An Introduction to Delegated Credentialing

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One thing is well known – credentialing can be a long and arduous process. A possible solution to this problem is delegated credentialing, but many do not know where to start. While it might seem like a big undertaking, with the right preparation and partner, it can be a straightforward process. We’ve created an introduction to delegated credentialing breakdown so you can better understand how to get started.

What is delegated credentialing?

Delegated credentialing occurs when a health care entity gives another health care entity the authority to credential its health care practitioners (e.g., a health plan delegates its credentialing to a physician group).

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:

  • State Licensure
  • DEA Registration
  • CDS (Controlled Dangerous Substance) Certification
  • Board Certification
  • Education Malpractice History
  • Professional Liability Claims Settlement History
  • Work History
  • Hospital
  • Disclosure Questions
  • Attestation Sanctions & Exclusions

Who can Delegate?

There are several entities that can delegate the credentialing process over to other entities.

Entities that can delegate are:

  • Health Plans(United, Cigna, Aetna,
    Blue Cross Blue Shield Plans)
  • Provider Networks
  • Preferred Provider Organizations (PPO)
  • Accountable Care Organizations (ACO’s)
  • Specialty Provider Networks(Dental, Vision)
  • Independent Physician Associations(IPA’s)

Here is a list of organizations that credentialing can be delegated to:

  • Provider Groups (single or multi-speciality, multiple or single location)
  • Independent Physician Associations (IPA’s)
  • Hospitals & Hospital Systems
  • Specialty Provider Networks (Dental, Vision)
You may have noticed that there is some overlap within these two lists. Some entities like IPA’s and Specialty Provider Networks can both delegate and be delegated to.

How often does credentialing happen?

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.

Regulators and Delegating Credentialing

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.

The Benefits of Delegated Credentialing

As a result of delegated credentialing, operational expenses can be lowered and provider groups can gain control and consistency in their revenue cycles with less effort.

Agreements for delegated credentialing can drastically reduce the time it takes to get a provider set up with a health plan. Delegated credentialing is one way that centralization can speed up the onboarding of new providers, cut down on scheduling delays, and boost satisfaction among providers. When they have less paperwork to do, they may see more patients.

How andros Can Help

By partnering with andros, your company will have instantaneous, automated access to hundreds of primary sources. andros provides a robust API that can be included in your most frequently used internal systems and processes. In order to facilitate reporting and automated workflows, verifiable technology can give validated, structured provider data.

Provider enrollment and delegated credentialing
Instead of wasting time jumping through administrative hoops, providers and provider groups can use the andros solution set to take control of the enrollment and credentialing processes.

Steps of enrollment

Traditionally, during the enrollment process, health plans had complete control over physicians and provider groups. Due to this, many people rush to submit their paperwork and qualifications, then have to wait a long time—often months—before they can start seeing patients.
andros can speed up the provider enrollment process using our data that leads the industry and clever automation.
The process of enrolling providers with each payer is then facilitated and automated by our awareness of each Plan’s criteria.

Our NCQA-certified accreditation occurs concurrently, dramatically increasing your capacity to see patients and get payments.

Take the next step with delegated credentialing

Obviously, the lengthy enrollment procedures at health plans are mostly due to credentialing being a tedious and manual administrative process. If you delegate credentialing to someone else, it will occur according to their schedule. Provider groups can take charge of the procedure and the schedule with delegated credentialing, and andros can assist.

Being delegated indicates that your credentialing procedure is stringent enough to satisfy the requirements of your partner’s health plans. They submit to your procedure, avoiding all the hassles usually connected with provider enrollment. By working with andros to become delegated, you can trust our NCQA-certified procedure, which qualifies providers up to 10x faster than conventional, manual methods.

Want to learn more about delegated credentialing? Check out our delegated credentialing webinar or reach out to us today!

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