Delegated Credentialing Expedites Provider Enrollment

Manually enrolling a single provider in a health plan can take anywhere from 3 months to 12 months.
 

Delays in provider enrollment are extremely costly. Every month enrollment is delayed, physician practice groups and health systems lose an average of $100,000 for a single primary care provider. For specialty care, the losses are even more staggering at $300,000 per physician per month.  

If you have more than 100 providers in your provider group, entering into a delegated credentialing contract with insurance payers can speed up the enrollment process so your providers can start seeing patients and getting paid sooner. Delegated credentialing occurs when a healthcare entity gives another healthcare entity the authority to credential its practitioners. Insurance payers delegate specific components of the credentialing process to provider/hospital groups that evidence the appropriate infrastructure, resources, and personnel to support this critical function. This is in contrast to non-delegated credentialing, where the payer completes the credentialing and enrollment process  

Benefits  

Faster enrollment and reimbursementDelegated credentialing reduces the time it takes for a payer to grant the Provider Identification Numbers (PINs) and Effective Dates for membership into the payer’s panels. Faster network participation means that providers get reimbursed sooner.  

More efficient enrollment processDelegated credentialing reduces the administrative burden of submitting hundreds of provider applications individually. Instead, all providers can be added to a single roster and submitted to the payer at one timeTracking and reconciliation processes are also easier with delegated credentialing.  

More control over provider data. Delegated credentialing allows organizations to have more control over how the network is reflected in payer directories. Demographic updates and network participation changes are efficiently handled through rosters, ensuring provider data accuracy.  

Greater provider and patient satisfaction. Faster onboarding means that providers can start doing what they love to do—taking care of patients—several weeks sooner. And patients benefit from receiving that care without the burden of surprise billing.  

How to implement a Delegated Credentialing Contract: 

Develop an internal credentialing program that is compliant with state, federal, and payer regulations. The program must include policies and procedures that prescribe how applications are handled, Primary Source Verifications (PSV) are conducted, and ongoing monitoring is implemented, and that demonstrate that a quality oversight program is in place to ensure the success and improvement of the program. You’ll need the proper operational infrastructure, resources, Peer Review Committee, and personnel to support the credentialing function.  

Before signing an agreement with a potential delegate, a health plan will evaluate the delegate’s ability to perform credentialing tasks. The evaluation includes reviews of the delegate’s policies, procedures, and files and an assessment of the delegate’s staffing and performance levels. Most health insurers will require that a delegate’s processes and procedures comply with National Committee for Quality Assurance (NCQA) standards and guidelines before they agree to delegate credentialing. 


Negotiate and enter into a delegated contract with your payer(s) 

You will need to negotiate each delegated credentialing contract individually. The contract will specify the roles and responsibilities of each party and the activities being delegated; the reporting frequency (at least semiannually); a performance evaluation process; use of Protected Health Information (PHI); and the right of the health plan to make final decisions. Fee schedules (if a higher rate is negotiated) will also be included. 

The credentialing software matters. 

Choose the right credentialing software to manage your data and delegated contracts, build your delegated rosters, and submit them to your payer(s). Each payer may have a different format pertaining to its delegated credentialing roster. 

After the delegated credentialing agreement has been signed, your organization will be responsible for verifying provider credentials and sending the payer an updated provider roster on a regular basis (usually monthly). Rosters include information on changes of status, address, billing information, and any new or terminated providers. When a health plan receives a roster update, a new provider is considered to be “Participating” in its network and is therefore eligible for reimbursement. Payers will perform yearly audits to ensure that policies and procedures are being followed and meet NCQA standards. 

Entering into and successfully running a delegated credentialing contract program is a significant undertaking. Partnering with an organization that has the expertise to help develop the program and provide the credentialing services will alleviate the administrative burdenAnother important consideration is working with an organization that is NCQA Accredited in Credentialing. Credentialing Services Organizations with NCQA Accreditation in Credentialing go above and beyond credentials verification to handle the entire credentialing and re-credentialing process and monitor provider performance between credentialing cycles. 

TractManager is the nation’s first and only Credentialing Services Organization with an integrated Contract Lifecycle Management solution to achieve NCQA  Credentialing Accreditation. TractManager’s Credentialing and Enrollment solution reduces enrollment timeframes from 60–90 days to 30–45 days through a delegated contract.  

To learn more about our credentialing solution, download our “To Delegate or Not to Delegate” white paper.

Author:

Anna Arutyunyan

Vice President, CVO, Provider Management

Anna has extensive experience in the development and implementation of full-scope credentialing programs.

 

To Delegate or Not to Delegate – That is the Credentialing Question

Realize improvements in the processes that govern the growth and representation of your network, shorten turnaround times for network participation, enhance provider experience and brand integrity, and expedite access to revenue.

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