Credentialing vs Contracting

You may hear “credentialing” and “contracting” used in the same context, but don’t get the two confused. There is a distinction between them! You may have also heard the phrase, “All crows are birds, but not all birds are crows.” The same goes for credentialing and contracting; contracting can be part of a credentialing process, but is not always, necessarily. So, what’s the difference?

Let’s start with the simple question: Do you want to be in-network with the insurance in question? If so, you will need to be credentialed and contracted. If not, you may still need some credentialing.

You can think of the major payors’ internal systems like social media: they need to build a profile for each entity in their systems so they can keep track of the claims being processed under that group. That profile starts with a TIN and NPI connected to an address and then individual providers are “linked” under it. Just because you have a “profile” in a payor’s system does not mean you are in network with that payor! It just means they will accept your claims and process them as an out-of-network provider.

To participate in a network, you must sign paperwork accepting contracted/allowed rates for the CPT code set related to your service. That way, your codes will (should) always be paid at the same rates according to each plan under contract. Contracted providers make agreements about the way patients’ bills will be treated when they are seen at that practice and in turn, they are provided with a designated provider representative at the payor’s office, which helps clean claims process smoothly. Some payors like Medicare only accept claims from in-network providers. Other small payors do not require a “profile” at all and will simply accept claims. Some require single case precertification from noncontracted providers.

MANAGING EXPECTATIONS:

Credentialing and contracting both require significant paperwork and can both involve a waiting period. Once your paperwork is filed, the insurance company will take time—possibly several weeks—to review it, and all they will say is that it has been accepted. There is no trick to obtaining faster turnaround times, but working with an experienced team like TMPS can eliminate the possibility of costly, time-consuming errors.

DOS AND DON’TS:

DO get your ducks in a row. Keep an organized file with your documentation according to your credentialing specialist’s instructions.

DO plan ahead. Get an idea of what networks you will want to participate in (or not) as soon as you start your business plans. Are you planning to grow your practice? Consider credentialing as a group rather than as an individual so you can add more providers underneath and avoid recredentialing as a new entity later.

DON’T make any sudden moves. Thinking of changing addresses? Switching owners? Unsure of your business name? Once credentialing has started, these kinds of changes can throw the process off drastically. You wouldn’t get a car loan while under contract to buy a house. Don’t render your paperwork incorrect.

DON’T worry. If you’ve planned ahead and are working with us at TMPS, your relationship with your payors is in the highly qualified and capable hands of our professionals!

Contact TMPS today. Admin@triumphmps.com or call 214-305-8805