The “One & Done” CAQH Integration Myth

By Anshul Rathi, Founder & CEO

A common myth we’ve come across in the provider network management industry is that a vendor’s CAQH integration can fast-track your payor enrollment and credentialing processes.


The reality is not so simple. Getting in-network with payors is a three-step process that involves:

  1. Contracting: Payors send you their standard contract that covers just about everything, including healthcare services for patients. Most prominently, it covers reimbursement rates for services rendered.
  2. Enrollment: This process takes care of placing your PC (Primary Care practice) onto insurance plans, networks, Medicare, and Medicaid, so that your organization can receive payment for services.
  3. Credentialing: This is a background check process on each provider on your roster to verify and assess a clinician’s education, training and experience.

When selecting a team/vendor to work with, keep in mind that each payor has a unique process for how it contracts and credentials providers.

These intricacies include which platforms they use, such as Availity, MDLive or CAQH, and required documents and information.

The best vendors will have expertise in each payor’s unique process and data requirements, apply using the most accurate information (no typos, please), and proactively ensure each provider’s credentialing application is up to date before the payors run their own primary source verification process.

These small efficiencies can reduce your contracting time by up to 50%. 
 
So how can your vendor’s CAQH integration can help you get in-network faster?
 
The simple answer is: that it can’t.

CAQH itself is a CVO, meaning only they can verify the data submitted by providers. CAQH integrations through your vendor can help streamline the collection of data for other submissions of multiple payor applications, but unless your organization is delegated for credentialing, CAQH and specific payors are still responsible for verifying the credentials submitted. So, your organization is still beholden to the (traditionally slower) timelines of CAQH and payors.
 
No healthcare organization should risk exposing themselves to blind spots related to payor enrollment and reimbursement processes that would inhibit their path to maximizing revenues in new markets. That’s why at CertifyOS, we offer an end-to-end solution, powered by API integrations and hundreds of verified data points.

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