What’s the Difference Between Payer Enrollment and Credentialing?

Healthcare management is a complex field that requires special training and continuous education for the best results. Unfortunately, some new medical practices struggle to keep up with rules and regulations, and they often struggle to understand the difference between specific terms.

However, learning the differences between payer enrollment and credentialing is crucial, as they are essential for the revenue cycle of your healthcare practice and can help create more effective systems.

So, if you are not sure about the processes behind these terms, read on to discover all about them.

What Is Payer Enrollment in Healthcare?

Payer or provider enrollment refers to the process of entering and participating in a health insurance network as a partner medical provider. Payer enrollment is vital for your practice, and it can help you get more patients, deliver better care, and increase revenue. 

Keep in mind that most patients only look for in-network providers, so when you enroll with an insurance network, you’ll have better chances of being selected by those people. 

However, payer enrollment is lengthy and time-consuming. In addition, it is complex, and each provider has a unique process and a set of requirements. Although most payers look to resolve the requests within 90-120 days, it is not unusual to wait over six months. 

You need to go through the application, provider credentialing, and other steps to become enrolled. So, credentialing is only one part of payer enrollment, which is why the terms cannot be used interchangeably.

What Is Provider Credentialing?

Credentialing is a part of the payer enrollment process that’s supposed to verify the competence and expertise of a medical provider. The insurance company needs to know you have the necessary skills and training to provide the required level of care.

Health insurance companies establish specific frameworks and guidelines to ensure the necessary level of patient care. They need to verify that a medical practice adheres to these standards, offering the best possible care and ensuring patient safety.

Provider credentialing is a lengthy process and includes verifying information about education, training, special certificates, work history, and other documentation.

Payer Enrollment vs. Provider Credentialing

Payer enrollment is the first step of the revenue management cycle, and it’s essential for maintaining and improving the cash flow of your medical practice. The term refers to the process of entering an insurance provider network and includes steps like identifying reliable payers, information gathering, credentialing, providing necessary information, and negotiating contracts.

So, provider credentialing is only one part of payer enrollment, and it includes verifying the competency and expertise of a medical provider. It is vital to ensure the necessary level of patient care and security, and every in-network medical provider must go through this process.

Who Can Help With Payer Enrollment and Credentialing?

Since payer enrollment and credentialing are complex and time-consuming processes, the best idea is to get professional help. A healthcare consultation agency like Peregrine Healthcare can help you navigate this process and reduce the time needed to enroll with selected payers. Click here to get our contact info, or visit this page to learn more about the services we provide.

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