The Value of Coordinating Credentialing and Contracting

While contracting and credentialing are different processes with different timelines, you may not know the two are interdependent. So how do the two relate?  Providers typically cannot contract with payer networks until their credentials have been verified. On the other hand, delays or inaccuracies in credentialing can directly impact contracting outcomes. Have you ever negotiated a contract with great rates but expired CAQH provider profiles got in the way of implementing the payer contract? Coordination between your credentialing and contracting processes will help ensure seamless network inclusion, reduction of denials and payment delays, and appropriate providers and locations linkages to your group contract. 

Kelley Sewell of KRS Management Group recently joined a MedTrainer webinar, Cracking the Code on Credentialing and Contracting to help healthcare organizations better understand the differences and interdependencies of credentialing and contracting. The result? Empowering healthcare organizations to streamline provider enrollment, reduce claim denials, and improve overall payer contract performance, both operationally and financially.

Provider Credentialing vs. Payer Contracting 

Credentialing is the process of verifying a healthcare provider’s qualifications to ensure they meet and maintain the standards required to deliver patient care. This is crucial not only for patient safety but also for maintaining regulatory compliance and minimizing liability risks. Credentialing is also time-intensive. Depending on the provider’s background and the efficiency of the process, it can take weeks or even months to complete. Errors or missing information significantly extend credentialing timelines, delaying the provider’s ability to deliver services under insurance agreements.

Contracting refers to the agreements that govern the relationship between healthcare providers and payers, namely insurance companies or health plans. Contracts define the terms under which providers deliver care and are reimbursed, including specific reimbursement rates and or rate methodology, billing requirements, covered services, and more. Contract timelines are driven by factors such as renewal dates, rate renegotiations, new products, and amendments (e.g., regulatory, plan administration, etc.). 

Best Practices To Syncing Credentialing and Contracting 

While the timelines and processes vary between the two, conducting credentialing and contracting activities in tandem is most beneficial. Syncing and streamlining the processes help healthcare organizations offer timely access to care for patients and maximize revenue potential. Best practices for coordination include:

• • Know What Goes Where: Payers may send a new contract or amendment to credentialing representatives for signatures alongside a credentialing application or attestation forms. It’s essential to know where each of these go within your organization.  Contracts should only be reviewed by the designated contract representative of the provider organization and signed only by the legally authorized signatory.
  • Prioritize Timely Follow Up: Regular follow-ups for credentialing and contracting can help identify and resolve potential bottlenecks promptly, keeping both processes on track.
  • Monitor Signatures: Under a group contract, although credentialing may be performed for each individual provider, individual providers should not sign individual contracts. This can lead to delays in payments, incorrect payments, and the need for claims reprocessing.
  • Know Your Provider Contract Type: Whether you have a facility, group or ancillary contract, they will each require different credentialing obligations. Knowing which type is appropriate for your organization will help  ensure you meet the correct requirements. 

Technology is another tool for efficiency that leverages automation, offers visibility, and streamlines workflows to optimize credentialing and contracting. MedTrainer’s credentialing software includes automated reminders and exclusion monitoring, customized workflows, access to centralized data, CAQH profile management, comprehensive reports, dashboards and more – all designed to help you work proactively when it comes to credentialing efforts.

WEBINAR: Reduce Claim Denials With Credentialing and Enrollment Improvements

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Don’t Leave Money on the Table

Conducting both processes in tandem will not only improve operational efficiencies and access to patient care, but will also ensure you’re not losing out on revenue. According to a MedTrainer poll, when asked what was their biggest source of lost revenue related to credentialing, over 51% of respondents stated initial credentialing taking too long.  Do you know how much money your organization is losing due to inefficient credentialing? 

Here are some tips to help maximize reimbursement throughout both processes.

Credentialing

• Stay ahead of recredentialing! Keep a schedule of when providers are due and when their verifications documents expire, among other deadlines.
• Keep Council for Affordable Quality Healthcare® (CAQH) profiles updated.
• Plan ahead for provider signatures.

Contracting

• Keep a schedule of contract renewal dates to renegotiate rates as soon as possible.
• Negotiate annual rate escalators so you don’t have to renegotiate every year.
• Know where you stand in the market compared to your competitors, especially your payer contract rates (which are publicly available on the health plan websites), service offerings, and quality scores/patient reviews.

In conclusion, credentialing and contracting are interdependent processes that play a critical role in the healthcare ecosystem. By adopting best practices, leveraging technology, and maintaining proactive communication, organizations can overcome common challenges, reduce delays, and maximize their revenue. If you’re ready to see how MedTrainer can save your team time and improve your credentialing process, we invite you to learn more about our features or schedule a demo.

Interested in increasing your payer contract rates and knowing how your rates compare to your competitors’? Learn more about how KRS Management Group can help.