Healthcare providers play a vital role in delivering quality care to patients, and it is essential for healthcare organizations to ensure that they have the right providers on their teams. Credentialing and contracting are two critical processes that healthcare organizations use to establish partnerships with providers.
Effective credentialing and contracting processes help healthcare organizations ensure that they are partnering with qualified providers who share their goals and values.
In this blog, we will discuss credentialing and contracting healthcare providers.
What Is Credentialing?
Credentialing is a process whereby individuals can demonstrate their qualifications and experience in a specific area. This is typically done through certificates and other verification forms, such as licenses, credentials, or degrees.
Credentials assure that the holder has obtained the necessary knowledge and experience to be deemed competent in certain areas. This is often used in professional organizations and the workplace to ensure individuals possess the skills and qualifications necessary for the job.
The credentialing process begins by completing an application and providing documentation that outlines an individual’s education, work history, training, and other relevant experience. This information is then reviewed by an organization or institution that will decide the individual’s qualifications. Once approved, the individual will be granted a credential reflecting their achievements.
What is Contracting?
Contracting healthcare providers is a common practice in the medical industry. It refers to an arrangement between a healthcare provider and a patient or organization. This enables the provider to provide healthcare services to the patient or organization in exchange for a predetermined fee. The provider can increase income while the patient or organization receives more comprehensive and cost-effective health care services.
Healthcare providers involved in contracting are usually independent practitioners such as hospitalists, dentists, psychologists, nurses, therapists, and other healthcare professionals. These practitioners can contract with hospitals, health systems, private practices, and other organizations that need their expertise and services part-time or full-time.
A contract typically outlines the expectations between the two parties and details concerning payment, access rights, patient privacy regulations, and other obligations for both entities.
What Is the Difference between Credentialing and Contracting Health Care Providers?
Credentialing and contracting are two distinct processes used to evaluate, prequalify and select health care providers (i.e., physicians, physician assistants, nurses, therapists, etc.) for participation in insurance or managed care programs, hospitals, ambulatory care clinics, and other health care delivery systems.
The distinction between credentialing and contracting is essential, as each process serves a unique purpose.
Credentialing evaluates the suitability and qualifications of a provider, while contracting specifies the payment terms for services provided. Both methods are integral components of the healthcare industry.
Credentialing involves a process to verify and validate the qualifications and competencies of a provider, such as whether they have the necessary licensure, certifications, and education to practice within their field. This is usually done through a formal evaluation process.
Contracting, on the other hand, pertains to the establishment of a contractual agreement between two parties. This negotiation is typically conducted between providers and payers and involves the payment rate for services rendered.
Conclusion
Credentialing and contracting are essential for healthcare organizations to establish successful provider partnerships. By understanding the benefits and challenges of credentialing and contracting, there are effective partnerships with qualified providers, improving patient outcomes and achieving their organizational goals.
If you need credentialing and contracting services such as DME credentialing, Wonder Worth Solutions is here for you! We have a team of credentialing experts with knowledge and experience in helping healthcare providers comply with the requirements to become contracted and credentialed with Medicare, Medicaid, and other third-party payers. Contact us now!
