Healthcare RCM consists of numerous terms that could confuse people with the same functionalities, but practically they differ from one another. One such thing is Provider enrollment and Credentialing. Check out the differences between both of them, clearly explained in this article.
Provider credentialing is the most critical step in healthcare RCM. Provider credentialing is a process that monitors the physicians’ capabilities in meeting the requirements. Provider credentialing also validates physicians in other fields such as:
- Physicians education
- License or registration
- Years of experience
- Degree certifications
- Indulgence of malpractices
Provider Credentialing, generally, involves a lot of physical work in the form of application completion, follow-ups on queries, Q&A sessions with payers, etc. So, it’s very important to understand the requirements and act as fast as to provide an able solution that helps both the payers and the providers, and make sure they are in line with the regulations.
Steps Involved in Provider Credentialing
Validation of Application – Collect all the required documents and validate
Credentialing – Review the physicians’ and providers’ history
Follow-ups – In case of missing documents, call them and make them available as per the requirement
Form Processing – It involves data capturing and linking to a particular facility/provider as per the payer’s database
Regulations – Providing information as per the policy and regulations, along with the CAHQ profile.
NPI Registration – Check whether the doctors, healthcare providers, facility, etc are enrolled under the state. In this way, a registration number would be allotted and we can easily doctors based on that for the payers.
Provider enrollment enables the healthcare providers to enroll their services, ensuring that the payers are eligible for the services offered to them and the providers could gain reimbursement for those offerings. In this way, the providers make themselves easily available in the healthcare insurance network and attract a greater number of payers to their services.
Provider enrollment ensures the constant supervision of payers’ applications, whether they are received and processed on time. These could have a great impact on the reimbursement procedures for the providers in the long run.
Steps Involved in Provider Enrollment
Application – Check whether the payer has appropriate information about the provider for claim submissions
Address check – Review and update the appropriate billing address and pay-to address
Enrollment of Electronic Transactions – The providers mainly opt for 3 types of transactions
- Electronic Data Interchange (EDI)
- Electronic Remittance Advice (ERA)
- Electronic Fund Transfer (EFT)
With proper provider credentialing and enrollment services, the providers can easily gain visibility from the payers, attracting more revenues and expanding the healthcare RCM processes. If not channeled properly, they could also lead to huge financial losses and damage to your business reputation.
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