The “One & Done” CAQH Integration Myth

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

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

1. Contracting: Payers 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 payer 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 payer’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 payers 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 - 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 payer applications, but unless your organization is delegated for credentialing, CAQH and specific payers are still responsible for verifying the credentials submitted. So, your organization is still beholden to the (traditionally slower) timelines of CAQH and payers.

No healthcare organization should risk exposing themselves to blind spots related to payer 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.