What Is Delegated Credentialing?

Provider credentialing is a highly regulated procedure that takes three to six months to complete and is necessary for hospital privileging, managed care enrollment, patient safety, and economical, high-quality healthcare. Practitioners become upset, insurance companies limit members’ access to physicians, and health systems experience delayed enrollment and reimbursement due to slow provider credentialing. By signing a delegated credentialing agreement with health insurers or payers, hospitals and health systems can expedite provider onboarding and reimbursement by cutting the enrollment process by weeks.

A Growingly Vital Approach

Healthcare businesses trying to stay up with the rapid growth of the industry can benefit greatly from delegated credentialing in terms of both time and money. In addition to helping provider groups maintain control and consistency over their revenue cycles, delegated credentialing can lower operating expenses.

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Benefits of Delegated Credentialing

Delegated credentialing can be beneficial in many situations. Healthcare organizations seek to expedite credentialing to get clinicians in front of patients sooner, even though health insurers are behind schedule with enrollments and verifications. The following is a summary of the advantages of delegated certification for organizations and health plans.  

• Benefits of Health Plans From

Efficiency of Time and Resources: It helps health plans that are understaffed or overloaded with new enrollees save time and resources.

Cost Reduction: Rather than hiring new employees internally, credentialing can be outsourced to a delegate to help reduce costs.

Faster Network Participation: More providers can enroll sooner because it shortens the turnaround time for network participation.

Managing Provider Volume: This allows overseeing more providers to accommodate network expansion.

• Benefits for Healthcare Organizations From

Faster Provider Enrollment: It drastically reduces the time needed to enroll providers, frequently finishing the process in less than two weeks.

Quicker Turnaround for Network Participation: This results in speedier payer payments, simplifying financial planning.

Effective Use of Resources: Practices might cut back on the time and resources required for provider enrollment, depending on the parameters of agreements.

Improved Provider and Patient Satisfaction: New providers may start immediately, which directly impacts patient satisfaction and treatment.

How to Put Delegated Credentialing Into Practice

Create a Program for Credentialing

• Regulatory Compliance: Develop a credentialing program that aligns with payer, state, and federal regulations. This ensures your processes are legally sound and meet industry standards.
• Policies and Quality Oversight: Incorporate robust policies, procedures, and bylaws. These should outline credentialing practices, enrollment application handling, and primary source verification (PSV).
• Engage Stakeholders: Involve key departments such as medical staff services, quality departments, credentialing committees, and peer review teams. Their collective input ensures the program’s efficiency and integrity.
• Ongoing Monitoring: Implement a quality control program that continuously monitors credentialing activities for compliance and improvement.

Assessment Before Delegation

• Pre-Delegation Evaluation: Health plans conduct a thorough review of the delegate’s credentialing policies, practices, and adherence to NCQA standards. This includes evaluating the staffing levels and performance metrics of the delegate.
• Preparation for Assessment: Ensure all documentation, such as policies, procedures, and credentialing files, are complete and updated to reflect current compliance standards.

Engage in Negotiations and Delegated Contracts

• Define Roles: Clearly specify the activities delegated to your organization versus those retained by the health plan.
• Reporting Requirements: Establish reporting schedules and formats to submit credentialing activities, typically on a semiannual basis.
• Performance Evaluation: Include clauses for periodic performance reviews and corrective actions in case of non-compliance.
• Confidentiality and PHI: Ensure adherence to laws governing the use and protection of Protected Health Information (PHI).
• Fee Agreements: Negotiate fee schedules that outline services covered and corresponding rates, tailoring them to payer-specific agreements.

Execute Credentialing

• Credential Verification: Conduct PSV and maintain up-to-date provider information, including licensure, certifications, and background checks.
• Provider Rosters: Submit accurate and timely rosters with updates on provider status, including new hires, terminations, and changes in practice details.
• Streamlined Onboarding: Enable new providers to participate in networks promptly after approval by the credentialing committee.

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Employ Credentialing Software

• Data Management: Utilize software to manage credentialing data, delegate contracts, and provide rosters efficiently.
• Customization: Ensure the software supports payer-specific roster formats and reporting requirements to avoid delays or errors.
• Technology Security: Maintain robust security protocols to protect provider data and comply with accreditation standards.

Annual Audits of Oversight

• Delegation Oversight Audits: Participate in audits conducted by health plans to verify compliance with NCQA standards and payer policies.
• Audit Preparation: Keep policies, procedures, and credentialing files updated. Ensure primary source verification meets payer and accreditor requirements.
• Error Mitigation: Address recurring errors or omissions promptly to avoid penalties, corrective actions, or termination of delegation agreements.
• Continuous Improvement: Use audit findings to refine credentialing processes and maintain high compliance standards.

Disadvantages of Delegated Credentialing

1. Health plans (delegating entities) may lose control over credentialing quality.
2. Variations in payer requirements can be confused if not managed carefully.
3. Delegating entities bear responsibility for credentialing decisions.
4. Many health plans mandate NCQA accreditation for delegates.
5. Routine NCQA audits add to administrative burdens.

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Conclusion:

Delegated credentialing streamlines provider onboarding, improves efficiency, and strengthens payer relationships. Organizations can ensure seamless implementation by adhering to regulations, maintaining robust processes, and preparing for audits. This approach ultimately enhances provider network management and patient care outcomes.