Credentialing & Contracting Process

physician credentialing service

Insurance Enrollment and CAQH credentialing are two separate and distinct processes but one cannot happen without the other. CAQH credentialing is the first step if you would like to be enrolled in the commercial insurance companies but CAQH credentialing on its own, will not fulfill the insurance enrollment process.  When we start on an enrollment project, one of the first things we do is verify whether or not a provider has a CAQH number.  Many providers will already have CAQH numbers if they have practiced in an outpatient setting.  This means that instead of obtaining a new number, we need to reset the login information and update the CAQH profile to reflect the new information.

Insurance enrollment and contracting is required if you would like to see patients from insurance companies. You are considered in-network upon successfully contracting with an insurance company. There are two parts to the enrollment process with an insurance company that you must go through if you want to be in network.  The first part of the process could simply be called the credentialing process.  This is where all of your training and education is verified by the insurance company.  This is where CAQH comes in as most major insurance companies pull some of the required information directly from the CAQH database.

The next part of the process is the insurance contracting and negotiations.  This is where, upon successful completion of the insurance credentialing process, the insurance company offers you a contract to pay for your services.  The contract will have all of the details regarding how and when you will be paid and what you are required to do in order to stay in compliance with the insurance company.  It is critical that these contracts are thoroughly reviewed to ensure you agree with the fees and terms set forth in the agreement.  These contracts can be negotiated for higher reimbursements but for most new practices there is very little leverage in negotiating new rates.  It is best you work with a company (like ours) that has established relationship with the payers to ensure you are offered the best possible contract for your services.  Many times and insurance company will take advantage of a new practice by providing them with a low ball contract because they know that the provider will likely sign whatever is put in front of him/her thinking that is the best they can get.

We have been providing insurance contracting and credentialing services to companies across the country for ten years and would love to help you.

 

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