Credentialing and Contracting: Don’t Get Confused

Introduction

Provider credentialing and contracting are usually used as synonyms, but technically these are two separate things. To put it in simple words, being credentialed means you are loaded into 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 contract 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 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, diplomas, certifications, attestations, and professional references are reviewed and verified through medical credentialing. Healthcare facilities need 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 the 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 promptly. 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 accepting third-party reimbursements. Credentialing comes first and then contracting. As many patients today are becoming aware of 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 in 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 log in to CAQH making sure that your profile is up-to-date and you don’t have any pending requests.
• Stay in touch with 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 PrimeCare, a reliable medical billing company, and get a competitive advantage. Let us help you organize and manage your credentialing and contracting responsibilities. Contact us today to learn more about credentialing services.