Essential for patient safety and affordable quality healthcare—and required for hospital privileging and managed care enrollment—provider credentialing is a highly regulated process that takes three to six months to complete. Slow provider credentialing results in delayed enrollment and reimbursement for health systems, reduced member access to providers on the insurance company side, and frustrated practitioners. For hospitals and health systems, entering into a delegated credentialing agreement with health plans/payers can shave weeks off the enrollment process, resulting in faster provider onboarding and reimbursement.
What is provider credentialing in healthcare?
Medical credentialing is the process of obtaining, verifying, and assessing a healthcare provider’s qualifications to provide care or services in or for a healthcare organization. Essentially, you’re ensuring that healthcare providers are competent to deliver safe, high-quality care. The credentialing process requires contacting several organizations, including medical schools, licensing boards, and other entities, to verify that providers have the necessary education, training, license(s), certificates, and other qualifications.
Who’s responsible for credentialing?
In non-delegated credentialing, the medical staff services department of a hospital or health system collects credentials data from physicians and other practitioners, submits a credentialing application for each provider, and then waits several months for the health plan to verify the credentials and approve or deny each application.
Then, healthcare providers must be re-credentialed at least every two years. If a provider is working in multiple facilities (even within the same healthcare system), he or she must be credentialed and re-credentialed at each facility where they work. The credentialing application process is time-consuming and frustrating for providers and the medical staff services department, which must follow up with payers frequently until the application is approved.
If your healthcare facility, health system, or provider group has more than 150 healthcare providers, entering into a delegated credentialing agreement with health plans/payers can speed up the credentialing and enrollment processes so your providers can start seeing patients and get paid sooner.
What is delegated credentialing?
Delegated medical credentialing occurs when a healthcare entity gives another healthcare entity the authority to credential its practitioners. Health plans/payers delegate specific components of the credentialing process—usually primary source verification—to provider/hospital groups that have the appropriate infrastructure, resources, and personnel to support this critical function. This is in contrast to non-delegated credentialing, where the payer completes the credentialing and enrollment process.
“Delegate” is used two ways in the credentialing arena. First, when used as a verb, “delegate” refers to giving another entity the authority to credential providers, as described above. Many larger healthcare organizations, such as hospital systems and health plans, delegate credentialing to an internal or third-party credentials verification organization (CVO).
Second, your healthcare organization can become a “delegate” (noun). Qualified healthcare organizations, including CVOs, can achieve delegated status with health plans/insurance companies. The delegate is responsible for conducting specified parts of the credentialing process—typically primary source verification—for the health plan/payer within a formalized delegation agreement.
Payers that seek delegated credentialing arrangements include commercial insurance companies (e.g., UnitedHealth Group, Cigna, Aetna, etc.) and The Centers for Medicare & Medicaid Services. CMS uses Medicare Administrative Contractors—private healthcare insurance companies that have been awarded states or geographic jurisdictions to process Medicare Part A and Part B medical claims or Durable Medical Equipment (DME) claims for Medicare fee-for-service beneficiaries.
Benefits of delegated credentialing
Faster enrollment and reimbursement
Delegated credentialing reduces the time it takes for an insurance company to determine whether it will accept the provider on its panel and provide an effective date for membership. Faster effective dates and network participation mean providers can begin billing and getting reimbursed sooner.
More efficient payer enrollment
Delegated credentialing reduces the administrative burden of submitting hundreds of provider applications individually. Instead, all providers can be added to a single roster and submitted to the payer “in bulk.” Tracking and reconciliation processes are also easier when using delegated credentialing. And waste and duplicative resources on the hospital and insurance sides are often eliminated, since the credentialing function requires duplicative work. Even when shared solutions such as CAQH Proview are used on both the provider and payer sides, a delegated relationship creates efficiencies within credentialing, directory maintenance, coordination of benefits, and other essential business functions, eliminating bottlenecks.
More control over provider data
Delegated credentialing allows organizations to have more control over how the network is reflected in payer directories. Demographic updates and network participation changes—which occur constantly—are efficiently handled through rosters, ensuring provider data accuracy and directory compliance.
Greater provider and patient satisfaction
Faster onboarding means that providers can start doing what they love to do—taking care of patients—several weeks sooner. And patients benefit from having access to:
- More practitioners—both physicians and advanced practice providers
- The appropriate specialists and subspecialists
- Conveniently located providers
- Care that comes without the burden of surprise billing
How does delegated provider credentialing work?
Your healthcare organization must meet several requirements to participate in a delegated credentialing arrangement. Most delegated relationships are for National Committee for Quality Assurance (NCQA)-certified organizations enrolling more than 150 providers, but every payer/health plan sets its own standards for what is acceptable. The threshold exists because credentialing efficiency increases once a certain volume is reached. NCQA and Utilization Review Accreditation Commission (URAC) require several elements for delegated credentialing, including a pre-delegation assessment, delegation agreement, and delegation oversight audits.
Follow these steps to implement delegated credentialing
Develop an internal credentialing program that complies with state, federal, and payer regulations. The program must include bylaws language and/or policies and procedures that describe how credentialing and enrollment applications are handled, and how primary source verification is conducted. In addition, bylaws and/or policies and procedures must demonstrate that a quality oversight program—which includes ongoing and focused monitoring—is in place to ensure the success and improvement of the program. You’ll need the proper personnel, operational infrastructure, and resources—which includes involvement from the medical staff services department, quality department, the peer review and credentialing committee, and other stakeholders—to support the credentialing and enrollment functions.
Complete the pre-delegation assessment. Health plans evaluate the delegate’s ability to perform credentialing tasks. The evaluation includes reviews of the delegate’s policies, procedures, and credentialing files, and an assessment of the delegate’s staffing and performance levels. Most health plans require that a delegate’s processes and procedures comply with NCQA standards and guidelines before they agree to delegate credentialing.
Negotiate and enter into a delegated agreement with your payer(s). The health plan and delegated entity enter into a mutually agreed upon delegated credentialing agreement. You will need to negotiate each delegated credentialing agreement with each health plan individually. This agreement will include several elements:
- Credentialing roles and responsibilities: Identify what activities the delegated entity will perform versus which the health plan will take on.
- Reporting requirements: The delegated entity must report its credentialing activities to the health plan at least semiannually. The agreement spells out the information required and the process by which the reporting occurs.
- Performance evaluation and remedies: Specify how the health plan will assess the performance of the delegated entity and what happens if the delegate doesn’t meet expectations (e.g., corrective action or termination of the delegation agreement).
- Right of final determination: The health plan has the right to make a final decision about any provider within its network, even when credentialing has been delegated.
- Use of Protected Health Information (PHI): Laws govern the use of PHI, and the agreement will likely reference such statutes.
- Fee schedules (if a higher rate is negotiated): A fee schedule is a list of fees or payments for specific provider services or supplies. The list will define all covered services and the negotiated rates for each service.
Do the credentialing work. Verify credentials and submit a provider roster to the payer. After you’ve signed the delegated credentialing agreement, your organization (or your CVO) will be responsible for verifying provider credentials and sending the payer an updated provider roster on a regular basis (usually monthly). Rosters include information on changes of status, address, billing information, and any new or terminated providers. The healthcare organization or health plan collects and reviews provider information and documentation by electronic or manual methods and then provides it to the delegate to conduct PSV. However, in some cases the delegate also collects the credentialing information and documentation.
When a health plan receives a roster update, a new provider is considered to be “participating” in its network and is therefore eligible for reimbursement. Depending upon the payer and the arrangement, following receipt of a roster a new hire could potentially be considered as participating in a plan as early as the effective date they were approved by committee.
Use credentialing software. Choose the right credentialing software to manage your data and delegated contracts, build your delegated rosters, and submit them to your payer(s). Each payer may have a different format pertaining to its delegated credentialing roster.
Participate in annual delegation oversight audits (aka payer reviews). Occurring at least once a year, delegation oversight audits check to ensure the delegated entity is following credentialing policies and procedures that meet NCQA standards. Payer reviews gauge your compliance with payer and accreditor rules, including:
- General policies and procedures regarding data handling
- Roster quality and accuracy
- Adherence to accreditor or certifying body standards
- Security related to provider data management technology
Repeated errors or omissions can result in a range of problems, from penalties to delegated contract termination. To avoid those traps, prepare for an audit by ensuring your credentialing/enrollment policies are up-to-date and remain in line with the health plan’s accrediting agency. Primary sources, for example, must meet the payer’s accepted standard.
Outsourcing credentialing and recredentialing
Entering into and successfully managing a delegated credentialing program is a significant undertaking. Partnering with a CVO that has the expertise to help develop the program and provide the credentialing services is an option that benefits growing healthcare organizations. For healthcare organizations expanding services through telemedicine, a CVO can be an essential guide when it comes to navigating states’ requirements, which differ greatly.
Why choose a credentialing service?
Use a CVO for fast, accurate, compliant credentialing and enrollment. Partnering with a CVO eliminates the administrative burden on your medical staff services department and frees up its personnel for analytical tasks. Most CVOs have access to tools such as CAQH ProView, an online provider data-collection solution that streamlines provider data collection by using a standard electronic form. And CVOs that carry NCQA accreditation in credentialing go above and beyond credentials verification to handle the entire credentialing and recredentialing process and monitor provider performance between credentialing cycles. Outsourcing credentialing to a CVO that is NCQA accredited in credentialing helps your healthcare organization:
- Streamline and automate credentialing processes
- Onboard physicians faster so they can see patients and get reimbursed sooner
- Minimize financial risk by reducing the likelihood of noncompliance, inaccuracy, and increased audits that drain financial resources and create administrative headaches
- Significantly reduce credentialing-related claims issues (e.g., edits and denials)
- Improve provider and patient satisfaction
If your organization has at least 150 providers, you should consider entering into delegated credentialing agreements with your payers. symplr CVO takes the stress out of credentialing, recredentialing, primary source verification, payer enrollment, state licensure application, and more.