While often used as synonyms, at the HMO/PPO they are two very different processes conducted by two very different departments.
Credentialing is a review of the physician or physician extender. It is a meeting of the credentialing team, typically physicians and other allied health professionals, who take a look at the physician’s record to see if there are any major blemishes, questions that need to be answered about their record, their Board certification(s) and the physician’s CAQH. This meeting is kept confidential and the contracting team is not allowed to attend the meeting. Once the review is completed, a note will be sent to the contracting team letting them know they are allowed to move forward with a contract or adding this physician to an existing contract. A review is also typically completed every three years to determine if there have been any major changes that warrant concern regarding the physician or extender’s record.
Contracting is a legal agreement between two companies (unless the physician is a sole-proprietor). The review here is quite different. The contracting department is determining if there is a network need for the physician, what rates can/cannot be offered, and to negotiate any special terms as needed. Many of the payers also have different contract entities so you could be contracted for PPO and POS plans but not HMO, Medicare Advantage or an EPO plan. It is important to try to contract for ALL products or both you and the payer will be confused (along with the patient).
Unfortunately, in some areas obtaining a contract is proving to be increasingly difficult. In Florida for example, many of the payers are not offering new contracts unless there is something ‘special’ about the services you offer (oral surgeon for example) and they have a specific need for those services. California presents a set of challenges as the capitated model that failed in most other areas is still alive and well in California. These Independent Practice Associations (IPA’s) neither want nor need external specialty services like phlebology. As such, a number of patients are locked away from an independent practitioner. Add in integrated delivery models such as Kaiser Permanente and the number of potential patients is yet again reduced.
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