credentialing specialist

What is the difference between a credentialing specialist and a physician enrollment?

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In the medical industry, it is very difficult for people to know the difference between a credentialing specialist and physician enrollment. In fact, most of the people in the healthcare industry are unsure about the difference between the two! Let us discuss the difference between the two in detail.

Let us discuss credentialing first!

Credentialing is the process of conducting a background and legitimacy check of the qualifications of a licensed medical practitioner. Many healthcare organizations conduct their own credentialing process or hire a specialized person or a credentialing agency to complete the process of credentialing without any hurdles. 

A Credentialing specialist does the validation of a private health plan provider and approves his/her joining to the network. A credentialing specialist, generally, is a primary source of credentialing. The specialist conducts a background check on the doctors or other health care providers professionally. This task involves a lot of manual work in terms of completing the application forms, conducting the background checks of the medical doctors and practitioners, thus, involves a lot of practice and expertise. In this process, credentialing specialist tasks include-

1- Getting the credentialing requests from the payers and completion of the application forms

2- Getting the practitioners verified through a physician

3- Updating the payer’s database

4- Follow- up with the payers

5- Updating the database and information as and when provided by the practitioner as per the company policies

In addition to this, a credentialing specialist ardently specializes in conducting and verifying the doctor’s or health care provider’s willingness, interest, expertise or experience to offer the best health services. As a specialist, your work involves dealing with an insurance group or a healthcare facility to adhere to the regulations and compliances. 

The job role includes the preparation and maintenance of reports of the credentialing activities such as staff membership, medical accreditation, and facility privileges. These specialists are expected to make sure that qualifications, certifications and medical training of the healthcare service providers, which should be renewed periodically, conforms to the federal regulations and compliances. 

A credentialing specialist also works for healthcare organizations. The major aim is to make sure that physicians, as well as healthcare facilities, are pertinent to the relevant regulations. In addition to this, they also maintain records of staff credentials and health insurance contracts. Their major task is to maintain close contact with the staff as well as insurance companies so as to obtain the necessary documents and inform them about any changes in policies and contracts.

As most of the work done by a credentialing specialist is on the computers, they should be well aware of the variety of computer programs, including the spreadsheet and word processing programs. 

Now, let us discuss physician enrollment!

On the contrary, enrollment refers to the process of persuading companies to participate in a health insurance network as a healthcare provider. In this, a medical practitioner or a medical company gets enrolled with the physician so as to provide the medical services to the payer/customer/patient.

During enrollment, a medical provider gets enrolled with a network of health insurance plans. This process involves requesting participation in the payer network, completing all the necessary credentialing requirements, verifying the credentials and then submitting the same to the payer, and finally establishing a contract.

Physician enrollment services help healthcare organizations to unravel the complex process of credentialing providers and successfully enrolling the healthcare providers in the payer networks. All the health care organizations should ensure that the providers working with them are enrolled through a physician so as to avoid any complications later on. Failure to complete the enrollment process might land the healthcare organizations into trouble. 

If a practitioner wants to participate in a health insurance network to treat the insured patients or get reimbursed for the insured plans, then the enrollment process is a must. In a physician enrollment, a medical provider gets entered into various health insurance plans, related networks, Medicaid and Medicare, so that the health care service provider gets paid for the services offered to the patients.

To conclude, both the credentialing as well as physician enrollments are a time-consuming process. Although they both might involve duplicative processes, accuracy and completeness are expected in both the type of processes for the smooth functioning of the healthcare industry.