The faster, safer, less-stress way to ensure credentialing quality

As part of symplr CVO’s ongoing commitment to innovative thinking in healthcare contracting, sourcing, and evidence-based research, this white paper is the latest dedicated to addressing quality management tools in the U.S. health system, specifically credentialing.

To learn more about how symplr CVO can partner with your facility to reach financial, compliance, and patient care goals, visit symplr.com today.

Abstract:

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.

In fact, credentialing is an area of healthcare operations that is often overlooked in enterprise- wide strategic planning. It isn’t until delays and backlogs result in serious financial and administrative woes in the form of bad debt or frustrated providers that most organizations will approach the topic. Even then, it’s usually with great trepidation and uncertainty.

The truth is that there is significant risk associated with provider credentialing — failures of credentialing have been linked to large malpractice suits, some of which set the legal precedents for the credentialing laws and regulations in place today. And 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.

Why would any health system or provider network want to take this on?

An effective credentialing program has proven to be successful in facilitating rapid network expansion, shortening provider onboarding time frames, improving quality and data management processes, increasing contracting leverage with managed care partners, and significantly enhancing the health of the revenue cycle.

In this white paper, we will establish a common understanding of credentialing, underscore the benefits and risks of delegated credentialing, and provide a road map for organizations interested in expanding into this critical area of healthcare.

Introduction to Credentialing

Credentialing has existed in some form or another since 1000 BC1 — a testament to its enduring value. In its simplest form, it is the process by which providers are deemed qualified to render patient care. In its truer, more complex form, it is subject to a plethora of standards and regulations that prescribe how and what is to be evaluated. So, what was once an interview before a panel of wise men is now a heavily regulated process that includes verification of specific data elements against primary sources, review of findings against legal and regulatory standards, and approval by a board of peers. Data-driven insights — from malpractice claims history to state and federal sanctions review — inform every step of the credentialing process to ensure a complete and accurate assessment of a provider’s capacity to render patient care.

Credentialing Process Overview

Credentialing takes place in multiple contexts in the healthcare industry and is the gate-keeping mechanism for the delivery of safe patient care. There are two primary instances where credentialing occurs: hospital credentialing (also known as medical staff credentialing), which precedes hospital privileging; and managed care credentialing, which precedes health plan enrollment. In the former, the requirements and procedures for credentialing are regulated by the hospital’s internal by laws, a combination of state and federal laws, and accrediting body standards.

Most health systems adhere to the accreditation standards of one of the following bodies:

• The Joint Commission (TJC)
• Accreditation Association for Ambulatory
• Health Care (AAAHC)
• Det Norske Veritas Healthcare (DNV)
• Healthcare Facilities Accreditation Program (HFAP)

An appropriately qualified, licensed independent practitioner (LIP) must apply for hospital privileges, comply with medical staff credentialing requirements, and be approved by a series of peer review and governing boards prior to being granted privileges to admit, consult, or treat patients in an in-patient hospital setting.

In the latter instance of credentialing, namely managed care credentialing, health plans comply with state and federal laws and accrediting body standards prior to approving providers as “in- network” to see patients. In contrast to medical staff credentialing, health plans typically adhere to the standards of one of the following accrediting bodies:

• National Committee for Quality Assurance (NCQA)
  • Utilization Review Accreditation Commission (URAC)

Similar to medical staff credentialing, providers — a classification that includes both practitioners and organizational providers such as home healthcare facilities, skilled nursing facilities, etc. — must complete an application, provide supporting documents, and comply with health plan-specific credentialing requirements to access members and be reimbursed for their services — a process known as managed care enrollment.

The general standards of credentialing specify at a minimum what information and supporting documents are required as part of the hospital privileging or managed care enrollment process, what elements must be primary-source verified, what procedures must be employed by the hospital or health plan to complete primary-source verifications, and the maximum amount of time that can elapse before a provider must go through the process again.

Regardless of context, the mission of a credentialing program is to ensure that every provider2 has both the legal authority and relevant training to deliver healthcare services prior to gaining access to members.3 Ultimately, the responsibility — by virtue of ostensible agency — is on the hospital or health plan to ensure that providers are appropriately vetted, approved, and monitored on a regular basis. In doing so, they establish a quality governance infrastructure that effectively mitigates risks associated with patient care.

As powerful a tool as credentialing is, if it is not properly implemented and managed, it can pose serious risk to the health plan or hospital in the form of inadequate network and care coverage, non-compliance with state and accrediting body standards, operational and financial strains, and impediments to strategic growth initiatives.

These pains are felt even more strongly by health systems or provider networks that face costly delays in new provider onboarding, highly manual and time-consuming application processes, frustrated providers, and significant issues in revenue cycle management.

Source: Industry norms and symplr’s experience with customers

Enter delegation.

Delegated Credentialing

Credentialing delegation has evolved to become a collaborative effort between health plans, health systems, and provider networks to offset these risks and ensure that high-quality care is available to members. Credentialing delegation is a regulated process by which one healthcare entity grants another healthcare entity the authority to perform a contractually defined set of credentialing functions on its behalf while maintaining oversight of the proper execution of these functions. The decision to delegate is not easy to come to, primarily because of ostensible agency — accountability for the proper execution of the delegated functions resides with the entity delegating the function, namely, the hospital or health plan.

Organizations must comply with strict policies and procedures when exploring delegation opportunities to safeguard themselves from the risks associated with entrusting another organization with such a critical process. As an example, health plans have minimum requirements regarding network size, experience, accreditation status, and operational infrastructure of a prospective delegate. Assuming the prospect meets the initial requirements, a formal pre-delegation assessment is conducted to ensure

In assuming the delegated functions, health systems and provider organizations realize unparalleled improvements in the processes that govern the growth and representation of their network, shorten turnaround times for network participation, enhance provider experience and brand integrity, and expedite access to revenue.

Faster enrollment and reimbursement.

Delegated credentialing reduces managed care enrollment time frames, directly impacting member access and reimbursements.

More efficient enrollment process.

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 health plan at one time. Tracking and reconciliation processes are also easier with delegated credentialing.

More control over provider data.

Delegated credentialing allows organizations to have more control over how the network is reflected in health plan directories. Demographic updates and network participation changes are efficiently handled through rosters, ensuring provider data accuracy.

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 receiving that care without surprise billing.

Roadmap to Delegation

Organizations must demonstrate operational competency and expertise in credentialing to qualify for delegation. To this end, a credentialing program must align state and federal requirements with accreditation standards in the following areas:

• Credentialing policies and procedures
  • Credentialing and recredentialing time lines and procedures
  • Assessment of organizational providers
  • Ongoing monitoring
  • Practitioner rights
  • Data security and management of credentialing information
  • Quality oversight and continuous monitoring
  • Credentialing commiftee and peer review

To mitigate the operational impact of varying standards and regulations, organizations must:

• Evaluate network distribution to determine state-specific regulations
  • Evaluate managed care contracts to determine health plan- and CMS-specific regulations
  • Evaluate what accreditation body governs their organization or their managed care partner

An effective and consistent credentialing program should comply with the standards while accounting for costs. As an example, in the State of New York, managed care credentialing requirements include primary source verification of practitioners against the Limited Access Death Master File; the State of Illinois does not have this requirement. Although consistency in the process enables scale and automation, and decreases the likelihood of errors and omissions, organizations should evaluate the financial impact associated with streamlining procedures against the strictest standards.

Credentialing policies and procedures.

The policies and procedures serve as the foundation for the operational structure of the credentialing program. The policies must define:

• Provider types that are within the scope and authority of the credentialing program
• Application source and supporting documents that are required from each provider
• Elements that will be verified and the sources that will be used for primary source verification
• Timeliness standards regarding credentialing, recredentialing, and provider notifications
• Ongoing monitoring of providers on a monthly or semiannual basis against state licensing boards for actions, and state and federal sanctions lists
• Provider rights as it pertains to appealing credentialing decisions or being granted

Data security and management of credentialing information.

Credentialing is the entry point of a large amount of data that must be appropriately stored and managed. The policies must define the parameters that allow for the secure and confidential exchange of provider data internally and externally with third parties as required to complete the credentialing process. There must be evidence in the form of training certificates and confidentiality statements indicating that personnel were, and will continue to be, trained in proper handling procedures.

Quality oversight and continuous monitoring.

Governing the entire credentialing program must be a quality improvement infrastructure that not only monitors personnel performance, but measures compliance to accuracy thresholds. The appropriate checks and balances — in the form of file audits, productivity reports, and annual policy review — ensure that providers are being processed accurately and efficiently and demonstrate the quality of the credentialing program to regulatory agencies and network partners.

Credentialing committee and peer review.

Not unlike what transpired in 1000 BC, today a committee of the provider’s peers is required to evaluate the information gathered during the credentialing process and assess whether the provider is qualified and capable of performing

duties as defined within the scope of their practice and specialty. As such, a critical component of a credentialing program is the establishment of a Peer Review Committee. In the broadest sense, the purpose of the Peer Review Committee is to provide organizational oversight and decision- making about credentialing and recredentialing of providers wishing to participate in the network. This is accomplished through the regular examination of programmatic and administrative performance measures. In concert with this, the committee identifies programmatic and administrative opportunities for improvement, recommends programmatic and policy changes based upon industry best practice, and partners with all departments to design, implement, and evaluate improvement initiatives.

The roadmap to delegation can be very difficult to navigate — the stakes are high, and the process is complex. But to reiterate: an effective credentialing program will facilitate rapid network expansion, shorten provider onboarding time frames, improve quality and data management processes, increase contracting leverage with health plans, and significantly enhance the health of the revenue cycle.

Conclusion

Delegation is the faster, safer, less-stress way to ensure credentialing quality.

Enforced standards of credentialing establish and govern quality and accountability in healthcare. Today, there is a prevalence of delegation in the market as organizations are realizing the benefits of this collaboration. As healthcare organizations expand their geographic footprint, the emerging web of regulations can seem impossible to navigate, making the establishment of a delegated credentialing program daunting, to say the least. Daunting, but certainly not impossible — getting there will require a partner with a proven knowledge of state and federal regulations and the industry standards that govern credentialing. While that might sound like a lot to ask, if a healthcare organization is to succeed in the constantly evolving landscape of credentialing, it’s essential.

About symplr

symplr is the leader in enterprise healthcare operations software and services. For more than 30 years and with deployments in 9 out of every 10 U.S. hospitals, symplr has been committed to improving healthcare operations through its cloud-based solutions, driving better operations for better outcomes. Our provider data management, workforce management, and healthcare governance, risk management, and compliance (GRC) solutions improve the efficiency and efficacy of healthcare operations, enabling caregivers to quickly handle administrative tasks so they have more time to do what they do best — provide high-quality patient care.

symplr CVO’s seasoned team of experts delivers an easy and effective way to onboard, credential, enroll, and support providers quickly and accurately. symplr CVO is NCQA Accredited and Certified in 11 out of 11 verification services. Learn how at symplr.com.