Credentialing

A Guide to Delegated Credentialing

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February 14, 2022

As a business owner, you never want to leave money on the table; this might be the case if you delegate all the credentialing to the payers.

Because provider credentialing is highly regulated, payers usually take a long time to verify and enroll providers in their networks. If providers are not registered on time, they may be frustrated and lose reimbursements. 

In addition, as your healthcare organization grows, the need to enroll more healthcare providers becomes more evident. 

You will lose more time and hurt your revenue cycle if you do not enter into a delegated credentialing agreement with your payers.

What Is Delegated Credentialing? 

Delegated credentialing refers to the situation in which a healthcare entity (health plans) gives authorization for accreditation to a healthcare organization.

Alongside verification, the delegated entity has the authority to make other credentialing decisions on behalf of the delegating entity. 

Some provider information that requires credentialing decisions to take place includes; State licensure, CDS (Controlled Dangerous Substance) Certification, Education, DEA Registration, Board Certification, Malpractice History, Work History, Hospital/ Facility Affiliations, Attestations, etc. 

Verifying data across the above spectrum for a single provider with different payers is mostly time-consuming, with adverse financial implications. Not to mention that this process ought to be repeated with each payer every two years. 

There should be a mutual agreement between parties involved in delegated credentialing. The contract should detail your obligations and comply with the requirements of the relevant regulatory bodies, e.g., NCQA, CMS, URAC, Federal and State Laws. 

Benefits of Delegated Credentialing 

Delegated credentialing pays significant dividends in time and money. Here are some strategic benefits of entering into delegation agreements with your payers.

1. Reduced Payer Enrollment Timelines

It is possible to significantly reduce the time it takes to enroll a provider in the health plans your organization participates with through a delegates credentialing agreement. 

Without delegation, provider enrollment can take somewhere between 3-6 months. But entering into delegation agreements with payers can reduce the duration to about 30-45 days.

2. Enhancing Provider Flexibility 

Often, providers are required to perform health procedures at several facilities within your health organization. This means they need to be credentialed at each of these facilities. It can be very redundant to verify each of the same credentials in several facilities.

Delegated credentialing gives room to centralize and optimize this process. Therefore, giving the provider time to focus on patient care and other aspects of their onboarding process like privileging and board approvals. 

Patient Satisfaction and Increase Revenue 

The money is in the care of patients, not in the juggling of several papers. When providers see more patients, it directly correlates with an increase in your organization's revenue. 

Also, when operations within your healthcare organizations are centralized through delegated credentialing, it facilitates faster onboarding of providers. Ultimately, this will, in turn, reduce scheduling time, thereby improving patient satisfaction with your organization. 

Steps To Implement Delegated Credentialing

Develop a compliant internal credentialing program. 

The internal credentialing program must include by-laws detailing policies and procedures on handling credential and enrollment applications. Also, the bye-laws must show that a quality oversight program is in place to monitor the progress and success of the program precisely. 

You will need the proper infrastructure, resources, and personnel. In most cases, this will mean the involvement of the credentialing committee, quality department, and medical staff services department. 

Complete The Pre-delegation Assessment 

While health plans are eager to delegate credentialing to health organizations, they still need to assess your ability to perform the credentialing task effectively. 

The assessment includes a review of your procedure and policies and credentialing files. Staffing and performance levels will also be assessed.

If you have developed a solid and compliant internal credentialing program, you shouldn't have any problems with the payer assessment. Most plans require that your processes and policies comply with NCQA standards and guidelines.

Negotiate a Delegated Agreement with your payer(s)

You will need to negotiate a delegation agreement with each payer individually. The deal will include the following elements;

 Credentialing roles and responsibilities. 

  •  Reporting requirements: You must report your credentialing activities to the payer at least semiannually (or as otherwise agreed). 
  •  Performance evaluation: This specifies how the health plan will evaluate your performance and indicates what happens if your organization does not meet expectations.
  •  Right of final determination: The health plan retains the right to make final decisions about any provider credentialing standing. 
  • Use of Protected Health Information (PHI): The agreement will also enact PHI laws by referencing such statutes (like HIPAA Rules). 

The Credentialing Process

Once you have signed the delegated credentialing agreement, Your healthcare organization or Credentials Verification Organization (CVO) can verify your provider's credentials and submit their roster to the payer every month. 

Rosters include updates on any new or terminated provider and updates in provider data like; changes of status, address, or billing information. 

When a payer receives the updates, newly credentialed providers are officially considered part of the insurance plan and eligible for reimbursement. 

Using a Credentialing Service 

CVOs ease the administrative workload on your medical staff service department. With access to tools like CAQH Pro view, CVOs can simplify the provider data collection process. A strong option on the table for you might be using a credentialing service. 

Credentialing services also carry NCQA accreditation and all other regulatory bodies' approval. Therefore, you do not need to worry about compliance issues when dealing with them. 

Outsourcing your credentialing workload to a CVO helps ;

  •  Hasten the process of provider enrollment. 
  •  Minimize issues due to credentialing-related claims issues (edits and denials) 
  • Automate and simplify the credentialing process

Are You Looking to Simplify Your Credentialing Process? 

Float Care simplifies the credentialing process for facilities with registered health practitioners who are seeking Board Certification in their specialty. Contact us today to learn more about our service and how it can streamline and support your credentialing efforts.

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