Credentialing & Privileging

Achieve Success With Delegated Credentialing

By Chris Hinton, CPCS, CPMSM; and Marlene Yates, RN, MSN, CPMSM, CPHQ

Delegated credentialing is the term used when a health plan (or other entity responsible for credentialing) agrees, through a contractual arrangement, to entrust the credentialing process (or portions thereof) to a qualified credentialing organization such as a hospital medical staff office. Delegated credentialing is not a new concept, but it is one that few have taken advantage of until recently.

To be successful, delegated credentialing requires dedication, commitment, research, and a great deal of hard work. So, you may ask, why would a medical staff office choose to become a delegated entity? Benefits of delegated credentialing to the provider, their organization, and most importantly the patient include the following:

1. Once the credentials file is approved by the organization’s credentials committee, the provider is added to the health plan’s payer panel. This ensures that the provider is paid for the services they have billed.
2. The organization no longer has to wait on the health plan to credential and approve the provider (which can take months!) because the health plan has “delegated” this activity to the organization.
3. Overall, this provides an increase in satisfaction for the patient, provider, organization, and facility personnel. The provider can begin to see patients earlier, thus improving access to much needed healthcare for those in the community being served.

As previously mentioned, this process requires a lot of work but can be accomplished through the diligence of a dedicated MSP.

The basic steps in the process are as follows:

1. Identify your resources. Partnering with the organization’s payer enrollment, legal, and managed care contracting teams is very important because of their expertise with health plans and the regulations involved. They also can help determine the feasibility with various health plans based on their knowledge of the local market. These resources will know the key contact for each health plan and can pave the way with relationships.
2. Network with those who have gone before you. We have a great network of MSPs, and many have already gone down this path. Start with your local or state association, because they most likely will be working with the same health plan representatives and can provide you with best practices, helpful policy hints, procedures, and more.
3. Develop an appreciation of NCQA and URAC standards, in addition to TJC and CMS standards. Take advantage of the numerous continuing education opportunities within NAMSS and the accreditation organizations to help you navigate the standards and requirements.
4. Obtain health plan audit tools. Many health plans have requirements that go above and beyond the regulations of NCQA, URAC, TJC, and CMS. Obtaining their audit tools will assist you in policy development and enhance your compliance with their particular plan. Your managed care contracting departments can often obtain these for you.
5. Develop departmental policies and procedures specific to delegated credentialing. Many organizations have policies and procedures in addition to medical staff bylaws, rules, and regulations. These are typically written to address TJC and CMS. There are specific nuances to the policy requirements of NCQA and URAC. These subtle differences must be included in your policies.
6. Prepare for pre-delegation audits. To determine if the organization is eligible for delegated credentialing, the health plan will perform a review of policies and procedures prior to the review of credential files.
7. Anticipate delegation audits. If the policies and procedures in the pre-delegation audit meet the required specifications, the health plan representatives will request an audit of the credential files of their enrolled participants. If the credential files meet the health plan’s requirements, then a delegation to the organization will occur. Once delegated credentialing is in place with a particular health plan, audits occur annually as long as a valid delegation agreement is in place. A vast majority of the audits are performed virtually.

Issues that may deter the implementation of a delegated credentialing program include the necessary staff power needed for starting up, continuous audit requirements, and the re-purposing of payer enrollment staff that will no longer be needed, with the exception of Medicare and Medicaid enrollment.

With the implementation of a delegated credentialing program, there is much opportunity to increase a medical staff office’s operational aspect and directly and favorably impact the organization’s revenue cycle. Through NCQA and URAC standards, health plans can be assured that organizations maintain a high-quality network for members and contracted clients.

This article appeared in the September/October 2019 issue of Synergy. 

Chris Hinton, CPCS, CPMSM, is the chair of the NAMSS Education Committee and incoming NAMSS Secretary-Treasurer.

Marlene Yates, RN, MSN, CPMSM, CPHQ, is the system wide director for medical affairs for Cone Health in Greensboro, North Carolina. Her responsibilities include oversight of the credentialing, privileging, and quality performance of the Cone Health medical and dental staff and oversight of delegated credentialing for the Cone Health Medical Group, Triad HealthCare Network (ACO), and the newly implemented Medicare Advantage insurer, Care N Care of NC.