Delegated credentialing is fundamentally transforming healthcare organisations that struggle with a long and complicated process of credentialing providers. In the traditional system, payers had the role of ensuring that healthcare providers were validated in terms of their prescribed qualifications and competencies before they were able to offer services and be paid. Nevertheless, with the increasing size of healthcare networks and the constantly rising need to enrol providers in a timely fashion, this established model may cause excessive delays and administrative overhead. Meet delegated credentialing, the strategic partnership in which payers give credentialing authority to trusted medical organisations, like hospitals or management services organisations (MSOs), to do the credentialing of providers on their behalf.
Besides accelerating the credentialing timeline, this methodology not only minimizes duplicative paperwork but also enhances compliance with any regulatory requirement, as any process does not work efficiently when using excessive paper. The benefits, risks, and qualifications to be met should be involved, whether you plan to work in an extensive health system or are considering partnering with an MSO.
This blog will cover what delegated credentialing is, why it is valuable or dangerous, and where it is available; what credentials payers want to have delegated, what requirements they place on vendors, and what vendors need to do to implement delegation effectively.
What is Delegated Credentialing?
Delegated credentialing is a situation where a given healthcare organisation accredits another organisation to carry out credentialing on its behalf. In other examples, a payer like a preferred provider organisation (PPO) might want to outsource credentialing of healthcare providers to a hospital or health system. It implies that the delegated body will assume all the roles of validating and evaluating the qualifications of providers, such as licensure, certifications, work experience, malpractice actions, and other related credentials, and credentialing decisions will be made. The payer does not recreate this verification process and accepts these decisions.
Compared to the confirmation of primary sources, the process is more involved as the delegated healthcare organisation assesses the providers thoroughly and conducts continuous oversight. In many cases, this is carried out officially by a delegated credentialing agreement, delineating positions, compliance requirements, reporting, and quality specifics, subject to coordination regarding regulatory organisations such as the National Committee for Quality Assurance (NCQA), URAC, and the Centers for Medicare & Medicaid Services (CMS).
Benefits & Risks of Delegated Credentialing
Delegated credentialing can have several essential advantages to healthcare organisations looking to simplify provider enrollment:
Benefits
- Efficiency and Speed: The credentialing services that are delegated tremendously reduce the amount of time needed in the process of payers credentialing their providers. Delegation can reduce this to 30-45 days, with the traditional model taking 120-160 days, which allows provider onboarding to be faster and revenue to be quicker as well.
- Streamlined Administrative Workload: It consolidates the work of credentialing in a selected organization (e.g., hospitals or managed services organisations) and eliminates excessive paperwork by the provider (when cooperating with many plans or many facilities). This eliminates wastage of time and errors, and it will relieve administrative resources.
- Guarantee of Compliance: Specialist Credentialing: Organisations to which compliance is delegated may have special accreditation and experience in credentialing that assures compliance with ever-changing state and federal guidelines, with the establishment of NCQA, URAC, and CMS, etc.
- Enhanced Provider and Patient Satisfaction-The process of credentialing takes less time, which gives providers more time to see patients, leading to improved access and patient satisfaction as well as workforce stability in healthcare organisations.
- Operation Control and Transparency: The delegated organisations would be in better control of operations related to credentialing processes; they would be able to proactively manage processes and monitor the quality in a constantly controlled manner.
Risks
Complexity, oversight, and management needs: Delegated credentialing requires robust management structures to adhere to accreditation, payer compliance, and quality surveillance. Failure to exercise proper supervision may result in error or non-compliance.
- Contractual and Legal Requirements: The delegated body continues to have a high level of responsibility to verify the provider as well as protect the patient about their protected health information (PHI), including addressing the legal aspects under laws like HIPAA. There are legal liabilities in case the standards are not met.
- Unfit for Everyone: Smaller medical practices can become exempted because of the inability to fulfil payer volume needs or accreditation standards, restricting their task of delegation, and requiring access to MSOs or IPAs.
Which Payers Allow Delegated Credentialing?
Larger health plans and insurance companies that have the infrastructure and resources to audit and trust the credentialing process of a healthcare entity generally approve delegated credentialing. Indemnity payers who do delegated credentialing usually are:
- Prominent statewide health care arrangements, e.g., Aetna, Cigna, and Blue Cross Blue Shield
- Preferred Provider Organisation (PPOs)
- Accountable Care Organisation (ACOs)
- Specialty provider networks
- Independent Physician associations (IPAs)
- Payer-dependent and region-specific policies include Medicare and Medicaid programs (guidelines)
These payers give their designated permission to hospitals, health systems, management services organisations (MSOs), or credential verification organisations (CVOs) to conduct credentialing on their behalf. It entails the payer auditing the credentialing processes of the healthcare organisation, which, in the case of being rigorous and compliant, can grant delegation authority.
Requirements to Qualify for Delegated Credentialing
Delegated credentialing requires high standards that require strict criteria to be met by the healthcare organisations, payers, and regulatory accreditation bodies. These needs warrant that the given delegated entity can perform credentialing activities with quality, compliance, and supervision. The usual core qualifications are:
- Accreditation: An organisation is typically required to be accredited by organisations like the National Committee for Quality Assurance (NCQA) or the Utilisation Review Accreditation Commission (URAC). Accreditation is a sign of fulfilling the set standards in credential quality and accountability of operations.
- Policies and Procedures in Place: The entity needs to have excellent and well-documented policies and procedures that abide by the payer and regulatory requirements. They should encompass the entire credentialing process, including initial credential, primary source verification, continuing surveillance, and re-credentialing.
- Credential Verification Expertise: The delegated organisation must demonstrate the ability to confirm important provider information such as licensure and DEA registration in the state, controlled substance certification, specified board certifications, education and training, malpractice and liability claim history, work history, accreditations, sanctions, and attestation statements.
- Compliance with Information Security and Privacy: Systems should be established to protect the security of the protected health information (PHI) according to all of the laws and regulations created by law, such as HIPAA, and guarantee the privacy of the information during the credentialing process.
- Monitoring and Quality Oversight of Performance: The organisation should institute regular audits, monitor the turnaround times and credentialing errors, use corrective action plans, and provide performance reports to payers. This involves a pre-assessment delegation testing by payers to test readiness for this process and regular post-delegation auditing.
- Scale and Efficiency: Many payers also require the organisation to credential a sufficient number of providers (usually 150 or more) to permit delegation, which will be enough to scale and efficiently manage its operations.
- On-Official Delegated Credentialing Agreement: A Formal delegated credentialing agreement requires a formally signed contract to be agreed upon by each payer that contains roles, responsibilities, compliance obligations, reporting obligations, and audit.
Implementation Steps for Delegated Credentialing
The successful implementation of delegated credentialing needs a systematic way to fulfill compliance, quality, and efficiency. The following are the main steps that healthcare organisations tend to follow:
1. Design an IC program
Develop and record a credentialing program in adherence with state, federal, and payer-specific regulations. This involves the drafting of bylaws and policies, which include the manner through which credentialing applications are handled, and the manner of carrying out primary source verification (PSV), as well as how the ongoing quality control shall be undertaken. Enlist the essential stakeholders, including the medical staff services department, quality assurance, and credentialing committees, to aid these functions.
2. Sample a Pre-Delegation Test
The credentialing capabilities of the organisations, policies, staffing, and performance of your organisation will be assessed by the payer health plan in a formal process. This establishes a commitment to manage sub-delegated tasks and, in many cases, it also has to conform to other norms such as NCQA or URAC.
3. Negotiate and sign the Delegated Credentialing Agreement
Get to agree with each payer to formulate a legally binding agreement with them. The sharing of the credentialing responsibilities, reporting (usually semiannual reporting), performance tracking, and relief, authority to make the final decisions retained by the payer, and compliance with privacy policies about protected health information (PHI) are among the Key points that this contract should clarify.
4. Carry out Credentialing activities
When the agreement is reached, credentialing activities become the job of your organisation or of a Credential Verification Organisation (CVO) that you designate. This includes the verification of the qualification of the providers, document handling, and the provision of updated provider rosters to payers frequently, mainly every month. Rosters monitor the information of the providers, such as status changes, addresses, and billing details.
5. Continuous Monitoring Quality Assurance
Check credentialing processes and performance regularly to make sure that compliance and accuracy have been observed. Move to take corrective steps where they are required and be ready to audit and continue conveying open communication with payers. Frequent performance audits and quality reviews assist in creating delegated status and trust.
Conclusion
Delegated credentialing is an innovative solution for healthcare organisations that want to manage their provider enrollment process, reduce administrative tasks, and speed up the time to get care. A payer and a provider both benefit from shifting credentialing to qualified and accredited partners who can increase efficiency and assure compliance. Nevertheless, effective delegation requires solid preparation, such as addressing payer-specific requirements on qualification and having strong compliance mechanisms.
When applied through robust credentialing infrastructure, transparent contracts, and quality assurance measures, healthcare organisations can tap into a significant operational benefit and be ready to scale in a rapidly evolving healthcare economy. Not perfect for all providers, particularly those at the smaller practices, delegated credentialing, either itself or through partnership with MSOs or IPAs, presents an attractive way forward in the steady handling of the credentialing process.
Finally, the adoption of delegated credentialing also allows medical organisations to concentrate on the quality-of-care provision and ensure that the processes of credentialing are at the highest level and regulatory compliant.
FAQ - People Also Asks
Can Small Practices Use Delegation?
Small practices are not usually directly qualified to be in delegated credentialing because of various payer site requirements that include minimum provider volume and accreditation requirements. They can, however, benefit through membership of an MSO or IPA with delegated credentialing agreements, whereby the smaller groups can tap into streamlined credentialing remotely.