Doctor Credentialing Vs Contracting - Here's What You Need to Know

Providing the highest quality of healthcare services - pandemic or no pandemic - is the primary goal for healthcare providers. However, they are often bombarded with complex terms such as healthcare credentialing for insurance, CAQH, contracting, payor enrollment, insurance participation, compliance billing, and network management.

In today’s world, apart from offering best quality medical facilities, medical credentialing and contracting or provider enrollment are among the most important processes for any kind of healthcare organization. However, a very few healthcare professionals are aware of the fact that credentialing and contracting are two distinct terms that require totally different sets of action.


Credentialing vs Contracting - Know the Basics

In order to become a trusted healthcare provider, credentialing is a must. However, most healthcare providers that are entering new ventures to boost their private practice are most often confused about following the do’s and don’ts of credentialing and procedures for billing third party networks.

There are plenty of healthcare credentialing companies out there in the marketplace to facilitate this entire process for businesses. Yet, it is important for healthcare businesses to have basic clarity about the exact difference between credentialing and contracting, and how these processes can have an impact on their revenue cycles.

This article will elucidate the concepts of healthcare credentialing and payer enrollment or contracting. You will also learn how these processes can be successfully implemented in a way to provide a boost to your business.


What is Medical Credentialing? Why is it Important to ‘Get Credentialed’?

Medical credentialing is the process that involves collection as well as verification of the professional credentials of any healthcare provider with a systematic approach. Medical training, licensure, and other various medical and legal registrations and certifications 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 on campus. 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.

The process of credentialing is a precursor to 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 indispensable for physicians to get credentialed before commencing their practice.


What is Contracting? Why is it Crucial in Medical Billing?

While credentialing is a part of primary source verification, contracting depicts an agreement between two or more parties, including insurer and care provider, and it creates one or more legal obligations. Among various elements of contracting, contracting applications consist of basic information and data about the healthcare provider such as education, licensure, national provider identifier (NPI) number, and other data established by state regulatory requirements.

Healthcare facilities and insurance payors often engage in negotiations to set and meet some targets and benchmarks through contracting. However, as approval of credentialing is often received before the approval of contracting, healthcare providers mistakenly consider this as a green light to commence with their practice and start treating patients.

It is important to understand that credentialing and contracting are totally different processes. The requirements of contracts differ by specialty, practice, size of the healthcare organization, as well as its location. Any provider who joins the facility has to implement credentialing along with the provider enrollment process to officially be a part of the existing group agreement.


How to Avoid Pitfalls of Self-Credentialing and Contracting and Boost Business Growth

Best practices for ensuring successful credentialing and contracting include:

  • Ensuring the accuracy in documents and completion of applications, where the updated information about address, TIN, and names among other factors matches.

  • Ensuring that your billing service provider is an expert and understands all the regulatory requirements before submitting your documents.

  • Ensuring that your professional references respond in time to various reference requests by contacting them beforehand.

  • Understanding that application approvals and the entire process takes months, and it is not possible to bill your patients before your contract is effective.

  • Consider consulting an experienced person or a healthcare credentialing company for reviewing your applications.

  • Keep in mind to have a copy of all your credentialing applications, documents, as well as contracts.

The entire process of credentialing and contracting is complex and tedious. Navigating through all these complexities on their own can cost healthcare providers a fortune while it can be even more time consuming than usual.

While healthcare providers are willing to focus on offering best healthcare services, a majority of them are preferring to outsource their credentialing and contracting application tasks to the best medical credentialing companies. It gives them more time to focus on patient care, while administrative needs of contracting and credentialing are taken care by doctor credentialing service providers. Connect with us now to get a competitive advantage with successful credentialing and contracting.

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