Healthcare Credentialing | symplr Blog

Do You Know the Difference Between Provider Enrollment and Credentialing?

Written by Amanda Vaughn | May 25, 2017 5:55:45 PM

Many people don’t know the difference between the credentialing and provider enrollment roles in business. That’s not surprising, as most people don’t have the need to know. You may, however, be surprised at the number of those in the healthcare industry that do not know the difference. While it is true that the two jobs are intertwined, there are distinct differences between the two that I'd like to make clear in order to help clarify why the enrollment specialist is often confused with a credentialing specialist. 

Before providers start seeing patients or providing medical services, they must be enrolled with major health plans to be considered “in-network,” “participating” or “effective.” They are not required to be enrolled with these plans to practice medicine; however, there are very few patients who will choose to pay out-of-network prices for an unenrolled provider’s services when they already pay a premium with their health plan or insurer. For the greatest cost savings, most patients will select their provider from a directory listing of network providers that their health plan maintains. To be listed as a network provider, each provider must be enrolled with the health plan. In order to be enrolled, the provider is generally required to be credentialed, thereby meeting certain criteria to be approved as a network provider.

When it has been determined that the enrollment process needs to begin, the next steps are often unclear, based on a lack of understanding of who does what. As part of the enrollment process, the provider needs to be credentialed with the payor. Do you need a specialist in credentialing or enrollment to help? The short answer is that you need the help of a provider enrollment specialist to guide you through the complexities that lie ahead. When a provider decides to enlist the expertise of an enrollment specialist, he or she can expect to be bombarded with questions and document requests, as the specialist will let the provider know what is expected before being able to begin the process. This includes, but is not limited to, document copies, online access, and signature pages. The provider will need to know countless details about the practice, whether the provider is a part of a group or not, and if the group already has contracts in place. The sooner the information is provided, the sooner enrollment can begin.  

The provider enrollment specialist knows who needs to be credentialed and who does not, such as providers who were already credentialed or mid-level providers who may not require credentialing. The specialist knows the timeframe of the process with each plan, which can take up to six months to complete; in some instances, the timeframe can be as short as 30 days or as long as a year. The provider enrollment specialist knows which plans will retro the effective date of participation, such as Medicare and many Medicaid plans, and knows how to prioritize which applications need to be submitted first. The specialist follows up throughout the process—on the applications submitted through completion of the process, when an effective date is provided, and when the provider is in-network. This final step completes enrollment, signifying that claims can be released for payment.

While it is never too early to enlist the help of a provider enrollment expert, the credentialing process only begins once an application is submitted to join the network. Once the application has been received in the credentialing department, it is checked for completeness before being processed. If anything is missing, the credentialing team will request the information from the credentialing contact noted on the application, which should be the provider enrollment specialist. The credentialing team authenticates the information submitted on the application through primary source verification, which includes a sweep of the National Practitioner Data Bank to see if there are unreported malpractice claims. They verify licensure, malpractice coverage, education and specialty training. The training verification is crucial, as health plans will not allow the provider to be listed under the specialty he or she requests without training and educational requirements being met. The provider’s record is carefully combed over, searching for actions against the provider which will need to be reported to the credentialing committee for final determination of entrance into the network. When the file has been thoroughly reviewed, it will be held for the next committee meeting for approval. Once approved, a “welcome letter” is sent out notifying the provider of the effective date, the provider number needed for billing, and other helpful information as may be needed to access web portals, claims status, and other information required of a network provider.

Overall, the function of a credentialing specialist is to verify information submitted and search for adverse actions that may exclude the provider from participation in the network. Typically the provider has very little interaction with the credentialing specialist, other than providing missing information. Once credentialing is complete, so is the communication with the credentialing specialist. On the other hand, the enrollment specialist maintains enrollment for the provider on a long-term basis, making sure that the provider data is kept up to date and that all credentialing/re-credentialing applications are submitted and approved in a timely manner. Perhaps the most essential job function of the enrollment specialist is maintaining communication between the provider and the health plans, asking and answering questions from both sides, and keeping the process running smoothly to ensure all involved are well-informed. The biggest setback to enrollment is not getting requested information returned from the provider quickly. Once all the correct information and documentation is received, the enrollment specialist will jump through all the credentialing and enrollment hoops for you!

We offer complete client support to help you navigate the complexity of provider enrollment, saving you time and money. Learn more about Payor Enrollment Services at www.symplr.com/products/payor-enrollment-services or schedule a demo at sales@symplr.com.