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Is “it” Enrollment, Credentialing or Both?

Is “it” Enrollment, Credentialing or Both?


Glen Beussink
Director of Development & Research
Midwest Health Care, Inc
 573.335.4715 | Email


When a medical provider wants to serve patients, in order to access that patient’s insurance plan, the provider must become a provider to that plan. Plans vary from Government or Commercial payers, but two distinct processes are required. The web of Enrollment versus Credentialing is tightly woven and entangled. We are seeing National and State agencies tackling these snares.

  • The Health Care Billers and Managers Association’s (HBMA) representative Mr. David Nicholsen, CHBME recently testified in front of the National Committee on Vital and Health Statistics Subcommittee on Standards.
  • Credentialing bills, HB 1490 and SB 742 in Missouri were promptly introduced and committees heard testimony.

Why all the scuttle? Simply put, Government Plans and Commercial Plans have separate critical components in becoming a provider to a plan. Many times these two terms are used interchangeably, when in fact Enrollment and Credentialing are two distinct processes. Generally speaking, HBMA is trying to clarify the use of the two terms on a national scale. In Missouri, many providers are fighting to simplify the process of credentialing. These two bills are evidence that there are problems in the way the commercial payers accept providers in the network.

Until we have a national description of the terms and some universal processes in place, we will continue to have a breakdown in communications and delay in getting the providers in network or enrolled by a government plan.

Some of you will remember the advent of Council for Affordable Healthcare (CAQH) and its purpose to end all of the enrollment and credentialing forms. Well, this never happened. Although many of the commercial plans want you to enroll on CAQH website, but then require you to go through the multitude of forms and individual process of credentialing or enrollment. Why can’t this be simplified and universally accepted?

Now that Medicare is mandating a “revalidation” of providers, this is yet another burden in the process of getting your providers to be an in-network provider.

Recently in Missouri, several plans have cut the time it takes to enroll in these plans. Is this a coincidence or a result of recent enrollment legislation? What do you think?

However, we applaud HBMA in trying to get a universal definition of enrollment and credentialing. There is a long way to go.

In the meantime, thanks to all the individuals who are working tirelessly in Missouri. We applaud you for your efforts and let’s hope HBMA makes some progress on a national scale.

Stay tuned for more information on this subject.

Glen H. Beussink, Dir. of Development & Research
Midwest Health Care, Inc.
300 South Mount Auburn Rd, Ste 100
Cape Girardeau, MO 63703
gbeussink@mwhc.net		 Midwest Health Care, Inc