Is delegated credentialing right for my provider group?

Credentialing is one of the most important things any medical group does outside of treating patients, and in some instances, it’s also one of the most difficult things. The right software for credentialing can simplify your day-to-day processes greatly and allow you to do things in a much smoother fashion. As a result, it’s worth establishing a delegated credentialing agreement to benefit your employees, your facility, and the patients in your care.

When partnering with a delegated credentialing firm, any entity will want to place their individual providers on the health insurer panels. This is because they’re eligible for reimbursement, which can speed up the collections process. Especially given length of time that’s typically associated with credentialing. Many hospitals and physician groups already have credentialing and review policies in place. However, adjustments are often necessary in order for an insurer to agree to a new credentialing policy, as a result of certain legal and regulatory requirements.

The financial costs of not having proper credentialing can be staggering. If you have a medical group with a new physician on board, and after onboarding you submit their enrollment to a health plan to credential a provider, that can take up to 90 days. And if you figure a busy provider can generate up to $5,000 per day in billing, that’s nearly a half-million in revenue to your practice that is at risk.

There are always questions when it comes to changing up credentialing providers (or anything in health care, for that matter). So we’ll try to answer some of the basic ones for you as you determine what the best course of action for your provider group is.

What is delegated credentialing?

When a health care entity gives another entity the ability to credential its practitioners, it’s known as delegated credentialing. Delegated credentialing goes beyond the verification of credentials because the delegated entity, such as a hospital or practice, is responsible for evaluating the qualifications of the practitioners and then making credentialing decisions on behalf of the delegating health care entity, such as a PPO.

How can I get started with delegated credentialing?

Implementing delegated credentialing isn’t easy said as done. There are many things that need to be done, even though health plans are usually eager to delegate credentialing work out because they then see lower administrative costs. The two things that are paramount are as follows:

1. In-house credentialing process implementation. Before you sign an agreement with a delegate for the credentialing, a health plan must have a full evaluation of the delegate’s capabilities so they can see the credentialing tasks handled. This includes a written review and delegated tasks, a review of policies, procedures and files. Additionally, the delegate’s staffing and historical performance must be assessed. When it comes to delegated credentialing, most insurers require that a delegate’s processes and procedures are compliant with NCQA Standards and Guidelines. NCQA Credentialing Accreditation signifies that your practice has an efficient and accurate process that verifies practitioner credentials through a primary source, and has a designated credentialing committee in place along with any local or state requirements.
2. Delegation agreement. A delegation agreement is a legal document that spells out the specific responsibilities of each partner, including the roles of each party and their responsibilities; the reporting frequency and performance evaluation processes; as well as any legal or potential remedies for non-compliance and the rights for final decisions between the parties.

Once a delegation agreement is finalized and all the other steps are completed, the organization that is responsible for the credentialing will send an updated provider roster on a regular basis to make sure all information is continually updated. It also ensures your health group is eligible for reimbursement, if and when any changes are made.

What are the benefits of delegated credentialing?

Delegated credentialing presents an array of benefits. The foremost benefit of delegated credentialing from a medical group practice’s perspective is eliminating weeks from the provider enrollment process. This is because a reduced turnaround for network participation means timelier reimbursement from payers. Delegated credentialing can also increase both practitioner and patient satisfaction, as your new providers can put their expertise to work and your patients benefit from that care.

Med USA understands that each practice is unique when it comes to its requirements for credentialing services. That’s why we create customized solutions including management and oversight services, initial hire packet and enrollment designs, provider and group enrollment assessments, CAQH maintenance and updates, Medicare and Medicaid enrollment, out of state and regional payer enrollment services, address services and facility address updating. In addition, we’ve developed a proprietary Provider Enrollment Packet to facilitate the gathering of required provider information and documents to credential a new provider as expeditiously as possible.

We’ve been privately owned since 1979 and offer world-class service accelerated by software that can make a difference. Find out more today on how we can connect and become terrific partners by clicking here.