Facility Credentialing vs. Provider Credentialing: Key Differences & Challenges | TriumpHealth

Credentialing is an essential step for both healthcare providers and healthcare facilities, but the processes, requirements, and challenges vary significantly. ensuring compliance, quality standards, and eligibility for reimbursement. While provider credentialing services focus on verifying individual providers, facility credentialing services involve a broader scope, ensuring an entire organization meets payer, accreditation, and regulatory requirements.

Many healthcare organizations face challenges in facility credentialing, especially in Ambulatory Surgical Centers (ASC) credentialing, Federally Qualified Health Center (FQHC) credentialing, and DME credentialing. Below, we outline the core distinctions between facility and provider credentialing and highlight solutions for streamlining the credentialing process.

The Role of Facility Credentialing

Facility credentialing is the process through which healthcare organizations – ranging from hospitals to specialty centers – are verified by health plans to ensure they meet necessary operational, quality, and safety standards. This process is crucial for facilities to be able to contract with payers (Medicare, Medicaid, and commercial insurers) and be included in a network as an approved provider.

Facilities include entities such as:

• Hospitals
• Ambulatory Surgical Centers (ASC)
• Federally Qualified Health Centers (FQHC)
• Skilled Nursing Facilities
• Laboratories
• Durable Medical Equipment (DME) Suppliers
• Community Mental Health Centers
• Home Health Agencies
• Substance Abuse Centers
• Hospice Centers

The Role of Provider Credentialing

Provider credentialing is the process of verifying an individual healthcare provider’s qualification, including education, training, licensure, board certification, and work history, to ensure they meet payer, hospital, and regulatory requirements.

Provider types include such as:

• Physicians (MD, DO)
• Dentists
• Nurse Practitioners (NP)
• Physician Assistants (PA)
• Physical Therapists (PT)
• Licensed Clinical Social Workers (LCSW)
• Mental & Behavioral Providers
• Other Allied Health Professionals

Similar to provider credentialing, facility credentialing involves ensuring compliance with state regulations, accreditation standards, and necessary insurance coverage, but the requirements are different in significant ways.

Facility Credentialing Process

• Involves verifying that the facility meets state, federal, and accreditation standards (e.g., Medicare, Medicaid, Joint Commission, NCQA, AAAHC).
• May require state licensure, business registration, liability insurance, site inspections, and accreditation from organizations like The Joint Commission or AAAHC.
• Facilities must contract with Medicare, Medicaid, and commercial payers to bill for services.
• Site inspections or surveys may be required by state agencies or CMS.

Facility Credentialing Services are required for payer enrollment to allow a facility to bill Medicare, Medicaid, and commercial insurers. These services include verification of state licensure, accreditation (Joint Commission, AAAHC), Medicare/Medicaid enrollment, professional liability insurance, and exclusion screening. Such services are essential for ASC credentialing, FQHC credentialing, DME credentialing and other facilities credentialing etc.

Professional Credentialing Process

• Involves verifying the education, training, licenses, board certifications, malpractice history, and clinical privileges of an individual provider.
• Required for insurance network participation and hospital privileges.
• Can be completed through CAQH, state medical boards, and payer enrollment portals.

Provider credentialing services focus on verifying provider qualifications, including education, work history, board certifications, state licensure, and hospital privileges.

In summary, the comprehensive facility credentialing support for healthcare organizations is more complex due to multiple compliance checkpoints and specialty-based accreditation.

Key Requirements for Facility Credentialing

Facility credentialing requirements often mirror those of provider credentialing but also come with specific distinctions:

• State Healthcare License: This ensures that the facility meets state regulations for delivering healthcare services.
• Accreditation: A recognized accrediting body like The Joint Commission must verify the facility’s quality standards. If not accredited, the facility needs a site survey by the state or CMS.
• Free From Exclusions and Sanctions: Ensures the facility has not been excluded from programs like Medicare or Medicaid due to legal issues.
• Professional Liability Insurance: Covers the facility for legal claims in case of malpractice or negligence.

Challenges of Facility Credentialing

One of the significant hurdles in facility credentialing is that facilities are fewer in number compared to individual providers. This disparity in numbers means that facility credentialing has been underdeveloped in comparison to the well-established systems for credentialing individual providers. As a result:

• Data and Document Management Complexity: Unlike individual providers, facilities may have multiple specialties or services that require separate credentialing, even if they share common documents like licenses and insurance.
• Manual and Clunky Processes: Many organizations use either repurposed individual provider credentialing software or manually enter data, which increases the risk of errors and delays. This process is also labor-intensive and frustrating for credentialing specialists.

What Makes Facility Credentialing Unique?

Credentialing for organizational providers (i.e., facilities) differs from individual provider credentialing in several ways:

1. Multiple Specialties: A single facility may offer multiple specialties, each requiring credentialing. For instance, an ambulatory surgical center may need separate credentialing for orthopedics, dermatology, and other specialties.

2. Shared Credentials: A facility may have a single DEA license and professional liability insurance that covers multiple specialties, but each specialty may also need verification for things like National Provider Identifiers (NPIs).

3. Multiple Locations: A facility can be spread across different sites, but it may share common credentials across these locations.

To streamline the credentialing process, it’s often beneficial to combine credentialing events for a facility’s multiple specialties. This reduces redundancy and accelerates the overall process.

Conclusion

Both facility credentialing and provider credentialing are vital for ensuring compliance and securing reimbursements from insurance networks. However, facility credentialing is more complex due to the diverse nature of facilities, shared credentials, and the requirement for specialized documentation. By using optimized credentialing solutions like TriumpHealth, both healthcare facilities and providers can streamline workflows, improve network visibility and maximize reimbursments.