Payor contracting and credentialing for physicians and other providers is an essential step in the reimbursement process. Healthcare payors are increasing the standards for providers to ensure that patients are receiving safe and effective care from qualified providers. As a result, healthcare organizations must implement processes that verify the credentials of potential new hires and partners.
The healthcare landscape is constantly changing, which makes it more challenging to meet the needs of both patients and payors. However, with careful preparation before signing contracts, your organization can successfully partner with new payors while protecting patient interests.
This article provides information about payor contracting and credentialing for providers, including what they are, why they’re important, the pros and cons of each one, examples of how you might use them in your organization, as well as helpful resources so you can begin implementing them in your organization today.
What is Payor Contracting?
Payor contracting occurs when an organization enters into a contractual agreement with a health plan to provide services. Payors often require this contract to ensure that providers meet certain standards for quality and safety. In many cases, providers must also meet certain financial requirements so that payors can ensure the providers can continue to provide quality care at an affordable rate.
Contracts between payors and providers are lengthy, complex documents that outline all parties’ rights, responsibilities, and expectations. To ensure that your providers are meeting all requirements, it’s important to carefully review any contracts before signing on the dotted line. If you’re a payor, it’s also critical to ensure that providers meet all contractual specifications before entering into a contract with them. In this case, you should carefully review your provider’s contract to ensure that all specifications are met.
What is Credentialing?
Credentialing is a process that verifies the credentials of new or potential providers. Credentials include licensing, certification, and/or board certification status. This process also verifies employment history, education, and references. Credentialing is typically an ongoing process in which providers must re-verify their credentials at regular intervals. Credentialing can be a manual or automated process.
Payor Due Diligence
Payor due diligence is a process in which payors thoroughly verify providers’ credentials and financial solvency to make sure they can provide high-quality care at an affordable rate. During the due diligence process, payors may also verify your organization’s financial solvency to ensure you can withstand financial instability.
Payor due diligence is especially important before signing a long-term contract. As part of the due diligence process, payors may ask providers to provide detailed information, including organizational charts, financial information, policies and procedures, and other documents. They may also conduct site visits to verify the information. If payors discover that your organization or providers don’t meet the standards they require, they may terminate the contract, preventing you from receiving reimbursement for services.
Provider Network Credentialing
Provider network credentialing is the process by which payors ensure providers meet all contractual and regulatory requirements before adding them to their network. Credentialing providers is an essential part of the contracting process. However, it’s also a critical step in ensuring that patients receive safe and effective care from in-network providers. Credentialing providers include a combination of background checks, verification of education and licensing, and pre-qualification of services provided. Credentialing providers can be a manual or automated process.
Certification Credentialing
Certification credentialing is the process by which a healthcare organization verifies whether a provider is certified to provide specific services. Certification credentialing is an essential part of the contracting process with managed care organizations (MCOs). Managed care organizations use certification credentials to determine whether providers meet all regulatory requirements before contracting with them on a case-by-case basis.
Credentialing providers is an essential part of the contracting process. However, it’s also a critical step in ensuring that patients receive safe and effective care from MCO providers. Credentialing providers include a combination of background checks, verification of education and licensing, and pre-qualification of services provided. Credentialing providers can be a manual or automated process.
Conclusion
Healthcare payors are increasing the standards for providers to ensure that patients are receiving safe and effective care from qualified providers. As a result, healthcare organizations must implement processes that verify the credentials of potential new hires and partners. The healthcare landscape is constantly changing, and it can be challenging to meet the needs of both patients and payors. With careful preparation before signing contracts, your organization can successfully partner with new payors while protecting patient interests. For Healthcare organizations, payor contracting and credentialing for providers are essential steps in the reimbursement process. Payors often require this process in order to ensure that providers meet certain standards for quality and safety.