Develop A Sustainable Credentialing Practice Using the Team Method

— By Matt Zabolotny

Credentialing and enrolling the providers within your company is a team effort. In order to efficiently verify skills, negotiate payer contracts, enroll practitioners and monitor denials, it is important to ensure these tasks are assigned to appropriate staff or departments. This paper will outline an effective approach to managing and tracking the time-consuming tasks required for credentialing and enrollment.

Before outlining the roles assigned to each of the four areas, it is important to understand the difference between credentialing and practitioner enrollment:

Credentialing involves verifying the skills, training and education of practitioners at the time of hiring. Verification is done by contacting the primary source where the provider was licensed, trained, and educated. Insurance companies use the same information and sources to allow providers to participate in their network.

Practitioner Enrollment (also known as insurance credentialing) is a piece of credentialing but not the entire process. Enrollment is an active operation of submitting applications, monitoring approvals, and communicating with payers to ensure a smooth and timely process.

Every company has functional areas that assist with credentialing and enrollment. Establishing the duties of the following staff members or departments and aligning their roles will ensure you have an efficient and effective credentialing model.

Human Resources

Verifying the qualifications of new staff members at the time of hire will give you a jump start on the credentialing process. Gather documents at the time a candidate accepts the job offer and communicate with other departments about new hires or terminations.

Payer Contracting

Executive level involvement is vital for maintaining a clear understanding of your obligations as a provider and developing good relationships with payers. After conducting a “deep dive” of your contracts, you will know if payer requirements align with the services of your company and how a contract is impacting your revenue cycle.
All Four Departments are Equal and Must work in Harmony!

Provider Enrollment

The department or team member assigned to provider enrollment must learn the requirements of each payer in order to successfully enroll your practitioners. Insurance payers are unique in their application requirements, method of submission, and turnaround time for approval. Developing a system of organizing your documentation and monitoring each application status is critical for an efficient and smooth process.

Revenue Cycle

Inaccurate credentialing and correctly enrolling providers can directly impact the financial health of your company. Insurance denials related to credentialing or contracting issues can lead to unnecessary claim rejections.

When these four teams work in tandem, you will see the benefits of developing and maintaining an efficient credentialing model. In order to successfully implement the Team Model, provide the necessary support and cultivate an environment of communication so no stone is left unturned. With consistency and commitment, you will gain a sustainable method for credentialing and enrollment.

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Partner with ZMark Health and our experienced, compassionate, and knowledgeable team will find solutions to meet the needs of your practice. Whether you are falling behind on claims management or juggling the complexities of provider credentialing — we can help.

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