Credentialing How Tos   /   December 2015

3 Things Delegated Entities Need to Know & Get Right

3 Things Delegated Entities Need to Know & Get Right

Delegated credentialing is a powerful strategy for provider organizations because it gives provider groups control and visibility into their activation dates with health plans. But many provider organizations struggle with setting up and maintaining an NCQA-compliant process that is cost effective and scalable and that meets the needs of the payers. This blog post provides some broad guidance around three key segments of a delegated credentialing arrangement. But before we dive into the three things to know, let’s recap the big idea of delegated credentialing.

Why It’s Important

Delegated credentialing helps payers reduce operational costs and and helps provider groups have better control and consistency in their revenue cycle. In an earlier post, we explained how this works as a benefit for provider organizations. In this way, delegating the credentialing function has become an increasingly important strategy for both provider organizations and payer organizations. We expect this trend to continue and gain momentum in 2016.

What It Is

Sallye Marcus of Anthem describes delegation as “a formal process by which the organization gives another [organization] the authority to perform certain functions on its behalf, although an organization may not delegate the responsibility for ensuring that the function is performed appropriately.” Let’s break it down even further: let’s say Peter Payer Company (“the delegator”) entrusts credentialing to Paula Provider Company (“the delegate”). Peter Payer still bears the responsibility to ensure that the credentialing is performed correctly by Paula Provider. This is typically accomplished via an annual audit.

3 Things to Know

1. Know Your Contractual Responsibilities. Beyond the technicalities of the regulatory standards (which we discuss below), delegates must understand their responsibilities.

Data transfer: Both delegator and delegate need to agree on how the information about credentialed providers will flow between the organizations. Typically, this happens with roster files being transferred between the organizations. You’ll want to agree that the format and delivery method are workable for both sides. We often see this process break down for two reasons:

  • One or both parties are limited by their technology and can’t deliver the right data in the right format.
  • One or both parties are understaffed, and the manual work of creating, updating and sharing roster files becomes unsustainable.

Another common mistake is that files with sensitive information are shared via email, which is a very real security risk.

  • Data quality: Payers that delegate credentialing to provider groups rely on the information about their providers for critical parts of their business. Often the phone numbers, addresses and office hours contained in the roster files are used directly in the payer’s provider directory. If the roster file contains poor-quality data, provider directory will be inaccurate. This directly impacts the ability of members/patients to access providers and causes a breakdown of trust between the payer organization and its members.

2. Know the Regulators and Why They Matter to Delegated Credentialing

  • NCQA: National Committee for Quality Assurance. Founded in 1990, NCQA drives improvement throughout the healthcare system. NCQA has become the gold standard for quality, and accreditation by NCQA represents well-managed and high-quality care and service. NCQA guidelines are often the basis of delegated contracts, so it’s critical to understand their standards and requirements inside and out.
  • CMS: Centers for Medicaid and Medicare Services is part of the Department of Health and Human Services (HHS) and administers Medicare, Medicaid, the Children’s Health Insurance Program (CHIP) and parts of the Affordable Care Act (ACA). CMS must ensure that their members have access to high-quality care. CMS adds additional requirements to certain parts of the credentialing process. If the delegate has contracts with CMS, it will be important to comply with the CMS-specific guidelines in addition to the NCQA baseline requirements.
  • Local state governments: may add further requirements. These are regulatory agencies that can have credentialing regulations, such as mandatory application, use of a universal organization to conduct primary source verification and/or specific turnaround times for credentialing processes. 

3. Know the Standards to Pass your Initial and Annual Audits

  • CR 1: Credentialing policies outline which credentialing procedures are completed within your organization and how they are completed. Reviewers will make sure that the language in your policies meets the requirements listed below and will review evidence of implemented procedures outlined in your policies. When it’s important: At initial contract setup and then subsequently each 2 or 3 years, the policies should be reviewed and updated to reflect changes in the regulations or the organization.
  • CR 2: The credentialing committee represents a decision-making process that includes comprehensive advice from experts. When it’s important: Show that you have a committee in place at the time of initial contract setup. In addition, show that documentation that the committee reviews happens for all providers that don’t meet the standard for a “clean file.”
  • CR 3: Credential verifications provides evidence for the reviewer that the elements outlined in your policies are followed. The reviewer pays close attention to the following: verification sources used, criterion for the state and specialty type of the practitioners and whether the review committee received the data in the correct amount of time. When it’s important: Continuously follow the NCQA guidelines for verification of credentials. Make sure that every provider file goes through the same process and that only the approved sources are used to verify credentials.
  • CR 4: Re-credentialing cycles show the reviewer that your organization’s credentialing process properly re-credentials its contracted practitioners in a timely manner. When it’s important: At initial contract setup, show that you have procedures in place for re-credentialing. At audit, show that your system is working and that procedures are being adhered to.
  • CR 5: Office site quality demonstrates that your organization’s practitioners’ offices meet quality standards and do not pose a safety or health hazard to patients. When it’s important: At audit, show the reviewer that your provider offices are up to par.
  • CR 6: Ongoing monitoring shows that your organization monitors its practitioners in between credentialing cycles. When it’s important: Continuously follow the NCQA and CMS guidelines for ongoing monitoring. Make sure that every provider goes through the same process and that only the approved sources are used for monitoring.
  • CR 7: Notification to authorities and appeal rights ensure that actions against a practitioner for quality reasons are handled with concern for the practitioner’s and patient’s needs. The reviewer considers timeframes outlined in policies and ensures that those timeframes are being met. When it’s important: At initial contract setup, show that you have procedures in place for re-credentialing. At audit, show that your system is working and that procedures are being adhered to.
  • CR 8: Organizational providers ensure that your organization has a process that verifies that contracted providers meet quality standards. When it’s important: At initial contract setup, show that you have procedures in place for credentialing organizational providers. At audit, show that your system is working and that procedures are being adhered to.
  • CR 9: Delegation ensures that your organization has a process for the oversight of entities to which it has delegated all or part of the credentialing process. Even though your organization has granted another entity to perform credentialing functions, it retains ultimate responsibility for the credentialing program and must ensure that the delegate is performing up to standard. Reviewers will look to audit all entities that perform credentialing functions on your behalf. When it’s important: At initial contract setup, show that you have procedures in place for credentialing organizational providers. At audit, show that your system is working and that procedures are being adhered to.

There are a lot of moving parts in a delegated credentialing arrangement, but the benefits to both payers and provider organizations cannot be overlooked. To simplify the process, CredSimple has developed technology-based solutions for credentialing and provider data management that make delegated credentialing run better for both payers and provider organizations. If you need help to start your delegated credentialing program or if you are spending too much time managing roster files, running credentialing or running audits, do yourself a favor and request a demo of CredSimple today to learn how simple delegated credentialing can be!

This article was inspired by the work we do with our clients and the session at the NAMSS annual meeting called Delegation Oversight 101: How to Pass Oversight Audits, presented by: Angela Dorsey, MA and Sallye Marcus.

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