment, also known as Provider Enrollment, is obtaining participation within a health insurance network. During this process, a request to join the network is submitted to start the application process. You will then go through the credentialing phase, and once approved, move to the final phase of enrollment, which is contracting.
Privileging is the process of authorizing a healthcare provider to perform a specific scope of services and procedures at a healthcare organization. During this process, a provider may go through a 2-step application process beginning with the pre-application phase to identify providers who meet minimum staff membership requirements. Once approved, they move to the application phase, which includes credentialing. When all of the information has been verified by medical staff services, recommendations are made regarding your appointment and privileges, presented to the Medical Executive Committee for final approval and granting of privileges.

Mistakes or missteps in either of these processes can be a massive setback in setting up these relationships and may gravely cost time and money for your practice. If you’re in the healthcare business, you know that you need to overcome several challenges. The amount of time it takes to conduct interim credentialing and full medical credentialing can be a lengthy and time-consuming process. Nowadays, it is a challenge to be an expert in all aspects of your industry. This is why many healthcare professionals consider outsourcing the process of Credentialing and Provider Enrollment to ensure quality outcomes. Companies offering Medical Credentialing Services such as Contracting Providers are trained to vet candidates, so why not leave this part of the job up to an experienced counterpart who may yield more successful results? Especially if it keeps you from the hassle and ensures you the highest quality of service. Let’s take a look at the top 5 reasons why healthcare professionals consider Outsourcing the Credentialing Process;

Collecting Documents

Healthcare professionals like physicians have a lot going on, and they tend to misplace documents from time-to-time. These documents may include copies of licenses held, malpractice insurance face sheets, and sometimes even their diplomas. Gathering all these documents can be very tedious, and quite frankly, no one wants to do it. Hiring Contracting Providers, an experienced Medical Credentialing company with the expertise in getting these types of documents, can save a tremendous amount of time in the locum’s background check process. Our experts know precisely how to get these lost documents and replace them as quickly as possible.

Licensures & Primary Source Verification

Verifying Licenses can be time-consuming, and worse, some physicians can be licensed in multiple states, and international candidates have also been licensed in foreign countries. License verification will need to be performed on each of these licenses to ensure no administrative action was ever taken against any of these licenses. Doing a thorough primary source verification on a candidate is also time-consuming. Hiring Contracting Providers, an experienced Medical Credentialing company, can reduce the time it takes to complete this process, as they know exactly where to get the primary source information. Plus, Contracting Providers typically have the necessary third-party PSV accounts already established for quicker reporting.

Malpractice Claim History

A malpractice claim history query will need to run against every malpractice policy the physician has ever carried. Often, many physicians do not realize how important it is to keep a copy of their malpractice face sheet. Contracting Providers can help the physician find and obtain all insurance information and obtain copies of all face sheets. Contracting Providers can then run the queries to request malpractice claims history to ensure no malpractice claims have been reported. If a malpractice claim has been reported, the credentialing company can get the necessary details from the physician and the insurance company.

Background Check

A national background check will be required for any locum physician. Because companies offering Medical Credentialing Services such as Contracting Providers have contracts with background companies, you can avoid the hassle of having to run the background yourself. You can communicate with Contracting Providers’ experts, the Medical Credentialing company to complete the process and sit back and wait for the results.

Results Delivery

Results are delivered to your agency in a neatly packaged file containing every item you will need to place this candidate into a locums contract successfully. Contracting Providers, A Medical Credentialing company will also handle hospital and payor enrollment Credentialing should you decide your agency needs to complete these items. As experts, Contracting Providers can store all of your candidates’ data in a system where you can access when needed. As a recruiter, do what you do best. Leave the vetting of candidates to the professionals at Contracting Providers. Don’t let any chance miss something that could potentially cost you a contract or your company’s reputation. Provider credentialing and enrollment with the payers is becoming more demanding and strenuous every single day. With most insurance panels getting a bulk load of work due to the burst in membership applications and a lot of them being particular about enrolling providers, the process of enrolling or registering your facility is becoming more challenging. Under the circumstances, outsourcing your credentialing and enrollment not only looks like an attractive option to increase efficiency but also makes financial sense. With Outsourcing, you no longer have to worry about revenue cycle leaks, for partnering with experts on credentialing will relieve your credentialing headaches and boost your reimbursements. You can say goodbye to incomplete applications and inaccurate data. Outsourcing your credentialing processes can put your mind at ease. At the same time, giving you more time in your hands to focus on what matters – your practice.