Updated: Jun 26, 2022
I started receiving several emails a day with questions regarding medical credentialing, contracting and enrollment. So I thought I can explain to more people through my blog. Let's get started.
What is medical credentialing?
According to the National Center for Biotechnology Information, (https://www.ncbi.nlm.nih.gov/books/NBK519504/), Credentialing is defined as “the formal process that utilizes an established series of guidelines to ensure that patients receive the highest level of care from healthcare professionals who have undergone the most stringent scrutiny regarding their ability to practice medicine.”
Why is credentialing so important?
*Builds Patient Trust
o Having patients trust is not only important for the practice, but it’s extremely important for the patient’s overall health. When a patient has full trust in the provider, the patient is more likely to follow the provider’s recommendation to keep the patient healthy. This will also allow open dialogue between the patient and provider.
*Ensures Compliance and Protection of Patients
o Practices and providers that applies for credentialing must undergo a stringent background check. This is to ensure the provider and / or practice does not have any criminal backgrounds, it will show lawsuits and pending lawsuits against the practice or provider.
o Providers undergo background checks through:
-HHS Office of Inspector General (OIG) List of Excluded Individuals and Entities (LEIE): Lists individuals excluded from working for healthcare organizations that receive federal funding
-U.S. General Services Administration (GSA) System for Award Management (SAM): Lists individuals and firms barred from receiving federal contracts or subcontracts
-Healthcare Fraud and Abuse Lists: Provide individual sanction histories using data from federal agencies and over 800 licensing and certification agencies across 50 states
-National Practitioner Data Bank (NPDB): Contains reports on medical malpractice payments and other adverse actions taken against health care practitioners and suppliers
-Global Sanctions and Watch List: Includes individuals named as national security threats by the Patriot Act
-State-Specific Exclusion Lists: Provide information about individuals barred from healthcare employment in specific states
*Providers also undergo background checks for:
-National Abuse Registry
-Sex Offender Registries
*Ensures Practice Revenue
o When the practice is credentialed, they can also become credentialed with the health insurances. This will allow for the practice and provider to bill for the services rendered to the patient.
o If the practice and/ or provider is not credentialed with the insurance, they are not able to collect the fees for the service provided. They may be able to bill as a non-participating provider, however, the amount is not guaranteed. Why take the risk of losing revenue?
*Medical Error Rates are Lower
o According to the National Library of Medicine (https://pubmed.ncbi.nlm.nih.gov/28186008/#:~:text=Recent%20studies%20of%20medical%20errors,third%20leading%20cause%20of%20death) there are as many as 251,000 deaths each year in the United States due to medical errors.
o Credentialing helps to reduce these errors by making sure practices and providers attend trainings throughout the year and must undergo mandatory certifications throughout the year as well.
What is insurance contracting?
Insurance contracting is an agreement for reimbursement of services between the provider and the insurance company. For an example, CMS (Centers for Medicare and Medicaid Services) sets the Physician Fee Schedule (PFS) (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched). A fee schedule is a complete listing of fees used by Medicare to pay doctors or other providers/suppliers.
Why is contracting with an insurance important?
Do you like to get paid for the hard work that you do? Well, so do providers. Contracting allows the providers to know how much they will be reimbursed for the services they provide, per their contract.
Every year, CMS updates the Physician Fee Schedule. Other insurance will follow the set Physician Fee Schedule and will base their fees according to this. The insurance companies will either pay more or less than the PFS, depending on if the provider is enrolled with their company, what percentage above or below the fee schedule the insurance pays and what services were performed.
What is provider enrollment?
Provider enrollment is when the provider (or practice) requests to become part of the insurance company’s network. It involves applications to be submitted for the process of applying to health insurances for inclusion in their provider networks.
Why is provider enrollment important?
A provider must be enrolled prior to contracting with that insurance company. Once enrolled, they will become what is called “in-network”. This means they are allowed to bill for their services and will be paid according to the contract between the provider and insurance company.
If the provider is not enrolled, they are not contracted and is considered “not in-network”. This means the provider’s office may need to request approval before providing services and may be paid at a very small fee for their services. In some cases, if they are not in-network, they may not be paid at all and will need to write off the services, which means a profit is not made.
To know what is needed to enroll, contract and credential, it is always best to contact the insurance company and ask what is needed. The process for these can take anywhere from 60-120 days. So, it’s best to request the required information upfront from the provider to ensure no delays.