Payor Enrollment Vs. Credentialing

The healthcare system in our country is far from intuitive. This leads to confusion when seeking to grow your plan in a volatile space. Emerging companies that want to take advantage of new technology, a new business model, or new source of capital need to understand the growth process to ensure their plan is sustainable and profitable.

Having a better awareness of the terms and requirements from both sides of the table – both as a practice and as a health plan – ensures everyone involved is on the same page and knows what needs to get done to start offering care.

What is Credentialing?

Credentialing is the process by which a new physician or healthcare provider verifies their qualifications – their credentials – to offer specific services and medical care. This largely involves providing documentation of the person’s license, training, education, and career. However, it’s more complicated than it sounds, as ideally the information comes from the source of the qualification, for example, the medical school, licensing agency, and prior employers/practices. There are additional applications and requests for information for other events, such as malpractice claims, all of which makes credentialing a major hurdle for onboarding a physician or entering a new market.

Credentialing also happens on a regular basis, with providers needing to re-credential their practicing staff every several years to ensure they’re still able to provide the services they offer. Because of this burden, many practices that don’t have large, in-house teams to handle these projects outsource their credentialing to teams who do this full-time in many markets. PayrHealth’s revenue cycle management team has decades of experience working in all 50 states and has the infrastructure and processes to make this process simple and quick whether you’re a practice or health plan.

Payor Enrollment

Credentialing is similar to payor enrollment but doesn’t operate on the individual level. Payor enrollment is the process by which practices become eligible for reimbursement of health plans like BCBS, Aetna, and government programs like Medicare and Medicaid. This is a crucial step toward financial health for a provider, as receiving timely, competitive reimbursement rates are the life blood of healthcare providers. Patients are increasingly unwilling to pay for out-of-network care, meaning contracting with the right payors gives you access to many new patient lives.

This is where market research comes into play for the payor enrollment process. Although certain private plans might have a large patient base in other states or counties, they may not in your target demographic or geographic area. PayrHealth maintains a database of robust information about each county in America and which health plans are most popular or most utilized by providers. This gives you insight into which contracts should be sought and what types of terms and rates you should negotiate for.

Payor Contracting and Credentialing with PayrHealth

The credentialing and contracting process is tedious and complex. Let our team take the hassle away from your practice with revenue cycle management services and payor contracting. Our team of experts has the industry knowledge and internal tools to handle these costly yet critical processes efficiently, saving you time and money while ensuring a strong financial status. Call or contact us online today to learn more.

Learn more about PayrHealth today

Our mission starts with an excellent experience and a target of lasting success for your health care organization. We see a future where providers and payors partner in making informed decisions for a strengthened healthcare system.

PayrHealth can take support your organization and its revenue goals. Connect with our team of experienced healthcare professionals to get the conversation started.