Different jargon and impressive titles for the physicians and the medical healthcare providers in the medical industry make it confusing to mix one with another. However, one of the commonest of them is the difference between credentialing and credentialing a healthcare provider.

To know the difference, it is essential to know what both terms mean. Before getting into a thorough discussion, take notes; credentialing is provided by a physician credentialing services, and contracting a provider would be possible once the credentialing is performed. Let’s explore more into them.

What is Credentialing?

When a healthcare provider is tested and verified on the given information through a formal standardized process, it is called credentialing. The process ensures that the nurse, doctors, and physicians are properly experienced and trained and are allowed to provide a high level of care and treatment to the patients of a certain practice.

The credentialing service for providers is performed and completed with the verification of the documents submitted by the provider. It is to ensure that all the documents are valid and appropriate for the practice. This is an integral part of the healthcare industry because many times insurance companies do not provide reimbursements to the practitioners who lack a certain amount of medical credentialing.

How is a Credentialing Process Performed?

The process of credentialing requires a hefty amount of Documentation with a potential accuracy level. It is also seen that the insurance companies or third-party payers slow down the process of adding providers to the list of penal, due to credentialing process.

Once a provider submits his documents to a payer, they are now allowed to be added as a penal for reimbursements. The first thing they do is start the process of credentialing and verifying the legitimacy of the credentials. These credentials and documents then go through a database such as CAQH. However, the process is lengthy and time-consuming but once the credentialing process is finalized, the provider will be added to the list of roasters making a contract with the payer.

Credentialing Providers and Contracting a Provider

People often get confused while understanding contracting and credentialing a provider and assume that they are the same thing. But in contrast, they are two significantly different processes and are performed differently. Credentialing, as said, verifies the credentials provided by the provider. It simply checks the legitimacy of the documents but does not allow the payer to get payments. Likewise, it does not associate practice with a fee schedule.

Unless you go through a legal binding or a contract agreement with the insurance payer for a fee schedule, you won’t receive reimbursements for your services. This agreement may also contain the agreement on the rates on which you will provide your services to the patients for a particular duration. The contract must be for one or two years or depends on the provider and the payers’ mutual agreement.

If you have a group of nurses and other doctors who work for you, you can add them to your contract and have them billed under the same contract.

The Guide to Credentialing Services (with Checklist) — Promedica Partners

Why it is good to Outsource Credentialing?

Several benefits are there when you outsource your credentialing service to a physician credentialing services provider. The most useful thing to mention is time saving and the fast process. With outsourcing, you don’t need to train your in-house team when there’s a team of experts in the same field you are seeking is ready to take on. With this keeping in mind, you and your managers at work will be able to prioritize work and devote more toward the care for patients and find ways to improve practice.

Credentialing and contracting services are experts in the field and often perform the tasks in a very small time making minimal errors. When the credentialing is done quickly, the claiming and reimbursement process can be started by submitting the claims to the insurers. Eventually, the revenue management would take a fast pace and you can see your patients without worrying about billing and coding.

With many advantages to mention here for physician credentialing services, like everything there’s a darker side to the credentialing service providers as well. First and foremost, you gradually lose control of the process and due to no longer direct involvement with the credentialing process, you cannot handle the process on your own.

Sometimes, credentialing services do not provide complete information, do not provide updates, and make things complicated as a follow-up in the medical credentialing is vital no matter how big or small the practice is. Before you outsource your credentialing to a company, make sure it is built on the foundations of experts and will manage your credentials efficiently. The most important thing that you need to be sure of is their compliance with the HIPAA standards.

What Is The Importance Of A Fee Schedule In Medical Practice?

When an agreement is made between payers and providers, a fee schedule is also an agreed-upon document that is referred to in the agreement but does not attach. This fee schedule document addresses the reimbursements for you and your staff services based on the CPT codes used. Oftentimes, the scheduled reimbursements depend on the Medicare reimbursement level in the practice locality.

Also, many times the fee schedules are made complex and hard to understand by the providers and they simply are meant to confuse the provider that they don’t get the information about what they are getting paid for. Sometimes, the fee structure which is agreed upon is not attached to the agreement.

The best suggestion to follow in this matter is to never sign a contract unless you understand the complete information and have the knowledge of what you will be receiving. Track the terms timely to monitor if some changes have been made in the fee structure over time.