The Importance Of Credentialing & Enrollment For Healthcare Providers

The Importance Of Credentialing & Enrollment
The Importance Of Credentialing & Enrollment

If you are or want to become a Healthcare Provider in the U.S.A., you have to undergo the Credentialing & Enrollment process. 

Complex Credentialing & Enrollment are two important steps for Healthcare Providers to ensure they meet the necessary requirements to practice. Credentialing verifies that a provider meets all qualifications, such as education, experience, licenses, and certifications, while Enrollment places the Healthcare Provider in the insurance network. 

Remember that Credentialing & Enrollment are two separate processes, often used interchangeably. To understand the difference between the two, you can refer to the Difference Between Credentialing & Enrollment

Credentialing has changed forms over the years but it has always been present in order to support the Healthcare ecosystem by, 

  1. Ensuring Quality Care – Ensures that Healthcare Providers are qualified to provide the highest standard of care to patients by verifying qualifications such as education, experience, licenses, and certifications. 
  2. Preventing Frauds – Aids in preventing fraud by verifying Provider Credentials and ensuring all claims submitted are accurate. 
  3. Improving Patient Satisfaction – Helps ensure that providers are qualified to treat patients, thus improving the overall quality of care and patient satisfaction. 
  4. Supporting Healthier Population – Supports a healthier population by providing access to quality Healthcare Services at an affordable cost. 

While the benefits are plenty for the entire Healthcare Ecosystem, Healthcare Providers gain severely as well with timely and accurate Credentialing & Enrollment. Let us understand the importance of Credentialing & Enrollment and How to get Credentialed effectively in this article. 

Importance Of Credentialing & Enrollment For Healthcare Providers 

To Practice Medicine Legally 

Credentialing & Enrollment help Healthcare Organizations ensure they are compliant with relevant laws and regulations, thus avoiding any legal implications or complications. 

To Enhance Reputation 

Credentialing & Enrollment processes can boost a Healthcare organization’s reputation, as it shows that the organization is committed to providing quality care by making sure all Healthcare Providers meet the necessary qualifications and are Enrolled in the insurance network. 

To Increase Network Efficiency 

By streamlining processes between Healthcare Providers and Payors, Credentialing & Enrollment allow Healthcare Providers to benefit from the existing network of patients that the Payor has. This improves the visibility and credibility of Healthcare Providers. 

Most Importantly, To Get Paid For The Services  

If a Healthcare Provider is not Credentialed & Enrolled, will he/she not get paid? 

Unfortunately, that is true. A Healthcare Provider who is not Credentialed & Enrolled will not be receiving the payments for the Medical Services that they provide. This, of course, affects their overall revenue cycle and cash flow. 

As an insurance company (payor), it is beneficial to delay the payments to Healthcare Providers. They receive the premium from individuals (patients) and hold back the payments to Healthcare Providers. This improves their overall cash flow and Revenue Management Cycle. 

While insurance companies like this idea, they cannot hold back the payment for long if a Healthcare Provider has completed the process of Credentialing & Enrolment and all documents are up-to-date.  

This is why it makes absolute sense for any Healthcare Provider to regularly focus on 

  • understanding the continuously changing process of Credentialing & Enrollment 
  • different needs/formats of different payors 
  • identifying the payors most relevant to his/her Healthcare Practice 
  • make a schedule of timelines and deadlines 
  • ensuring the Enrollment is obtained and renewals are made well in time (Re-Credentialing is equally important) 

How Can Healthcare Providers Get Credentialed & Enrolled? 

It is not uncommon for Healthcare Providers to find complex credentialing burdensome and a distraction from their core capability of providing Healthcare Services. Despite efforts and attention, it is easy to miss out a step or two in the complex process of Credentialing & Enrolment. You can learn more about The Process Of Credentialing in this blog. 

To handle the complexities, Healthcare Providers often delegate this cumbersome task to Credentialing specialists who, 

  • dedicatedly navigate the Healthcare Provider through this process of Credentialing & Enrollment 
  • collect and store all relevant documents for Credentialing in a single, easily accessible place using the power of technology 
  • understand the needs of various payors which are relevant to the Healthcare Provider 
  • fill out the application to receive Credentialing & Enrollment status with relevant governing bodies and selected payors 
  • track the status, understand issues if any 
  • solve the underlying issues and ensure clearance of the application 
  • obtain the Credentialed & Enrolled status for the Healthcare Provider 
  • keep a track of the status and make necessary renewals for Re-Credentialing & Enrollment 

Getting a Specialist on board to assist with this important step makes a huge difference by offering,  

  • relief from the administrative burden of the complex Credentialing & Enrolment process 
  • Time to focus on the primary job of providing Medical Services 
  • faster receipt of Credentialing & Enrollment status 
  • improved cash flow with the reduction in claim denials 
  • higher patient referrals from the network of Specialists 
  • reduced overall costs in terms of time as well as money by ensuring a simple and seamless Credentialing experience 

Having understood the importance of Credentialing & Enrollment, it is important that you choose the right partner for your Credentialing & Enrollment needs. We have compiled a quick checklist right here for you to refer to while Choosing The Credentialing Partner for your organization or practice

For further doubts or queries, you can get in touch with Credentialing experts at Apaana Healthcare by filling out the quick form here.

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