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Contracting Vs Credentialing- 5 Key Differences

Whether there is a pandemic or endemic, the primary goal of healthcare professionals is to provide the highest standard of medical treatment. However, technical terms like credentialing in medical billing, CAQH, contracting, payor enrolment, insurer participation, compliance billing, and network management often confuse them.  Medical credentialing and contracting are among the essential processes for any healthcare organization in the modern world.  However, only a small percentage of healthcare workers know that contracting and credentialing are two distinct concepts requiring completely different procedures.

Several medical credentialing services in the market can help physicians with this complete procedure. However, healthcare organizations must understand the fundamental distinction between contracting and credentialing in medical billing.  The concept of payer enrolment or contracting and healthcare credentialing will be explained in this article. Additionally, you will discover how these procedures will effectively apply to help your organization.

What is insurance credentialing?

“Credentialing confirms you are who you say you are: an educated, eligible, and licensed provider,” as Giuffrida puts it. The payer verifies your professional documents throughout this procedure, including your licenses, degrees, attestations, certifications, and personal references. Giuffrida claims that certain employers will even check your resume. To conduct business with you, she explains that insurance companies must verify that you are a true professional. That is logical, right? An insurance company wouldn’t want to pay a provider without having a verified provider’s identification, just as a practice owner wouldn’t want to recruit a new employee.

Healthcare facilities implement credentialing in medical billing to permit individual healthcare providers to offer services and operate their practices on campus. When healthcare providers go through the insurance credentialing process with insurance providers, they are thought to have the right to accept third-party payments. Credentialing is a step preceding contracting. Patients are increasingly refusing to see doctors who are not in the insurer’s network as they become more aware of the value of credentialing.

What is Contracting, and why is it important?

After the provider has been approved by the payer following the credentialing, the payer will then offer a contract for participation. According to Giuffrida, “Contracting (being in the network) is an optional arrangement given by most insurances that formally ‘includes you as a participant with that insurance. Being contracted limits your ability to bill and collect from patients and frequently requires haggling prices with the relevant insurance provider.

However, since people frequently obtain greater coverage for in-network treatments, being in a network will probably result in getting a more consistent flow of patients. Contract requirements vary depending on the specialty, practice size, and location of the healthcare company. To formally participate in the current group agreement, each provider who joins the institution must execute credentialing in addition to the provider enrolment procedure.

Avoiding Self-Credentialing Glitches

The following are best practices for ensuring effective credentialing and contracting:

  1. Assuring document and application completeness, where current information regarding address, TIN, and names, among other things, aligns.
  2. Before submitting your paperwork, make sure that your billing service provider is knowledgeable about and conversant with all legal requirements.
  3. By getting in touch with your references in advance, you can make sure that they react to reference inquiries promptly.
  4. Recognizing that; i) It is not feasible to bill your patients before your contract is in existence. ii) The application approvals and the complete procedure may take months.
  5. When assessing your applications, think about seeking advice from an authority or a healthcare credentialing organization.
  6. Remember to save a copy of all of your contracts, paperwork, and applications for credentialing.

Credentialing and contracting are laborious and complicated processes. Healthcare providers may spend a lot of money and time trying to figure out all these complications on their own. However, these days healthcare providers are eager to concentrate on providing the best possible treatment and many of them prefer to outsource their contractual application and credentialing responsibilities to the top medical credentialing firms. As the administrative requirements of contracting and credentialing in medical billing are handled by professional credentialing service providers, it frees physicians to devote more time to patient care. Get in touch with us right now to get a competitive edge through effective contracting and credentialing.

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