Delegated credentialing can feel intimidating to both new and seasoned MSPs in managed care, hospital, or CVO environments. But the intimidation is replaced with confidence once you understand the foundations of the delegated credentialing process. Here are the six steps necessary for successful delegated credentialing:
- Facility contract: The group or facility must have an existing facility contract with the health plan or provider network. While the contract has nothing to do with credentialing itself, it contains the fee schedule and is the basis for the relationship between the two entities. A delegated credentialing agreement can’t exist without first having a facility contract. In addition, there must be an established process in place that outlines the eligibility criteria of the group or facility to enter into a delegated credentialing agreement.
- Credentialing policy and procedure audit: During the first part of the pre-delegation audit, the health plan or provider network evaluates the group’s or facility’s policies and procedures for compliance with regulatory and accrediting bodies like NCQA, URAC, or CMS managed care. This evaluation determines if the group is in full compliance or close compliance with standards and regulations. Managed care standards are extremely prescriptive regarding policy language and procedures, so it’s critical to see where there might be gaps.
- Credential file audit: Once the policies have been reviewed and the group or facility has agreed to make any necessary policy changes to be in compliance, the health plan or provider network conducts the second part of the pre-delegation audit, namely the credential file audit. Typically, the audit encompasses 10 randomly selected initial credentialing files and 10 randomly selected recredentialing files. Each file is reviewed for compliance with the relevant standards. If the files are in full compliance or there are readily fixable minor issues, the group or facility generally moves forward for review and approval by the health plan or provider network.
- Credentials Committee: Once the pre-delegation audit is complete, the health plan or provider network presents the results to its Credentials Committee. Recommendations are made to the Credentials Committee for approval to move forward with the delegated credentialing agreement or approval with conditions. Conditions outline a prescribed time frame for the group to submit a corrective action plan addressing the deficiencies identified during the pre-delegation audit. The contract can’t be signed until the pre-delegation audit is complete and the Credentials Committee makes the decision to enter into the delegated credentialing agreement with the group or facility.
- Delegated credentialing agreement: The delegated credentialing agreement is a mutually-agreed upon written document that outlines the credentialing responsibilities of each party. Sometimes everything is delegated while, other times, some functions remain in-house. The agreement also contains language that the group or facility must remain in compliance with managed care standards, termination rights of each party (with or without cause), and required reporting. The required reporting includes what needs to be reported, the format in which it must be reported, and to whom it must be reported. Required reporting includes semiannual credentialing activity and complaint monitoring, and annual credentialing system control monitoring.
- Oversight: Once the delegated credentialing agreement is signed by both parties, the organization is required by the standards to conduct continual oversight. NCQA and CMS require an annual review, while URAC requires a review every three years. The oversight consists of a review of the credentialing policies and procedures, as well as a random sample credential file audit. The results are presented to the health plan or provider network’s Credentials Committee. Failure to comply with the required reporting or to participate in the oversight audits places the group in a breach of contract status and leads to termination of the delegated credentialing agreement.
Delegated credentialing confers several benefits to health plans and provider networks. For the physician, group, or facility, it reduces duplication of effort and provides a shorter turnaround time to be on par with the health plan or provider network. For example, the time frame may be two weeks instead of three to six months. For the health plan or provider network, delegated credentialing reduces in-house credentialing numbers and standardizes processes, and members receive in-network benefits more quickly. Understanding the process removes the intimidation factor and creates the road to success.