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Among healthcare practitioners, there is sometimes confusion between “payer enrollment” and “medical credentialing”. The process of payer enrollment and credentials verification is intricate and it becomes more so with each passing year.

Contract with a CVO

Without the proper verification services, small practitioners – and large ones too – lose money drowning in paperwork. This is where outsourcing to a Credentials Verification Organization (CVO) is a sound investment. A CVO can handle medical credentialing and payer enrollment processes simultaneously. They do all the heavy lifting so practitioners can focus on patient treatment and staff can focus on more critical tasks.

A service that handles credentialing and insurance enrollment is a lifesaver when paperwork becomes tedious and complicated. Such as is the case with the difference between payer enrollment and credentialing.

Defining payer enrollment

Payer enrollment is the process of requesting enrollment in a healthcare insurance panel and plan. The process requires a plethora of application documents. Then, once those applications are submitted, medical credentials must be submitted. Supporting documents are attached. The credentials must be verified before the practice is accepted by the provider. If all goes well, a contract will be created and signed.

Defining medical credentialing

Medical Credentialing is the exhaustive process by which background, education, identity, residency, licensing and other criteria are verified. Medical credentialing and physician credentialing are terms that are sometimes used interchangeably, but medical credentialing applies to any professional who administers care: physicians, therapists, nurses, radiologists, etc.

Because the individual physician credentialing is exhaustive, it takes roughly 4 months to complete. Required credentialing data includes street addresses, a recent photograph, a copy of a National Provider Identifier (NPI), and more.

This basic information must then be coupled with more extensive information. Most of this information is a logical follow-up to the primary questions. Three letters of recommendation are required from providers who have observed the physician’s practice. Current hospital affiliations must be presented. Some of this information can be unique to the physician’s legal status – such as military personnel records, proof of Green Card or labor visa status, or Locum Tenens Practice Experience form.

What are the differences between medical credentialing and payer enrollment?

Payer enrollment (aka provider enrollment) credentials are specifically used for applying to an insurance panel. Medical credentialing is a repository of information to verify the valid status of a healthcare practice and each of its members.

Types of payer enrollment

Payer enrollment processes vary. New hires will undergo a different process than those used when applying staff members to MediCare. Different types of enrollment have various institutional references. For example, Centers for Medicare & Medicaid Services (CMS), are the typical resource when enrolling a practice into a Medicare program.

The 8 typical steps of payer enrollment

Citing the National Association of Medical Staff Services payer enrollment’s typical steps in an ideal setting are as follows:

  • Requesting enrollment
  • Completing the plan’s credentialing
  • Submit copies of licenses
  • Sign contract
  • Steps unique to the contractor. These include additional requirements the individual payer has amended to their enrollment plan.

Types of medical credentialing

The items that medical credentialing requires were covered in this article, What Is Medical Credentialing? more exhaustively. A short summary of them is as follows:

  • Proof of identity
  • Education and training certificates
  • Military service (if applicable)
  • Professional licensure
  • DEA Registration, State DPS, and CDS Certifications

Board Certification

  • Affiliation and Work History

Criminal background disclosure reports

  • Sanctions disclosure reports
  • Health status
  • NPDB
  • Malpractice insurance
  • Professional references

These items are used when a medical practice files an application with a CVO like Advantum Health’s credentialing subsidiary Med Advantage. From there, the CVO will file this information in their databases to verify and format the submission. The final verification report is automatically archived.

By submitting your medical and physician credentialing data to a CVO, you can eliminate errors from the payer enrollment process. Fewer errors result in fewer resubmissions and save the practice both money and time.