Contracting and Credentialing are critical components of any successful medical or psychological practice. It is especially important for small practices and Applied Behavioral Therapy practices. Though understanding the finer points of each, and which one needs to come first requires a little bit of a deep dive into some important details.

What Is Credentialing?

Credentialing plays a critical role in provider qualifications as well as reimbursement rates. Not to mention the licensing necessary to practice in most communities.

It is a strict and formal process of verifying each provider’s professional qualifications. In this way, the credentialing process ensures that physicians, psychologists, nurses, and other clinicians have the proper education, training, and experience to provide their patients with the highest level of professional care.

While different industry sectors have minor differences in the type of information they require for a specific condition, all provider credentialing process is completed by verifying all provider documents. This also ensures that they are up to date with current standards, valid, and have been meeting all activity requirements for the specific windows of time for their profession.

It’s also worth bearing in mind that a lot of health insurance companies will not even offer a reimbursement rate for a physician or clinician without the proper medical credentialing.

How Does The Credentialing Process Work?

The credentialing process relies on highly accurate and detailed documentation to ensure that the physician or clinician has the qualifications and experience necessary to provide services to patients. The accuracy requirements are intense and even a single missed data file, incongruity, or incorrectly entered a piece of data can cause massive delays.

In some of these cases, it can even lead to outright denial, requiring the individual to start the process all over again.

The majority of insurance companies, payers, and public health institutions use the credentialing process to regulate the speed of adding excess providers to specific panels. Anytime you submit your credentialing request to the payer or health institution, they start the process of verifying the legitimacy you’re your credentials by cross-checking them with various databases.

This includes the CAQH. Only once the credentials have been 100% verified, can the provider in question be added to the roster associated with the connected contract.

The Difference Between Contracting & Credentialing Providers

Some think that contracting and credentialing are the same thing. Though in reality, they are relatively different processes. Especially in the eyes of insurance companies and public health institutions.

Credentialing is a detail-oriented process that serves to verify the legitimacy of any provider. However, it doesn’t directly involve payment from an insurance payer. While it’s certainly a factor in determining reimbursement rates, credentialing doesn’t connect a provider to a fee schedule.

To receive payment from an insurance payer or a public health institution a provider needs to go through the process of obtaining a legally binding contract that includes an associated fee schedule.

This contracting process might involve negotiation and requires agreeing to the rates that you will be paid to provide your services to patients. It is not until after this contracting process that a provider can panel or add new providers to their agreement. Some small practices might have a group agreement that allows you to add additional providers to the group and have them billed under the same fee schedule or reimbursement rate.

Outsourcing The Credentialing Process

Some small practices choose to outsource their credentialing and contracting process. With this approach, the risk is that you no longer have direct understanding and control over the process.

The benefit is that it takes a lot of the pressure and stress of accuracy off your hands. It also ensures that when your credentialing information is submitted that a highly trained expert has ensured that all the correct information is presented accurately. This goes a long way toward ensuring that your credentialing process is approved as fast as possible. When you factor in the value of your time, outsourcing your credentialing and contracting process can also be a major cost-saving move for a small practice or solo practitioner.

Not to mention that credentialing and contracting services can often perform these services much faster and without as many errors, which will also help your group capture revenue and see your patients faster.

If you do outsource your credentialing process, you need to make sure that the company you choose has the experience to credential your practice effectively. They need to have a system in place that makes their work transparent to you and that they are certified to be HIPPA compliant.

The Benefits & Drawbacks Of Outsourcing Contracting Negotiations

A lot of payer institutions and insurance providers have set reimbursement rates in the fee schedule for specific services. Many times these negotiations are relatively straightforward, and the payer institution doesn’t allow for much wiggle room. They tend to draw a hard and fast line, that even the best outsourcing agency can’t push much beyond.

Though there are some specializations, where there is some wiggle room in the negotiating process. Especially if your practice is relatively new and offers a high-demand service for your region. In a scenario like this, outsourcing to a third party can maximize your chances of getting the highest possible reimbursement rate. As they are experts who know the ins and outs of the negotiating process far better than medical professionals who have minimal training in real-world contract negotiations.

A lot of ABA therapists who offer services for children with Autism Spectrum Disorder in a region where previous services have been minimal will choose to outsource their credentialing and contracting to a third party. Not only does it increase the chances of your ABA practice receiving the best possible rate, but it lets you spend more of your time focusing on developing the services the surrounding community needs, rather than chasing paperwork and double-checking data fields.

When considering an outsourcing agency, it is critically important to find a negotiation service that charges based on performance. You want to see some type of clause where they only get a better rate if they get you better contracts. A service that charges an hourly rate or a flat fee regardless of performance then there is no guarantee you will get paid better rates.