Providers are individuals (doctors, nurses, etc.) or groups (hospitals) that provide care to patients. There are a variety of types of care that providers can give to patients. Here’s where patients receive care:

• Inpatient care: Medical care where the patient stays in the hospital overnight or longer, covered by Medicare Part A
• Outpatient care (ambulatory care): Medical care provided during a visit, with no plan for the patient to stay overnight, covered by Medicare Part B

Here’s the type of care patients receive:

• Primary care: General medical care from a primary care doctor (PCP), who may refer patients to specialists if needed, primarily outpatient
• Secondary care: Specialized care from medical experts like cardiologists or dermatologists, usually after a referral from a PCP
• Tertiary care: Advanced, highly-specialized care for complex conditions, such as organ transplants or neurosurgery, often in top-tier hospitals

Licensing, credentialing, and enrollment

Licensing

Clinicians need to be licensed in each state they provide care in and the process can vary greatly state by state.

Licensing generally involves submitting various documents to state boards, like proof of graduation, proof of completion of residency, and the fee for licensure. Some states have more arduous requirements, like fingerprints, notarized documents, and additional coursework/CME completion.

In some cases, compacts exist to streamline the process. For example, the Interstate Medical Licensure Compact (IMLC) has a common application for Physicians across 34 states and the District of Columbia.

Credentialing

Credentialing refers to the verification that a clinician has the requisite experience, credentials, and good standing to practice medicine.

Typically, credentialing is discussed in the context of a health plan’s responsibility to ensure the providers in their network are in good standing; however, it’s also common for practices to credential their providers at the point of hiring to ensure that they will deliver quality care.

The process of credentialing involves the collection of provider information in a database and verification of that information at its source via primary source verification (PSV). The health plan will then submit this information to a credentialing committee who will make recommendations on credentialing.

For provider organizations, establishing their own credentialing process also sets them up to eventually take on delegated credentialing responsibilities. Delegation is important because larger practices are able to take on the credentialing process independently and faster, with periodic audits from the health plan.

Separately, credentialing is not to be confused with privileging, when the hospital gives the provider the authority to practice certain types of medicine at the facility.

Enrollment

Payor enrollment is the process of getting your clinicians contracted and enrolled with a health plan. In order for clinicians to be enrolled with health plans, they need to be credentialed with health plans.