What is the difference between medical Credentialing and Payor Enrollment?

These two words are often used interchangeably, even though the process for each is quite different.

what is the difference between payor enrollment and credentialing

Unless you are a professional credentialing specialist, or just have a passion for all things credentialing, the terms and processes can sometimes become confusing. That’s why we put together this quick guide to help you sort through the similarities and differences of payor enrollment and credentialing.

(PSA: technical information coming atcha!)

What is Credentialing?

Credentialing is the process of verifying the provider has the skills required by way of verification of training, education, licensing, competency and other elements, as designated by regulations and policy and procedures. It also involves the onboarding process of gathering certain elements as described below. Credentialing is the term used by medical staff services and insurance companies when describing the process of primary source verification, and onboarding, whether it be for medical staff appointment, or network participation.

Some important credentialing verification documents are:

  • State License

  • DEA License

  • Board Certification

  • Education and Training

  • Hospital Affiliation

  • Malpractice Insurance Certificate

  • References

What is Provider/Payer Enrollment?

You may hear both Provider Enrollment or Payer Enrollment used to describe this term. These terms are one-in-the-same and used by Provider and Payer Enrollment Specialists to refer to the process of requesting participation in a health insurance network. The process involves requesting participation, completing the credentialing process, submitting supporting documents and signing the contract.

The initial payer enrollment process typically occurs either when a provider is hired at an existing practice, or when a physician or group of physicians is opening their own practice.

How do they work together?

While both Credentialing and Payer/Provider enrollment go hand-in-hand and rely much on each other to complete the process of contracting, credentialing, peer review and participation, it is very time-consuming. Without the correct knowledge of Insurance Company policies, applications and requirements you could find yourself moving nowhere fast.

Although the process can take anywhere from 30 to 180 days for any provider to fully complete, it is best to have a team of experts on your side. By taking this off your hands, you can do what you do best -- taking care of your patients.

Here at CredentialGenie, we have a team of credentialing specialists with years of experience to help you do just that! We are experienced with all major Commercial and Government Carriers, all specialties, in any state. If you'd like to learn more, shoot us a quick email at hello@credentialgenie.com or schedule some time to chat here!