Credentialing vs Payer Enrollment

Vetting a medical service provider requires more than a background check. Along with exhausting administrative tasks, paperwork, and manual record keeping, a healthcare organization needs to make sure the medical personnel they approve are credible and can be trusted with their patient’s health and care.

In this post, we will explore credentialing, payer enrollment, the difference between the two, and how each is an important step in maintaining the health and wellness of our provider network.

What is Credentialing?

Credentialing is the process of vetting a medical personnel’s professional qualifications, including:

• Education and training
• Licensure and certifications
• Experience

This is done before the provider can join a network or be hired by a healthcare facility. It helps to ensure they have the skills and knowledge to provide safe and effective patient care.

The credentialing process involves three stages:

1. On-boarding. Provider applies and submits all required information, including license, education, certifications, references, work history, etc.
2. Background confirmation. The application receivers, healthcare facilities, insurance companies, or credentialing organizations review the application and verify the information.
3. Approval. If no issues are found, the provider is approved to work with a healthcare network.

To find out more about provider credentialing, see our Comprehensive Guide to Credentialing.

What is Payer Enrollment?

Payer enrollment, also known as provider enrollment, focuses on verifying a provider's eligibility to receive payment for services rendered. This involves checking:

• Licenses and certifications
• Malpractice insurance coverage
• Practice location
• Tax identification numbers

Payer enrollment follows effectively the same process as credentialing. The provider submits an application and requests to join the network. The providers review the application, run a background check, and approve the application if the information is valid.

Credentialing vs Payer Enrollment

In order to receive payment for medical services, healthcare providers must go through two processes: credentialing and payer enrollment. The main differences between these two lie in the entities involved, application requirements, and timing.

Entities Involved in the Process

The credentialing process can be carried out by one of the following—depending on the organization's preference:

• Insurance companies,
• Healthcare organizations, or
• Credentialing services

Whereas payer enrollment is carried out by the health plan.

Process Timing

Credentialing takes place prior to a provider’s ability to provide services and typically takes up to 30 days.

Alternatively, payer enrollment involves verifying the applicant’s information for approval so that the provider can join the provider network pending approved credentialing and enrollment evaluation—the last step to fully enrolling and enabling the healthcare provider to be paid for services rendered ultimately.

Re-Credentialing and Payer Enrollment Processes

Credentialing is a recurring activity. Every 1–3 years, providers go through the credentialing process again to ensure that their credibility and patients’ safety remain intact.

However, the payer enrollment process occurs once the provider applies for enrollment, but it is only updated if necessary.

How Can CVOs Help with Credentialing and Payer Enrollment?

Both credentialing and payer enrollment processes are time-consuming. It takes months of work and exacting precision to verify a healthcare provider’s documents and background, and many organizations don’t have the time or staff to execute that work without errors.

With healthcare providers needing credentialing and payer enrollment, delegating the task to credentialing service providers (CVOs) increases turnaround times, decreases errors, and ultimately helps drive both health equity and better patient outcomes.

How Can Certify Help?

Credentialing solutions like Certify are available now to speed up the process and make credentialing and provider enrollment effortless for all entities involved—providers, insurance companies, and healthcare organizations.

We help providers get “in-network” with health plans but serve providers and health plans differently.

Certify helps providers with payer enrollment and also assists health plans with credentialing using our API-driven technology to make the entire process automated, streamlined, and efficient for both healthcare and health plan providers, saving their partner organizations both time and money.

Talk to our team of professionals today to learn more about our credentialing and payer enrollment processor. Book a free demo now.