What Is Credentialing & Enrollment? Is There A Difference?

Provider Credentialing and Enrollment processes form the foundation on which patients place their confidence in the Medical Industry. Very often used interchangeably, Credentialing and Enrollment are actually two distinct terms, each with its own purpose and process. The overlap happens when Credentialing is used as an umbrella term to cover the entire process. We’re going to break it down, to highlight the difference.

What is Credentialing?

Credentialing is the process of verifying a Healthcare professional’s qualifications, training, work experience, and license. It is also known as primary source verification because it involves checking qualifications at their source.

This process is followed by and includes another step known as Privileging. Privileging is the permission given to Healthcare Practitioners – after Credentials have been verified and established – to perform specific services at a center.

Credentialing is useful to Healthcare facilities as part of hiring protocol and to insurance companies to help Providers enroll in their network.

What is Enrollment?

Once Providers have gone through Credentialing and Privileging, it is time for the next step. Enrollment is the process of applying for participation in a health insurance network as Providers. Enrollment involves requesting participation supported by the required documents and the subsequent signing of the contract.

Enrollment helps providers by validating them in a public health plan and allowing them to bill the agency for services provided. It is this contract that facilitates reimbursements for services provided as In-Network Providers.

Is there a difference?

Yes. Credentialing is a two-step process that includes Credentialing and Privileging. Provider Enrollment is the next step. Provider Enrollment always follows the Credentialing process; after Credentialing has been fulfilled and Privileging sought. This makes Credentialing a necessary and faster route to Enrollment.

Why are Credentialing and Enrollment important?

Broadly speaking, without Credentialing and Enrollment, it is impossible for Healthcare Providers to provide treatments and services and receive reimbursements from insurance companies for the same. Also, Credentialing and Enrollment operate as a checks and balances system to ensure quality and standards in the Healthcare system. Other benefits include:

• Helping reduce Medical errors and malpractice
• Demonstrates and encourages professionalism in the industry
• Inspires confidence, builds trust, and maintains high standards
• Help in maintaining staffing levels
• Streamlining of insurance reimbursements

Larger practices typically hire a team to deal with Credentialing while smaller practices may choose to handle the process in-house. In either case, time is of the essence. Here are some pointers that will help accelerate and streamline the process:

• A Provider must start the process well in time. While the standard time to obtain Credentials is between 3 and 6 months, any error may add weeks to the process.
• Keep an eye on Re-Credentialing dates – the process of Re-verifying the Provider’s professional Credentials – if overlooked, may cause a suspension in the practice.
• Credentialing and then Re-Credentialing can be quite overwhelming for any practice, large or small. Outsourcing the grunt work to a professional physician Credentialing software service frees up time and lets the Provider deal more effectively with the practice.

Looking at passing on this paperwork-intensive job to someone reliable? Apaana Healthcare is a professional physician Credentialing software service that will help you free up your time and let you make more money. With Apaana Healthcare’s efficient software backing you up, you won’t have to worry about differences in Credentialing procedure over states, disruptions in work caused by the frequency of the process, the hassle of getting your hands on peer references or taking time out of already taxing time schedules to deal with mountains of documentation. You will also sidestep issues caused by candidates providing incomplete information which leads to exhaustive communication between the Credentialing body and the candidate. Such delays result in staff scheduling issues and eventually losses in your business.

Let us let you work with a single-minded focus. At Apaana Healthcare, there are no distractions, only rigorously followed procedures. To understand how exactly we can assist, visit our website, or?get in touch .