What Is the Difference Between Medical Credentialing and Payer Enrollment?

Many people are unsure of the difference between medical credentialing and payer or provider enrollment. Even some individuals in the healthcare industry don’t really know how they differ!

The fact is that both are a type of credentialing process: Medical credentialing generally refers to primary source credentialing, which is a type of a professional background check on doctors and other health care providers.

Payer enrollment (sometimes known as provider enrollment), on the other hand, is the process by which a medical provider gets entered onto insurance plans, networks, Medicare and Medicaid so the provider can be paid for services rendered to those patients.

Payer Enrollment Basics

Most providers choose to be enrolled with major health plans in order to be considered “in-network.” This is an important distinction because patients almost always prefer to be seen by in-network health care providers. Plan participants usually realize cost savings by using in-network providers.

In order for a medical provider to be enrolled with a payer – a network, plan, Medicare or Medicaid – they must meet specific criteria to be credentialed. At this point, an enrollment specialist like 1st Assistant can be very helpful to the process.

It’s important that all application information be complete – if anything is missing, we will be notified and we will submit the correct information for you. The networks review proper licensing, any malpractice claims, provider specialty training and education. The application and approval process can take some time to complete – for example, Medicare and Medicaid typically take up to 120 days and commercial carriers like Aetna and Blue Cross typically take up to 90 days to complete.

Our payer enrollment specialists will follow up on all applications until an effective date is assigned to the health care provider. This signals that the provider has been approved as in-network and claims can now be paid.

Our Relationship With You Is Long-Term

Your relationship with us doesn’t end with your network acceptance. We will continue to keep your data up to date and ensure that any recredentialing applications including CAQH re-attestations are submitted on time. We’ll coordinate with the health plans and make sure they get all new and updated information quickly and accurately.

You’ll see that having a payer enrollment expert like 1st Assistant takes a huge administrative burden off your staff so you can focus on providing excellent health care for your patients!

Let Us Manage All Your Payor Enrollment Services

If you require medical credentialing and payer enrollment needs for your practice or medical facility, please contact 1st Assistant. Our experienced and dedicated specialists will provide all credentialing and enrollment services quickly and will monitor your account for ongoing updates and re-attestations. Heidi Henderson, our company owner and President, is eager to meet you and discuss your payer enrollment needs. Please call us at 512.201.2668 or contact us via the website.