Credentialing and Payer Enrollment: What’s the Diff?

Medical credentialing means doing a kind of background check on doctors and other healthcare providers. So credentialing is required for individuals who provide health care.

The most comprehensive type of credentialing is primary source verification, where only original sources are used to confirm the accuracy of an individual healthcare practitioner’s qualifications. Examples include direct contact with educational institutions to verify degrees and checking on licensing from a medical board.

In contrast, payer or provider enrollment is a process so a health care provider or provider group is able to be reimbursed for services performed from major health plans. These include Medicare, Medicaid, insurance plans and networks. Only a provider that is properly enrolled with these plans will be able to bill for services to covered beneficiaries and get paid for those services.

Providers Must Be Enrolled with Health Plans To Be Considered “In-Network”

Most of us have individual insurance coverage that requires that we visit “in-network” healthcare providers to receive the maximum benefits from the plan. To be considered in-network, providers must be enrolled with the health plans.

In order to be enrolled with payers such as Medicare, Medicaid, a network or an insurance plan, the healthcare providers must meet very specific and rigorous criteria. Initial applications must be submitted and periodic re-validations are required too.

Any application must be complete with all required attachments in order to proceed through processing. This could be a very big problem as the provider may not receive any reimbursements from the plans until the payer enrollment process is complete. There are, of course, reimbursements for out-of-network benefits, but only if the patient has those benefits on their plan.

Let 1st Assistant Handle Credentialing and Provider Enrollment for You

You have enough to do to give excellent care to your patients and to run your office too. At 1st Assistant, we have the skills and experience to take over all your medical credentialing and provider enrollment needs.

We will work with you to make sure your applications and re-validations are accurate and complete. We’ll help gather information on licensing, specialty training and educations, and any malpractice claims.

Instead of someone on your staff making tedious follow-up calls to check on application statuses, our payer enrollment specialists will handle this for you. You can read about our many other credentialing and enrollment services here.

The bottom line is that individual medical credentialing and provider enrollment are similar processes to make sure that your providers are qualified to provide excellent services to your patients and that your business is properly set up with health plans to receive reimbursement. 

Let us relieve your staff of this administrative burden – we are here to help and are just a call away!

Let Us Manage All Your Payer Enrollment and Credentialing 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, Vice President of Credentialing, is eager to meet you and discuss your payer enrollment needs. Please call us at 512.201.2668 or contact us via the website.