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Streamlining Provider Credentialing

March 11, 2024
March 11, 2024

A Guide to Delegated Credentialing

One of the things most people look for today, regardless of industry, is how to perform a task accurately and quickly. The need to be efficient is paramount, and when it comes to provider enrollment and credentialing, it’s essential. When done poorly, the process can be time-consuming and inefficient, resulting in revenue loss for busy healthcare providers. However, an approach to gaining success is delegated credentialing. In this blog post, we'll delve into what delegated credentialing is, its benefits for both the organization delegating and the organization being delegated to and how the process works.

 

What is Delegated Credentialing?

Delegated credentialing is a process where a healthcare entity grants another healthcare entity the authority to credential its providers. For example, a preferred provider organization (PPO) may delegate credentialing responsibilities to a hospital or medical group. This goes beyond credentials verification, as the delegated entity is responsible for evaluating qualifications and making credentialing and appointment decisions on behalf of the delegating entity.

When organizations step into a delegated credentialing agreement, there must be a mutually agreed upon arrangement that outlines all the necessary obligations as they pertain to different regulatory bodies, like the National Committee for Quality Assurance (NCQA), Utilization Review Accreditation Commission (URAC), Centers for Medicare & Medicaid Services ( (CMS), and federal and state laws. Delegation agreements can be a separate agreement or an amendment to an existing parent contract/agreement.

 

Benefits of Delegated Credentialing

When done properly, delegated credentialing can save organizations significant time, enabling patients to access care more quickly. The benefits vary based on the organization.


From a Health Plan's Perspective

  • Time and Resource Savings: Delegated credentialing allows health plans to save time and resources, cutting costs.
  • Faster Turnaround: It reduces the turnaround time for network participation, accommodating network growth efficiently.
  • Increased Provider Satisfaction: Delegated credentialing supports contracting efforts and enhances provider satisfaction.

From a Healthcare Organization's Perspective

  • Expedited Enrollment: Delegated credentialing enables organizations to eliminate weeks in the provider enrollment process, completing it in as little as 7-10 days.
  • Timelier Reimbursement: A reduced turnaround for network participation results in quicker reimbursement from payers.
  • Enhanced Provider and Patient Satisfaction: Providers can quickly contribute their expertise, benefiting providers and patients.


How Delegated Credentialing Works:

A healthcare organization must have a robust 'in-house' credentialing process to participate in delegated credentialing. Ensuring this involves a comprehensive evaluation of the process.

The first step lies in ensuring the organization meets accreditation standards, which means the organization has a process in place that:

  • Verifies practitioner credentials through a primary source, a recognized source, or a contracted agent of the primary source.
  • Has a designated committee in place to review practitioner credentials and make credentialing recommendations.
  • Aligns with state requirements.

Now, every delegated contract will have organization-specific requirements, but standard contracts should include:

  • Roles and Responsibilities
  • Reporting Frequency
  • Performance Evaluation
  • Use of Protected Health Information (PHI)
  • Remedies for Non-Compliance
  • The Right of the Plan to Make Final Decisions

Once this has been done, the delegate will be authorized to complete credentialing for the delegating organization. As part of this agreement, the delegate will be required to share a provider roster with the delegating entity about once per month. This roster will then be used to either associate or disassociate a provider with an organization and provide high-level information on a provider, including their change of status, address, and billing information. When the delegating party receives an updated provider roster, any new provider listed can be considered "Participating" and, therefore, eligible for reimbursement.

 

Simplify Delegation

Organizations should think carefully about what organization they partner with as a delegated credentialing entity. When considering this partnership, consider these criteria:

  • Is the entity NCQA Accredited/Certified for the function being delegated?
  • If the entity is not NCQA Accredited/Certified, will it work with you to achieve Accreditation/Certification?
  • If so, can it earn Accreditation within a timeline that meets your needs?
  • Does the entity have established systems and processes, and enough staff to handle the scope of delegation? If there are gaps in capability, will the entity work to achieve the level of capability needed?
  • Do your incentives align?
  • Can you work with the entity to achieve common goals?
  • Can you and the entity work together as strong partners?

 

Activities That Can Be Delegated:

The NCQA permits delegating several activities, including credentialing, re-credentialing, case management, utilization management, disease management, and health promotion. However, certain activities, such as those involving member experience, privacy and confidentiality, and marketing information, cannot be delegated.

 

Conclusion

By embracing delegated credentialing, healthcare organizations can unlock a win-win solution for providers, plans, and ultimately, patients. Streamlined processes, quicker enrollment, and enhanced provider satisfaction make delegated credentialing the future of efficient and effective healthcare administration. Partnering with the right NCQA-accredited delegate empowers medical organizations to focus on what they do best – delivering high-quality care – while leaving credentialing in the hands of experienced experts.

Take the first step towards a faster, more efficient future for healthcare – find out how CredentialStream® can help with all your credentialing needs, including delegated credentialing. Arrange a demonstration with one of our experts today.