Credentialing and Contracting: Don’t Get Confused
Provider credentialing and contracting are usually used as synonym, but technically these are two separate things. To put in simple words, being credentialed means you are loaded in the insurance company’s system. Normally when you are only credentialed, it means you are out of network with the insurance company. Now, contracting is the process of becoming a contracted with the insurance company. Being a contracted provider means you have a fully executed contract between yourself (or group) and the insurance company and are considered to be an in-network provider. Let’s understand both the terms and know how they are interconnected.
What is Medical Credentialing?
Medical credentialing is the process that involves collection as well as verification of the professional credentials of any healthcare provider with a systematic approach. Your NPI, CAQH, professional licenses, diploma’s, certifications, attestations and professional references are reviewed and verified through medical credentialing. It is essential for healthcare facilities to implement credentialing in order to allow individual healthcare providers to offer their services and run their practice. Insurance companies will do ‘Primary Source Verification’ which is the process of requesting and receiving verification of your stated credentials from the College or other entity that issued the diploma or certificate.
In credentialing process, it’s very important that your documents are accurate and they all match. Problems begin when there are inaccuracies such as a change of rendering providers or practice ownership and discrepancies between various records. Another problem area can occur when professional references do not respond in a timely manner. It is a good idea to contact your references before they receive a reference request.
Healthcare providers are considered to be credentialed when they follow the process of insurance credentialing by becoming affiliated with insurance companies, eventually to accept third party reimbursements. Credentialing comes first and then contracting. As many patients today are becoming aware about the importance of credentialing, they are refusing to visit practitioners who are not in their insurer’s network. This makes it essential for physicians to get credentialed before starting their practice.
What is Contracting?
Contracting is the process of applying for and obtaining participation with insurance plans. Once the credentialing phase is complete and the payer has approved the provider, the payer will extend a contract for participation. Healthcare facilities and insurance payors often engage in negotiations to set and meet some targets and benchmarks through contracting. The requirements of contracts differ by specialty, practice, size of the healthcare organization, as well as its location.
Contracting or being ‘in network’ is an optional relationship offered by most insurances that makes you an official ‘participant’ with that insurance. Being contracted restricts your freedom to charge and collect from patients and often involves negotiating rates with that respective insurance company. That said, being in network means you’ll likely get a steadier patient stream, because patients typically receive better coverage for in-network services.
Often providers enroll in a plan and then never review the performance of the contract. Years go by, insurers do not update your contract to reflect updated reimbursement rates. Does your biller or associated billing company periodically review contract performance and update your contracts?
Boosting Your Credentialing and Contracting Process
- Make sure all of your documents are accurate and that the information matches. Update any details as needed (e.g., address, names, or TIN).
- Frequently login to CAQH making sure that your profile is up-to-date and you don’t have any pending requests.
- Stay in touch of your references before they receive a reference request.
- Don’t wait. the application process can take months, and in most cases, you won’t be able to bill as an in-network provider until your contract is effective.
- Consider having someone experienced in enrollment review your applications before you submit them.
The entire process of credentialing and contracting is complex and tedious. Does the staff member or biller submitting your applications understand the regulations or are they just trying to complete a form? Thousands of dollars can be lost and payments may be interrupted if there are errors or inconsistencies in your credentialing and re-credentialing. Connect with E2E Medical Billing Services and get a competitive advantage. Let us help you organize and manage your credentialing and contracting responsibilities. To know more about our ‘provider credentialing service’ contact us at 888-552-1290 / [email protected]
What are the difficulties you faced while credentialing and contracting? Let us know in the comment section below.