Comparing competencies in credentialing and in provider enrollment

At its most basic, credentialing is the verification of health­care practitioners’ education, training, and current compe­tency. Depending on the specific items that need to be verified, this process can be lengthy.

Provider enrollment, however, casts an even wider net. When practitioners and provider organizations seek to join health plans to treat insured patients and receive in-net­work reimbursement (which is higher than the alternative), they must go through a credentialing process for each health plan with which they wish to partner.

The average provider is enrolled into 18–30 different plans, each of which requires compliance with federal regulations and accreditation standards, as well as with a litany of other requirements determined by the plan, state, and/or mem­bership population. Although credentialing requirements lev­ied by the National Committee for Quality Assurance—the primary accreditor in the space—are less stringent than their hospital-focused counterparts, individual health plans might impose additional requirements, such as querying the Social Security Death Master File, or more rigorous varieties, such as receiving office visits. All told, enrollment with a govern­ment or commercial health plan can take as long as seven months: 7–30 days to obtain all of the practitioner’s creden­tialing data and another 30–180 days for the health plan to complete the credentialing and approval process. Applica­tion denials can add even more time.

Source: News & Analysis