Credentialing in house can be painful for health plans and other types of payors, adding the time and administrative stress of continually tracking and updating new providers, locations, and information. It can be burdensome for provider organizations too, submitting new documents with each provider, location and information changes, not to mention the anxiety of waiting for provider approval. And up against an ever-clicking clock, it can feel like application and enrollment overload for both sides!
Delegated credentialing can ease some of that pain, helping payors and providers ensure information is accurate and updated more efficiently and on a timely basis. And andros offers the expertise and experience to help both payors and provider organizations put an effective delegated credentialing program in place.
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Delegated credentialing occurs when one health care entity gives another health care entity, the authority to credential its health care practitioners.
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For example: Health Plan A has a good working relationship with a physician group, Physician Group B. In an effort to alleviate some of of its own administrative burden, Health Plan A decides to delegate credentialing to Physician Group B. As the “delegated entity,” Physician Group B is now responsible for making credentialing decisions on behalf of Health Plan A, including: evaluating practitioners’ qualifications, and verifying credentials.
Delegated credentialing goes beyond credentials verification because the delegated health care entity (e.g., the physician group) is responsible for evaluating practitioners’ qualifications and making credentialing decisions on behalf of the delegating health care entity (e.g., the health plan).
The data required to make credentialing decisions include:
Entities that can delegate are:
Here is a list of organizations that credentialing can be delegated to:
Every two or three years, healthcare professionals must renew their credentials. A single corporation may have multiple locations, each of which requires its own set of credentials. There is the option of using either an external or internal credentials verification organization (CVO) to handle the verification of credentials.
NCQA (National Committee for Quality Assurance): NCQA’s mission is to drive improvement across the healthcare delivery system. Their guidelines are the gold standard and are sometimes considered crucial for entities to review their standards.
CMS (Centers for Medicare and Medicare Services): The US Department of Health and Human Services administers Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and portions of the Affordable Care Act (ACA). CMS has additional requirements that go beyond the NCQA’s guidelines.
Verification by the government at the local level may involve filling out an application, using a global organization to check primary sources, and/or meeting specific deadlines.
Delegated credentialing offers benefits that extend to both Health Plan A (the “delegator” or “delegating entity”) and Physician Group B (the “delegatee” or “delegated entity”). Becoming a delegated entity grants provider organizations more direct control of the process, reducing error risk, ensuring information is updated on a timely basis, and bypassing the anxious wait for provider approval. For payors, delegation allows them to credential more providers faster, ultimately leading to an expanded footprint and more patients. These advantages can be quantified in three ways: savings in time, cost and administrative burden.
Delegated credentialing cuts down on the time it takes for a prospective provider to become a participating provider in a network. By handling almost everything in-house, delegated entities can handle documentation quickly, relieving payors of the administrative burden.
For Payors, delegating credentialing typically gets providers practicing sooner, leading to an expanded geographic footprint, more services being provided, more members and, ultimately, a more positive impact on the organization’s revenue cycle.
For Provider Organizations, practitioners becoming participating providers sooner, leading to similar outcomes: more services provided, more patients treated, and consequently, increased revenue.
Delegated credentialing can reduce administrative burden for both the payor and the provider organization. Delegated entities save time because they are no longer required to submit credentialing documents and applications directly to payors; payors save time by passing much of the administrative process over to the delegated entity.
There are a number of steps to be taken to ensure delegation is done correctly. First, not all entities are the right fit or eligible for delegation; typical eleigible organizations include provider groups, hospitals, independent physician associations and specialty networks such as dental and vision.
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Once a provider organization is determined to be eligible, a series of steps need to be taken in order for the delegated program to move forward.
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These include establishing credentialing policies and procedures and forming an internal credentialing committee. Payors are also required to conduct a pre- delegation audit. When helping organizations implement these steps, the andros team also facilitates discussion to ensure consensus and clarity about the roles and responsibilities of each party.
While Delegated Credentialing is not a “perfect” process, it has obvious benefits to payors and provider organizations alike, saving time, cost and administrative burden. When done in a manner that is a true partnership between the Delegator and the Delegatee, with consistent communication and clear policies and procedures in place, it can be a tremendous benefit to all, and helps to ensure quality service is more accessible to patients seeking out medical care.
But it isn’t always easy to get started.
These are just a few of the questions to consider before you begin to consider delegated credentialing. And these are just a few of the areas where andros can help, working with you at every step to ensure your delegated credentialing program is a success.
To learn more about delegated credentialing and find out if it’s right for your organization, attend our upcoming webinar or reach out to us at info@andros.co.
A delegated credentialing entity is a healthcare organization that has been given authority by another healthcare organization to credential its healthcare practitioners. For example, a health plan can delegate the task of credentialing to a physician group, making the latter responsible for making credentialing decisions on behalf of the former. The credentialing decisions include evaluating practitioners’ qualifications and verifying their credentials such as state licensure, DEA registration, education, malpractice history, work history, and others.
Delegated credentialing offers three main benefits to both the delegating and delegated entities. Firstly, it saves time as the delegated entities can handle documentation quickly, thus expediting the process of credentialing. Secondly, it offers cost benefits as it allows providers to start practicing sooner, leading to more services being provided, more patients treated, and subsequently, increased revenue. Lastly, it reduces administrative burden by allowing delegated entities to handle most of the administrative processes associated with credentialing.
In delegated provider credentialing, one healthcare entity (like a health plan) delegates the responsibility of credentialing to another healthcare entity (like a physician group). The delegated entity is responsible for evaluating practitioners’ qualifications, verifying their credentials, and making credentialing decisions on behalf of the delegating entity. The credentialing process is done every two or three years, and involves renewing credentials for each location. Verification is carried out either internally or through an external credentials verification organization (CVO).
The responsibility for credentialing lies with the delegated entity. It is their role to evaluate practitioners’ qualifications and verify credentials. The entities that can delegate this process include health plans, provider networks, preferred provider organizations, accountable care organizations, specialty provider networks, and independent physician associations. The organizations that can be delegated to include provider groups, hospitals, hospital systems, independent physician associations, and specialty provider networks.
Delegated provider credentialing is a process where one healthcare entity (such as a health plan) delegates the responsibility of credentialing its healthcare practitioners to another healthcare entity (such as a physician group). The delegated entity is then responsible for evaluating the qualifications of practitioners, verifying their credentials, and making credentialing decisions on behalf of the delegating entity. This process helps in saving time, reducing costs, and lessening the administrative burden associated with the credentialing process.
Managing a high-performing provider network shouldn’t mean choosing between innovation and integration. Yet for many health plans, that’s exactly the challenge. You’ve adopted new tools
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