Demystifying Credentialing

Introduction

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Navigating the intricate world of credentialing, also known as provider enrollment, can be a daunting task. Despite its pivotal role, misconceptions often cloud the understanding of credentialing. And if not handled with care, it can result in wasted time and delayed payments. Let’s delve into some common credentialing misconceptions and shed light on the process.

Understanding Credentialing

Myth 1: Credentialing is Exclusively for Doctors and Nurses

One prevalent misconception is that credentialing is exclusive to physicians and nurses. However, the truth is that credentialing encompasses a diverse range of healthcare professionals, including therapists, pharmacists, and even entire healthcare facilities. By extending beyond clinical roles, credentialing ensures the integrity and inclusivity of the entire healthcare delivery system.

Myth 2: Credentialing is a One-Time Event

Contrary to popular belief, credentialing is not a one-off event. It involves regular review and renewal to ensure that healthcare providers maintain their qualifications and adhere to evolving industry standards. This ongoing process serves as a continuous improvement and accountability mechanism within the healthcare workforce, providing a sense of security and responsibility.

Myth 3: Credentialing is Synonymous with Licensing

While often intertwined, credentialing and licensing serve distinct purposes. Licensing grants legal permission to practice within a specific jurisdiction, whereas credentialing verifies qualifications and competence within a healthcare organization or network. While licensing establishes the legal framework, credentialing ensures adherence to institutional standards and best practices.

Dispelling Common Misconceptions

“I can transfer my company’s existing contract to my new business.”

Each insurance contract is specific to the practice’s tax ID and may not be transferred to an entirely new tax ID. You must obtain a new contract with each insurance company for each tax ID.

“Part-time providers don’t need to be credentialed.”

A common misconception is that co-signing notes for part-time providers is an acceptable workaround for all insurance companies. This is not correct. Although it is allowed for some, you must reference your insurance contract for their exact policy.

“There is no way to get around a closed panel.”

There are ways to overcome a closed insurance panel. One option is to write a well-written appeal letter highlighting the ways your practice is different from others in the area. Another is to join an Independent Physicians Association (IPA). IPAs charge an annual membership fee, and by joining, you are added to their existing contract with the closed panel insurance company.

Conclusion

While credentialing myths have persisted, expert partners like Provana Health are here to assist. Whether you need help with compliance, getting a startup practice in-network, or enrolling a new provider faster, we’re just a call away.