Michigan Health System Develops NCQA-Compliant Credentialing Program in 3 Months

This large Michigan health system includes a network of eight hospitals, 145 outpatient locations, and nearly 5,000 physicians. The health system’s Accountable Care Organization (ACO) and physician group partnered with symplr to utilize symplr CVO and symplr Provider to design and implement an NCQA-compliant credentialing program. Within three months, symplr’s solutions helped the health system develop the necessary policy infrastructure and implement a credentialing Peer Review Committee. The committee utilized symplr CVO and symplr Provider to ensure the accurate credentialing and review of all participating providers.  

THE CHALLENGE

Creating space for strategic growth opportunities, improved revenue cycle management, and stronger data integrity 

Credentialing is one of many quality management tools that healthcare organizations implement to monitor patient safety. While most will agree that it plays a valuable role in establishing and governing high-quality provider networks, very few appreciate its impact on strategic growth opportunities, revenue cycle management, and data integrity.   

There is significant risk associated with provider credentialing — credentialing mistakes have been linked to large malpractice suits, some of which set the legal precedents for the credentialing laws and regulations in place today. While the fundamental structure of evaluating competency and qualifications remains unchanged across organization types, variations in regulations between state, federal, and accrediting bodies render already complex procedures nearly impossible to absorb.  

Like many large healthcare organizations, this health system’s ACO and physician group quickly appreciated the value of an internal credentialing program and its impact on quality and strategic growth initiatives. Building a provider credentialing program is a time- and labor-intensive process that usually takes eight months to a year to complete and requires considerable expertise and staff resources. This organization’s goal was to develop a quality-centric credentialing program that would allow it to establish delegation agreements with partner health plans. 

THE SOLUTION

Exceeding goals by leveraging industry expertise 

symplr CVO and symplr Provider enabled the health system to evaluate state, federal, and NCQA standards to design a fully compliant credentialing program. symplr's experts closely collaborated with the customer on policy requirements, quality oversight functions, and continuous program governance. A readiness assessment indicated that the health system can successfully evidence competency and compliance in credentialing in preparation for pre-delegation audits. symplr CVO and symplr Provider helped the health system develop a program that would pass the stringent pre-delegation assessments, where payers evaluate these components of the credentialing infrastructure:

• Credentialing program  
  • Policies and procedures  
• Quality oversight program  
  • Monitoring of processes and personnel  
• Experience and expertise  
  • Accreditation status, e.g., NCQA 
• File review  
  • Evidence of compliance with policies and procedures 
• Ongoing and performance monitoring  
  • Sanctions and member complaints review process 
• Peer Review Committee  
  • Composition and charter 
• Reporting capabilities  
  • Software and technology 

symplr CVO and symplr Provider provided review and guidance to the health system in evaluating delegation agreements to ensure they included required components such as delegated functions and responsible parties, quality improvement procedures, oversight of delegated functions, and terms for corrective action and revocation. 

THE RESULTS

Digitization, best-practice workflows, and cross-organizational transparency 

Through its partnership with symplr, the Michigan health system’s ACO and physician Group: 

• Designed and developed an NCQA-compliant credentialing program in just three months, including: 
  • Credentialing Policies and Procedures 
  • Quality Improvement Program 
  • Provider Performance Thresholds and Case File Standards 
  • Credentialing Peer Review Committee Charter and Participants 
  • Non-Discriminatory and Confidentiality Attestations 
  • Annual CPRC Calendar with Agenda Items and Deliverables  
• Established delegation capabilities that meet all NCQA and health plan standards 
• Obtained two delegation contracts within six months of launching the delegated credentialing program 
• Established quality governance over the health system’s network