Is it provider enrollment or payer enrollment? What do you mean when you say credentialing? Are you processing 837s or EDIs?
Improving healthcare is difficult. It’s even more difficult when we aren’t even speaking the same language. Providers, payers, patients, and intermediaries often use the same words to mean different things, or different words to mean the same thing. Almost every area of healthcare is guilty. In the world of provider data management, the lack of standard terminology, for a relatively small set of tasks, is rampant—perhaps a reflection of the often-convoluted processes necessary to facilitate them.
As leaders in provider data management, we’re committed to creating clarity in terminology across the industry, starting at home. Today, we set the record straight on what we mean when we use the following terms: EDI enrollment, payer enrollment, credentialing, and contracting.
EDI enrollment is essentially the initial process performed to kick off electronic exchanges between payers and providers. Technically, EDI stands for Electronic Data Interchange and must take place between providers and payers before electronic claims—which are all electronic now—can be submitted for services rendered.
While there is consensus around what EDI enrollment is, its terminology tends to confuse people. Sometimes EDI enrollment is referred to as “provider enrollment,” by clearinghouses, referencing providers being enrolled with payers. By providers, it is sometimes called “payer enrollment.”
Once EDI enrollment is completed, providers can then work within the EDI environment to send and receive a set of transactions tied to claims and payments:
- Electronic Data Interchange for Claims (EDI): EDI 837s are the electronic claims providers submit to payers which detail services and request payment for those services.
- Electronic Remittance Advice (ERA): Commonly referred to as 835s, ERA is what payers use to respond to their providers’ 837s explaining why a claim was denied or how much was accepted.
- Electronic Funds Transfer (EFT): EFTs are the approvals, or orders, payers send to banks to release funds to providers.
- Claims Status Inquiry (CSI): EDI 266 and 267 refer to the inquiry a provider makes on the status of a claim and the payer’s response to that inquiry, respectively.
- Eligibility Verification (EV): Providers use EDI 270 and 271 to verify that a patient is eligible for particular services to be covered by the payer. These go hand-in-hand with prior authorizations.
There are other EDI tasks, each with their own numbers, but these are the most common.
So, what do we mean when we say, “payer enrollment?” Well, to us, payer enrollment is the process of an individual clinician being credentialed by payers.
But wait, wouldn’t that just be credentialing? No, not exactly. Health systems, hospitals, and medical groups credential individual physicians as part of their internal onboarding processes. But then payers turn around and do the same thing. What’s even more confusing is that payers may refer to this as “provider enrollment.” Yes, the same term as EDI.
And this is exactly why it’s important to create a common set of definitions with these terms. Much of the confusion comes from—and underscores—the burdensome duplicative nature of tasks on the administrative side of healthcare. Payer enrollment can be confusing, so we wrote a whitepaper clarifying what it is and why it matters.
Ok, so what exactly is credentialing then? Credentialing, at a high level, is the process of obtaining and verifying a clinician’s identity, qualifications, and competencies. This is done by the hospital or practice the physician is joining, and by payers as well.
From a provider’s perspective—and similarly the perspectives of a clearinghouse or RCM vendor—it’s really broken down into three steps:
- Primary source verification (PSV): A healthcare organization’s process of sourcing information such as proof of residency, board certifications, state licensures, and practice history to confirm the legitimacy of an individual clinician to be employed. It’s like a background check.
- Privileging: Once this step is done, a healthcare organization will approve and authorize their new clinician to perform specified clinical services within specific facilities. It’s essentially making the clinician a new user in the provider’s system and blessing them to perform services.
- Payer Enrollment: Well, by now, you know what this is, but if you forgot—it’s the process of an individual clinician being credentialed by payers.
As is evident by now, these terms, and the transactions themselves are really just like little red nesting dolls—a task within a task within a task.
Contracting is the process of negotiating and establishing a products and services agreement between a healthcare provider and insurance payer. These contracts cover rates for reimbursement, specific terms and conditions, particular payer networks, and more. It’s an area that Madaket is planning to help automate in the not-too-distant future. More information to come.
Words have power. While the terminology of provider data management transactions may not have universal understanding yet, we believe getting to a common set of words and their definitions will help us simplify and improve healthcare.
Learn more about Madaket’s solutions for EDI Enrollment and Payer Enrollment.