Organizations of all sizes have struggled to solve the challenges of building healthcare provider networks, especially for Medicare Advantage, on schedule and on budget. Healthcare organizations have to analyze patient demographics and local geography, then make wise choices where to invest. They need to comply with complex regulatory requirements and demanding timelines. But despite these
Delegated Credentialing: Easing the pain of credentialing your providers
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.
What is Delegated Credentialing?
Delegated credentialing occurs when one health care entity gives another health care entity, the authority to credential its health care practitioners.
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.
The 3 Advantages of Delegated Credentialing
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.
Less Administrative Burden
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.
Before You Delegate
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.
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.
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.
Getting Started with Delegated Credentialing
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.
- For provider organizations, do you have established credentialing policies and procedures and a credentialing committee established?
- For payors, do you have a clear delegation strategy and an established process in place?
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.
More To Explore
The process of building a provider network is challenging. There is constant change in government regulations, a fast-paced competitive environment, and various information sources. Building a solid and profitable network requires the right strategy. The best network to build will depend on such things as your goals and member population, but network development strategy mistakes