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A to Z of Payor Enrollment Credentialing process

Healthcare credentialing started ages ago, and it is still important. Payor enrollment credentialing involves a lot of parts and parties. In the payor credentialing process, providers have to enroll in insurance companies. The insurance company requires documentation of education, training, and skills. At the same time, the organizations monitor the healthcare outcomes of the care providers. The reporting and monitoring require constant checking by the healthcare facilities and the insurance companies. The whole process requires a lot of work. In this blog, we will try to cover the maximum information about the payor credentialing process is? What are provider credentialing services? The ways to accelerate the enrollment process. We suggest reading the full blog to get the answers to these questions.

What is payor credentialing?

Payor credentialing in healthcare is a process of verification of the credentials of healthcare providers. Payor credentialing ensures that healthcare providers have the necessary licenses, certifications, and skills for patient care.

The terms provider credentialing process, healthcare credentialing, payor credentialing, physician credentialing, medical credentialing, or doctor credentialing are used alternatively. Healthcare credentialing is commonly used in physician enrollments, but the same system is used for the credentialing process of nurses and other healthcare providers.

Different terms are used for payor credentialing

In the healthcare industry, different terms are used for provider credentialing, including

Insurance credentialing:

Formally getting enrollment on insurance panels is called insurance credentialing. In this process, the insurance company confirms the credentials of a healthcare provider before enrollment.

Paperless credentialing:

It is the replacement of paperwork. In this process, the software accelerates the whole credentialing process, decreasing or eliminating the need for paperwork.

Medical Sales representative credentialing: Medical Sales representative credentialing is also known as vendor credentialing. This credentialing process refers to healthcare organizations checking and monitoring sales representatives’ educational backgrounds.

In the non-medical context of credentialing, there are two types of credentialing.

Personnel Credentialing:

Personal credentialing refers to the credentialing process of employees or vendors.

Political Credentialing:

Political credentialing refers to the credentialing of political parties to assign credentials to delegates.

The Authorities regulate payor credentialing

The following authorities regulate payor credentialing.

  • The federal Centers for Medicare and Medicaid Services
  • The Joint Commission on Accreditation of Healthcare facilities

Both the authorities need healthcare providers to be credentialed. A healthcare provider or company that doesn’t follow the CMS protocols is not entitled to get paid by Medicare and Medicaid. In the U.S, leading healthcare provider institutes follow the Joint commission credentialing. Many states have separate laws for credentialing. Some of the groups have established standards for credentialing. Organizations also get these additional credentials. The other credentialing institutes are

  • The national committee for Quality Assurance (NCQA)
  • Utilization Review Accreditation Commission (URAC)
  • The Accreditation Association for Ambulatory Healthcare (AAAHC)
  • Det Norske Verutas (DNV)

How payor credentialing helps Healthcare providers

Payor credentialing is the verification of qualification for the care providers to accomplish their responsibilities. The process requires contact with multiple organizations, including confirmation from medical schools, licensing boards, or entities. These entities confirm that the information provided is correct. On the other hand, the insurance company or credentialing entity confirms the past reported issues. If any point is found, the healthcare provider will not be credentialed for treating the patients.

The Steps of Payor Enrollment Credentialing

Payor Enrollment credentialing has three principal steps

Gathering information

A healthcare institute or insurance company requires background information like educational degrees, licenses, etc. The care provider must submit the complete information through an online questionnaire or email.

Sometimes, the healthcare organization or insurance provider works with a third party called “Credentials verification organization” (CVO) or Provider Credentialing services providers. CVO works with the care provider to collect and verify the information. To speed up the credentialing process, organizations often outsource CVOs.

Check the information

In most cases, healthcare institutes or insurance companies countercheck the information from licensing agencies, medical colleges, or other entities.

Sometimes, healthcare institutes or insurance companies use credentialing software to check the information from licensing companies and other institutes. The professional credentialing services providers also perform the duty of verification checks.

For credentialing, verifying medical incidents, malpractice claims, or information that puts a question mark on the healthcare provider is necessary. These reports confirm whether to credential a provider or not.

Provider Credentialing

After verification of all credentials with no negative issue, the insurance company or entity awards credentials.

After completing and signing the contract form, the healthcare institute decides to enlist the care provider in the specific list of in-network providers.

Important information is required from the healthcare providers for the credentialing process.

Regardless of changes, the basic information regarding healthcare providers remains the same. The common information companies require from the healthcare providers is

  • Name
  • Gender
  • Ethnicity
  • Residence and practice address/ Mailing address with contact numbers
  • Citizenship photograph
  • Recent Photograph with current CV mentioning Date of Birth.
  • Social Security number
  • Education/ Specialty certificates and qualifications.
  • Training along with the career history
  • Focus Patient age
  • Language
  • Hospital and medical group affiliations
  • Practice Tax ID number and National Provider Identifier Number (NPI)
  • Practice contact number
  • Malpractice/ Sanctions or disciplinary action history
  • Professional liabilities
  • Peer References

The time frame for the provider Credentialing process

The verifications from different entities require time. Even in ideal circumstances, completing the payor credentialing process takes 30 days. In most cases, the process takes 60 to 90 days. In case of incomplete or missing information, the process may take more than six months.

The professional credentialing process may take more than six months if the state laws are different or the educational institute delays the verification process. At the same time, healthcare organizations use paper or email applications and communicate with the provider via fax machines. The manual or paper-based applications require more time to complete the process.

Why do healthcare providers or healthcare facilities need credentialing?

  • Healthcare provider companies need credentialing to add or remove a healthcare provider to their entity.
  • Suppose a healthcare provider changes his demographic location and the demographic data changes. So, he needs this data to be updated with the insurance companies. It will become more complicated if the care provider changes his demographic location to another state with completely changed care regulations.
  • Maintain contracts or renew the expire-able documents
  • CAQH enrollment attestation/ re-attestations
  • Payor validation/Re-validation

Does the lengthy payor Enrollment credentialing process affect healthcare providers or facilities?

The lengthy credentialing process has a financial impact on healthcare providers or facilities. A healthcare provider waiting for the credentialing process to be completed cannot check patients. Whereas if a provider waits for the credentialing from the insurance company cannot see patients with the specific insurance provider.

Every day of healthcare providers not working can cause multiple dollar losses to the healthcare facility. When a one-day loss is accumulated to a six-month loss, it can be a considerable loss. So, healthcare organizations must complete the payor credentialing process as soon as possible.

How to guarantee a smooth, professional credentialing process?

The provider credentialing process is long and tiresome for providers and healthcare facilities. At the same time, you can make this process smooth and quick. Here are some suggestions

Checklist of the credentialing institute

If you are a care provider

  • Keenly check the requirements of the insurance providers and fulfill all requirements.
  • Submit all required information
  • Answer every question, and provide the necessary explanation and the annexed documentation if required.
  • Proved attestation or re-attestation
  • Provide all the documentation
  • Provide malpractice insurance fact sheet.
  • If you have any unsettled malpractice cases, provide the summary.

How can a professional credentialing service provider help healthcare providers?

Outsourcing professional credentialing services can help healthcare providers reduce the time of the credentialing process. A professional credentialing service provider will

  • Keep the data of the insurance companies and providers up-to-date.
  • The credentialing services provider can initiate and complete the credentialing process on time.
  • Professional credentialing service providers often train their employees to avoid unnecessary time delays or minor errors.
  • Avoid unnecessary paperwork and speed up the process by using electronic communication.
  • Build healthy relationships with the multiple payers
  • Report real-time credentialing status or enrollment transactions.

Benefits of payor Enrollment credentialing

Outsourcing Payor credentialing comes with the multiple benefits

Minimize Human Errors:

When you hand over the credentialing process to a professional credentialing service provider, you can observe minimum human errors. Payor credentialing is routine work for the credentialing service provider, who is used to the paperwork. So, outsourcing payor credentialing can minimize human errors.


Every healthcare organization strives for cost reduction. It is also significant to avoid unnecessary expenses. Outsourcing a professional credentialing provider can reduce paperwork and errors in data. Streamlines the process that can save not only time for healthcare providers or entities but saves the cost of resubmissions

Quick Process:

Outsourcing a professional credentialing services provider ensures timely completion of the process. If you hire a full-time credentialing team, it will help you with the on-time re-credentialing process.

Improved efficiency:

Some healthcare professionals still use spreadsheets and believe in paperwork across different departments. They need a professional digitalized organization to work for them without disturbing their routine tasks. The organizations that use a central database can reduce the time of verification and up-dation. Even the software can send automated reminders and alerts. You can easily access the analytics and follow up with the insurance companies. Automation of different processes removes the physician’s and healthcare organization’s burdens.

Data Security:

Professional credentialing services providers usually use electronic health records instead of paperwork. The electronic systems are not only encrypted, but they provide you with larger data security than paperwork. At the same time, remote access to editing, uploading, and sharing documents ensures data security from breach or loss.

The Bottom line

The payor credentialing process collects multiple data, points, reviews, character assessments, etc. A single error in any information can cost a lot of loss to the provider or the healthcare entities. In a nutshell, every healthcare provider institute aims for the highest quality healthcare. Healthcare entities credential their providers from multiple insurance providers To ensure high quality. For the patients, credentialing is important because they do not want a care provider without confirmation from insurance companies.

A delayed payor credentialing can lead to losses because, during the credentialing process, the healthcare provider cannot see patients, or insurance companies will not reimburse the payments for the services rendered. Outsourcing the payor credentialing process can be a good option to reduce or minimize the losses.

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