Do you know the difference between provider credentialing and provider enrollment?

What is the Difference Between Provider Credentialing and Provider Enrollment?

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CredentialingOne Blog

What is the Difference Between Provider Credentialing and Provider Enrollment?

Posted on Friday, June 12, 2020

Many healthcare professionals experience confusion over the terms provider credentialing and provider enrollment, and justifiably so – there is plenty of overlap between them. However, understanding the differences will help you better navigate the complex credentialing process.

What is Credentialing?

Credentialing is the process of verifying a provider’s qualifications for practicing medicine. The provider’s education, licenses, certifications, work history, references, and more are validated through primary source verification (checking with the original source that issued each credential). Additionally, background checks of the provider’s financial, criminal, and/or social media history may be conducted.

Credentialing is completed as part of the hiring process, in order to obtain hospital privileges, and as a key step in provider enrollment.

What is Provider Enrollment?

Provider enrollment is the process of adding a provider to commercial and/or government health plans so that the provider/practice can be reimbursed for services provided to patients.

To join a commercial health plan, the provider must follow the payer’s specific application and credentialing process. If the provider is approved and signs a contract with the health plan, the provider will be considered “in-network.” This is very exhaustive work, yet the credentialing process is even more strict and detailed for enrollment with government health plans like Medicare and Medicaid.

Most patients will not seek care from an out-of-network provider. Provider enrollment is therefore not only essential to getting paid but also for attracting patients.

Provider Credentialing Vs. Enrollment – What’s the Difference?

Credentialing and enrollment both entail similar tasks related to the verification of a provider’s credentials, and credentialing is a part of provider enrollment. You can think of credentialing as an umbrella term used to encompass all instances where validating a provider’s qualifications is necessary – for the purpose of attaining employment, hospital appointment, and/or participation in health plans.

Because credentialing is a condition of hiring, granting hospital privileges, and contracting with payers, the work involved becomes very repetitive and laborious as each entity (the practice, hospital(s), and payers), must ensure the provider is qualified.

There is even more redundancy when you factor in the lack of standardization among health plans. Each payer has its own unique credentialing requirements and most providers will enroll in a dozen or more different health plans in order to remain competitive. This equates to a lot of time and paperwork – the average time it takes to credential one provider with one payer is 8 to 10 hours per application.

The repetition only continues as providers must renew their appointment with a hospital (usually every two years) and complete periodic recredentialing with commercial insurance companies and revalidation with government payers.

Outsourcing Credentialing and Enrollment

CredentialingOne can take care of this redundant and time-consuming work for you.

We handle everything – from completing documentation and submitting applications, to following up on them until each provider has an effective start date with each payer, to the ongoing credentialing maintenance needed to keep payers and practices compliant with health plans.

Our services include credentialing for all provider types and new/existing practices of any size, provider enrollment in commercial and government health plans, recredentialing/revalidation, hospital appointment and reappointment, and much more.

Additionally, we provide monthly monitoring and maintenance of documents, certifications, CE, and malpractice insurance, as well as automated alerts to ensure you never become inactive with a payer as a result of credentialing noncompliance.

To schedule a complimentary consultation on how we can help you with provider credentialing and provider enrollment, contact us today.

By Stephanie Salmich

Lengthy checklists representing the time-consuming process of primary source verification.

Primary Source Verification

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CredentialingOne Blog

Primary Source Verification

Posted on Friday, April 17, 2020

What is Primary Source Verification?

Primary source verification (PSV) is the process of validating a provider’s credentials through direct contact with the person or organization that actually issued the information.

Lengthy checklists representing the time-consuming process of primary source verification.

CredentialingOne can complete the time-consuming PSV process for you.

According to The Joint Commission, PSV is:

“Verification of an individual practitioner’s reported qualifications by the original source or an approved agent of that source. Methods for conducting primary source verification of credentials include direct correspondence, documented telephone verification, secure electronic verification from the original qualification source, or reports from credentials verification organizations (CVOs) that meet Joint Commission requirements.”

PSV requires detailed documentation, which should include:
  • Date the PSV was conducted
  • Method of verification (e.g. letter, fax, email, phone, website)
  • Agency and/or individual person contacted for verification and their contact information
  • The information that was specifically verified
  • Results of the PSV (e.g. questions asked and their answers)
  • Person who conducted the PSV and their signature

Why is Primary Source Verification Necessary?

Primary source verification is vital to accurate and credible credentialing. It is simply inadequate to accept information submitted by a provider or document photocopies at face value.

PSV protects your patients’ safety by helping to ensure your practitioners are qualified to care for them. Furthermore, it protects your organization from legal risks and compliance issues.

PSV is the standard form of verification for the healthcare industry and helps healthcare facilities meet the accreditation requirements of The Joint Commission and NCQA.

Primary Sources Vs. Secondary Sources

The Joint Commission has deemed some entities “designated equivalent sources,” meaning it considers them to provide information identical to that provided by the original source. Your options for PSV are contacting the original source or any designated equivalent sources.

You should only use secondary sources to verify credentials in cases where it is truly not possible to contact the original source (such as when the issuing agency or hospital has closed) and designated equivalent sources are unable to verify the information. For example, if an establishment is no longer in operation you may try contacting any successor organizations or find out where original documents may have been sent.

Primary Source Verification Services

PSV is a very involved and time-consuming process that entails manual, repetitive tasks that must be completed for EACH credential and for EVERY provider. Some designated equivalent sources also require payment to gain access.

Fortunately, CredentialingOne can contact/access each of these sources (original sources and/or designated equivalent sources) for you as well as document the completion of PSV for each of your providers’ credentials. We also monitor providers’ compliance, so you don’t have to manually track credentials and documentation and can ensure they’re renewed before they expire.

For more information on primary source verification and how CredentialingOne can help, contact us today.

By Stephanie Salmich

An emergency sign outside a hospital is shown, along with the blog title: COVID-19 Resources for Provider Privileging During a National Health Emergency.

COVID-19: Resources for Provider Privileging During a National Health Emergency

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CredentialingOne Blog

COVID-19: Resources for Provider Privileging During a

National Health Emergency

Posted on Monday, March 30, 2020

An infographic outlining different providers hospitals may call upon to help during the coronavirus crisis, which notes that many regulations are temporarily changed for provider privileging during a national health emergency.During a national health emergency such as that caused by the coronavirus, many facilities experience a provider shortage.

To combat COVID-19, you may need to expand your team of healthcare professionals by relying more heavily upon retired and volunteer providers, part-time clinicians, practitioners from other states, practitioners from other departments, and telehealth.

Provider Privileging During a National Health Emergency

During a health crisis, hospitals strive to grant privileges to these clinicians as quickly as possible while still protecting patients by providing them with qualified practitioners.

The federal and state governments, along with other regulatory entities, are temporarily adjusting some licensing and privileging requirements to accommodate the greater need for more providers and access to care due to COVID-19.

CredentialingOne can help you navigate any new and/or temporary rules and ensure your patients receive safe care from competent providers.

To start, we’ve compiled a list of resources to consult regarding provider privileging during a national health emergency:

An emergency sign outside a hospital is shown, along with the blog title: COVID-19 Resources for Provider Privileging During a National Health Emergency.

Many regulations are temporarily changed for provider privileging during a national health emergency.

1135 Waivers – the U.S. Department of Health & Human Services (HHS) is authorized to issue waivers during the COVID-19 national emergency. You can find information on blanket waivers and how to apply for individual waivers here. You must send individual waiver requests to your CMS Regional Office, and office email addresses can be found here.

Disaster PrivilegesThe Joint Commission has posted requirements for privileging, re-privileging/re-appointment, and telehealth privileging during a disaster.

Medicare Provider Enrollment – the Centers for Medicare & Medicaid Services (CMS) is offering new flexibilities regarding Medicare provider enrollment, including waiving certain screening requirements, allowing licensed providers to perform services outside their state of enrollment, and expediting applications; see its FAQs.

Medicare Telehealth CMS has expanded Medicare telehealth to include a wider scope of services so that more patients can access care from home; see its FAQs and Fact Sheet.

States Waiving Licensure Requirements/Renewals – the Federation of State Medical Boards (FSMB) created this table along with links to the original sources declaring the changes in response to the coronavirus.

States Expediting Licensure for Inactive/Retired Licensees – the FSMB created this table, which includes links to states’ resource pages.

The Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP) this program verifies registered healthcare volunteers’ credentials in advance, so they can respond more quickly to help in a crisis. (Hospitals should check with their insurance companies to determine how volunteer providers may/may not be covered by their malpractice insurance.)

For additional information, you can also contact your specific state medical association.

These resources may be updated as the COVID-19 situation progresses.

If you need further guidance on provider privileging during a national health emergency, please contact us – we’re here to help.

By Stephanie Salmich

An accuracy meter hits Level 100… prevent claim denials with accurate and timely credentialing.

Prevent Claim Denials with Accurate and Timely Credentialing

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CredentialingOne Blog

Prevent Claim Denials with Accurate and Timely Credentialing

Posted on Thursday, March 5, 2020

In order to prevent claim denials, accurate and timely credentialing is essential to your practice. Credentialing has a major impact on the revenue cycle as the slightest error or interruption in the process can result in claim denials, underpayments, and reimbursement delays.

And payments for services delivered are not the only thing at stake – you also risk losing the business of patients who don’t want to go out of network while you wait to be accepted by their insurance plans.

You can prevent claim denials and other damages to your revenue cycle through accurate and timely credentialing. By both avoiding credentialing mistakes and completing the credentialing and recredentialing processes as quickly as possible, you can protect your practice’s cash flow and revenue integrity.

Below we outline just a few of the credentialing mistakes that can affect reimbursement by holding up credentialing applications and/or causing claim denials.

Avoid these mistakes that cause application processing delays or rejections:

  • Not allotting enough time for the credentialing process
  • Errors in credentialing application paperwork and contact information
  • Omitting required information or documentation from applications
  • Leaving form fields blank or not fully completing each form
  • Unexplained gaps in work history
  • Unresponsive or lagging peer references
  • Malpractice insurance for the practice a provider is leaving, rather than the one they are joining
  • Outdated or incomplete CAQH application
  • Lack of follow-up on application status

Avoid these credentialing-related billing and compliance mistakes:

  • Submitting a claim using physician or practice data that does not match what the payer has on file
  • Submitting a claim for an office location that is not in the payer’s system
  • Failing to confirm payers have the correct provider billing address
  • Forgetting to notify a payer when a provider terminates (e.g. resigns, retires), when the plan requires the practice to do so within 30 days of the termination
  • Not realizing that credentialed providers may need to opt-in to new plans that a payer has added
  • Not realizing that credentialed providers may need to opt-out of new plans that a payer has added, or they may automatically be included in them
  • Missing deadlines for CE requirements
  • Missing renewal deadlines for expiring certificates, licenses, insurance, etc.

These solutions can help ensure you avoid credentialing mistakes that impact the revenue cycle:

Prevent Claim Denials with an Annual Health Plan Audit

An accuracy meter hits Level 100… prevent claim denials with accurate and timely credentialing.

CredentialingOne’s accurate and timely credentialing services can prevent claim denials and protect your revenue.

Conduct an annual health plan audit to verify your providers are participating in the correct plans, payers have been updated on your current roster of providers, and front desk staff understand the plans with which you hold contracts.

You should audit regularly to keep up with provider and front desk turnover and periodic changes to health plans. CredentialingOne provides a health plan audit service, which typically takes fewer than 30 days to complete.

Prevent Claim Denials Related to Ongoing Credentialing Maintenance

Additionally, you should continuously monitor your providers’ compliance with health plans. Even after providers are enrolled with payers, there are plenty of opportunities for reimbursement issues resulting from compliance violations and/or recredentialing/revalidation errors.

CredentialingOne tracks our clients’ expirables (e.g. certificates, licenses, malpractice insurance, CE credits) and our automated, real-time messaging alert system notifies practices and providers of upcoming deadlines 120, 90, 60, and 30 days prior to expirations.

Through deficiency management we can help you prevent claim denials related to avoidable compliance breaches.

Prevent Claim Denials by Outsourcing Credentialing

Outsource credentialing with CredentialingOne and we will prevent claim denials related to credentialing issues for you. Our Credentialing Specialists are experts in correctly and quickly completing all tasks related to credentialing and compliance for our clients.

We make sure you avoid the credentialing mistakes listed above and our credentialing technology solutions streamline the process to get you credentialed and recredentialed with your payers faster.

Contact us today to learn more about how our accurate and timely credentialing services can prevent claim denials and protect your revenue.

By Stephanie Salmich

A physician reads our 5 Tips for Provider Credentialing on a tablet.

5 Tips for Provider Credentialing

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CredentialingOne Blog

5 Tips for Provider Credentialing

Posted on Monday, February 10, 2020

A physician reads our 5 Tips for Provider Credentialing on a tablet.

Follow these 5 tips for provider credentialing!

Here are 5 tips for provider credentialing to help you navigate the complex credentialing process that can often seem overwhelming.

5 Tips for Provider Credentialing:

Credentialing Tip #1: Don’t Delay!

This may be the most important credentialing tip: Get started ASAP. Begin collecting and organizing relevant documents and other material immediately. This includes CVs, references, updated contact information, education/work history, and more.

Even if a payor won’t start the credentialing process until 60-90 days out from a provider’s start date, it’s never too early for you to prepare. Because the credentialing process is lengthy and affects reimbursement, some healthcare organizations will not schedule a new provider’s start date until they’ve received all credentialing paperwork from the new hire. For example, you may not be able to start until 120 days AFTER you’ve submitted all (complete and accurate) requirements.

Many providers find that the credentialing process takes longer than expected. Do everything in your power to prevent delays that can result in postponed employment start dates and claim denials.

Credentialing Tip #2:  Be Proactive

Anticipate that there will be issues. Besides starting the credentialing process early, there are other actions you can take to minimize your chances of encountering delays.

For example:

  • If three references are required, obtain five. This way if one of your references can’t be reached, it won’t hold up the rest of your application.
  • If you can help it, don’t wait until the summer to start the credentialing process. Payors receive a lot of applications in the months following graduation, so you’ll probably see delays during this busy time.
  • Triple-check your paperwork and have another experienced professional look over your application to make sure you’re not missing anything. Mistakes and omissions are major causes for delay. If everything is correct on your first submission, it will save you a lot of hassle down the road.
  • Follow up. Stay on top of your application by checking its progress at least weekly. This will ensure you detect and resolve any deficiencies as soon as possible, since many states allow 60 days or more for payors to inform you of errors.

Credentialing Tip #3:  Understand Your State’s Regulations

Be aware of your state’s unique requirements or allowances. For instance, in some states you can bill for services performed during the credentialing process and in others you cannot.

Reciprocity agreements also exist between certain states and payors. If you’re already credentialed with a payor in one state, the payor may fast track your credentialing for another state!

Keep yourself updated on changes to industry laws at both the federal and state level so you can avoid any new or obscure rules falling through the cracks and causing difficulties. Likewise, you wouldn’t want to miss out on the benefits of laws that work in your favor, such as those related to reciprocity.

Credentialing Tip #4:  Use Credentialing Technology Solutions

We’re not talking about spreadsheets! You no longer need to manually track your compliance using this outdated method.

CredentialingOne offers a messaging alert system that updates you throughout the entire credentialing process. We also send automated reminders to providers 120, 90, 60, and 30 days prior to expirations of licenses, certifications, and other compliance requirements. You won’t miss critical deadlines because you’ll automatically be notified well before malpractice insurance must be renewed or continuing education credits are due.

Additionally, CredentialingOne technology can auto-populate forms, making the extensive amount of credentialing paperwork more manageable. We also recommend using our cloud-based technology for easier and quicker access to data, which speeds up the credentialing process.

Credentialing Tip #5:  Outsource Credentialing

When you outsource with CredentialingOne not only will you gain the benefits of our technology solutions, but your credentialing work will also be handled by a team of credentialing experts. You won’t have to worry about many of the credentialing tips above, such as keeping track of industry changes or following up on applications, because we will do those things for you – plus much more.

Whether you outsource credentialing or give it a go yourself, these 5 tips for provider credentialing will help make the process much smoother, faster, and an overall success!

By Stephanie Salmich

Preventing clinician burnout: Two clinicians cross their arms and appear stressed out.

Preventing Clinician Burnout by Outsourcing Credentialing

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CredentialingOne Blog

Preventing Clinician Burnout by Outsourcing Credentialing

Posted on Monday, January 20, 2020

Preventing clinician burnout is increasingly important to the success of healthcare organizations and the wellbeing of healthcare professionals.

Clinician burnout leads to higher turnover and costs, affects organizational productivity and morale, lowers the quality of care delivered, decreases patient satisfaction, and can result in medical errors and clinician depression and/or suicide.

Why Are Clinicians Experiencing Burnout?

Paperwork and administrative burdens, as well as working long hours, are top contributors to clinician burnout.

  • In a 2019 Medscape study, 59% of physicians said “too many bureaucratic tasks (e.g. charting, paperwork)” contributes most to their burnout.
  • “Spending too much time on paperwork” was one of the top three reasons nurses gave for wanting to leave their profession in RNnetwork’s national study.
  • Per the American Medical Association, a physician’s chances of experiencing burnout increase by 3% with every additional hour worked each week.

Doctors and nurses didn’t choose their profession for the joys of paperwork; most providers’ true passion is found in helping patients. Yet, physicians participating in a study published in the Annals of Internal Medicine spent almost 2 hours on administrative tasks for every 1 hour spent face-to-face with patients, and 1 to 2 hours of personal time at night on clerical work. And research published in the Annals of Family Medicine found that PCPs spend over half their workday in the EHR (during and after clinic hours).

Preventing Clinician Burnout by Outsourcing Credentialing

Before clinicians can even begin their careers, they immediately face the time-consuming administrative tasks required for credentialing and obtaining hospital privileges. Then once credentialed, on top of the excessive time devoted to clinical paperwork and documentation, they must balance ongoing credentialing maintenance in order to continue practicing medicine.

Preventing clinician burnout: Two clinicians cross their arms and appear stressed out.

Preventing clinician burnout begins with outsourcing credentialing.

Why not remove a few layers of administrative work by outsourcing credentialing?

CredentialingOne completes all hospital and health plan applications, tracks them to completion, and follows up on them for clinicians. We also provide re-credentialing and re-validation services, while monitoring clinicians’ compliance and sending them automated alerts concerning pending expiration dates.

Whether you are a new provider, starting a new practice, hiring new providers, opening a new location, or dealing with credentialing maintenance and compliance – we can help. Let us lighten your workload and give you back some valuable time.

Outsource credentialing and start preventing clinician burnout and reducing physician burnout for those already experiencing it.

By Stephanie Salmich


Outsource credentialing with CredentialingOne in 2020.

Why Outsource Credentialing in 2020?

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CredentialingOne Blog

Why Outsource Credentialing in 2020?

Posted on Monday, January 6, 2020

There are many reasons to outsource credentialing this year. Below are just a few of the benefits of choosing a credentialing services provider to manage the process for you.

Outsource Credentialing to Ensure Credentialing Compliance

Credentialing can become “out of sight, out of mind” following completion of the initial credentialing process.

However, the credentialing life cycle of a practice includes maintenance of provider credentials. Monitoring CE credits, expiring certifications, licenses, and insurance is a detailed task and without a dedicated credentialing team of experts, opportunities for human error are significant.

Re-credentialing or re-validation with commercial and government payors is also a part of the credentialing life cycle. Payors will re-credential or re-validate a provider every 2 to 3 years. Failure to complete re-credentialing or re-validation will result in claim denials and lost revenue.

Outsource Credentialing to Prevent Claim Denials

Credentialing directly affects the cash flow of a practice. Yet, many practices do not think about credentialing until something triggers there is a credentialing-related issue.

A BIG trigger occurs when a claim is denied or reimbursement is lower than anticipated. If the issue is not due to how the claim was filed, then the reason may be related to provider credentialing.

For example, a provider may not have completed re-credentialing or may not be participating in the plan in which the patient is enrolled. Non-credentialed or non-paneled providers do not receive any reimbursement for their services from plans with no out-of-network benefits (e.g. HMO plans).

Lower-than-expected claim reimbursement can also be attributed to the out-of-network benefits the patient’s plan offers. PPO plans, for instance, have out-of-network benefits with higher deductibles, co-pays, and lower co-insurance levels.

Every practice needs an experienced team solely committed to credentialing maintenance so that nothing slips through the cracks. Outsourcing with the CredentialingOne team yields the additional advantage of innovative technology that monitors credentialing compliance and automatically alerts you to pending expirations.

Outsource Credentialing to Save Time & Resources

A provider may see 25 to 35 patients (or more, depending on the practice) on an average day. Providing medical treatment is a full-time job; but making sure the practice is profitable is also both essential and time-consuming. This is the main reason practices outsource services to experts in various industries.

CredentialingOne’s expert staff and technology complete all credentialing documentation, track applications through fulfillment, and follow up when necessary. With CredentialingOne you can maximize cash flow by preventing claim denials and other credentialing issues and do so without sacrificing time and attention away from patient care.

Outsource credentialing with CredentialingOne in 2020.

CredentialingOne: Your external credentialing solution. Outsource credentialing with us in 2020.

Providers are in the business of healing – providing comfort and compassion to patients and their family and friends. Most chose this profession for their passion for helping others, not for the extensive administrative work and time that the credentialing process requires.

Connect with CredentialingOne in 2020 – outsource credentialing this year and let us take the burden off your hands!

By CredentialingOne

An annual health plan audit is performed.

Why an Annual Health Plan Audit is Critical to Your Success

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CredentialingOne Blog

Why an Annual Health Plan Audit is Critical to Your Success

Posted on Tuesday, December 3, 2019

Conducting an annual health plan audit is critical to the success of your practice. Over the life of a practice, providers and staff come and go and insurance companies add and terminate health plans. Keeping track of these changes is key to protecting your practice from legal issues and ensuring adequate cash flow.

Protecting Your Practice

When a new provider joins a practice, they must of course become credentialed and linked to the practice’s payor contracts in order to be considered “in-network.” However, most practices forget that they must notify their payors when a provider leaves their practice as well.

Payor contracts include language requiring a practice to send notification within a specific time frame when a provider terminates. Not only does notification of the termination date keep the practice compliant with these contracts, but it also protects the practice if the provider experiences malpractice issues or sanctions after leaving the practice.

Performing a health plan audit can ensure all payors are up to date on the providers currently associated with your practice.

Improving Front Desk Collections

A health plan audit is also crucial for front desk collections.

Turnover of front desk staff is not uncommon for any practice. It is vital that both your new and experienced staff members know the plans in which each provider participates. They also must be knowledgeable about the payors with whom your practice holds contracts.

Without a current roster of plan participation, the front desk will not know the appropriate co-pay or deductible to collect and your cash flow will bear the consequences.

An annual health plan audit is performed.

An annual health plan audit helps your practice maintain compliance and improves cash flow.

CredentialingOne’s maintenance and compliance services include an annual health plan audit. We can also provide health plan audit services on a standalone basis for clients.

The health plan audit process usually takes fewer than 30 days to complete.

Contact us today to learn more about how an annual health plan audit can protect both your practice’s liability and cash flow.

By CredentialingOne