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What is Contracting and Credentialing?


Patrice Pash walks you through what contracting and credentialing is and when your startup should begin preparing for this vital urgent care process.

Hi there, I'm Patrice. And today, we're going to talk about contracting and credentialing, what it is, and when you should start in the start up process for your new urgent care.

To begin, contracting and credentialing are actually two separate pieces of a very important part of your whole startup process.

Contracting, in a nutshell, is basically going to the various payers or insurance groups, if you will, and asking for an agreed upon reimbursement structure from each of these payers, in other words Blue Cross Blue Shield, Aetna, Signa, United Health Care, all those ones that you're very familiar with, and getting them to agree with you in contract form of what they're going to reimburse you.

Credentialing, on the other hand, is essentially, well, think of it as a background check, if you will. These might include things like having the payer look into your educational history, work history, licenses, board certifications, things of that nature. They're going to collect all that information on your various providers that are going to be working for your urgent care and put that into a check form and decide if they're going to credential all of your providers.

Now, starting this process is extremely important because it takes--it can take anywhere from four to six months or better to get these various payers completely contracted for your new urgent care.

The thing to remember, however, is the Affordable Care Act that everyone has heard so much about has increased credentialing verification requirements, especially for Medicare and Medicaid enrollment. And this is because of the fraud and abuse that has occurred in the past.

Because of the time involved in this process, contracting and credentialing should be begun as soon as possible. You need three things that are extremely important to begin this process.

You need your tax ID structure for your new urgent care, you need a verifiable location or address. We call that a United States Postal Service verifiable address. And you need a physician to begin contracting under.

Once you have these three things, you should start as soon as possible so that once you're building and all of your other things are ready, you can start seeing patients as soon as possible and be assured that you'll be reimbursed to the fullest extent.

Join us next time when we're going to talk more about contracting and credentialing.

We'll see you then.