credentialing following the lead of many successful groups over the past 15 years. You may even be surprised to know that your clients already have many of the components of a credentialing program built into their current processes. A Group Credentialing Program Readiness There are key requirements for a successful credentialing program, many of which can be met by tweaking existing processes and adding tasks. Groups need standardized information gathering from their provider members (application and attestation), primary source verification of credentials, policies and procedures for all aspects of the program, and a credentialing committee. Formal communication to group members on committee decisions is also required. The group will credential all providers at the start of the program (initial credentialing) in accordance with approved policies and procedures and will credential all new providers as they join the group. They will then need to be re-credentialed no later than 36 months from each provider’s committee approval date. Between credentialing cycles, each provider is monitored to ensure they have not been sanctioned by Medicare, Medicaid, or any state medical board. Once the credentialing program is operational, it is time to approach all payors (except Medicare fee-for-service and state Medicaid fee-for-service programs) and request a review of the program for delegation. We are often asked whether a group must have specific language related to credentialing in their participant contracts in order to bind group members to the credentialing program. The response is that they most likely do not. Most agreements are vague in detailing the obligations of each party, yet all will likely require that members comply with groups’ administrative requirements. ACO contracts most likely require that participants: • adhere to policies and procedures • remain free of sanctions throughout their affiliation • remain licensed to practice without restrictions Depending on the level of information the group collects from its members, some form of an application – a consent for the group to access primary sources such as the National Practitioner Data Bank (NPDB) on their behalf and an attestation to the integrity of the self-reported information – will be required. An existing governing body or a subset of a board of directors, which is representative of the group’s specialty composition, can provide the structure for a credentialing committee. The group’s policies and procedures will need to be enhanced to add credentialing policies and procedures, and they will have to be reviewed and periodically modified to meet the changing 10 HBMA BILLING • JULY.AUGUST.2014 needs of the group. This includes a process for the group to take action when members do not meet the organization’s standards. If your client groups have the ability to bind members to the program, adding some structure and processes allow the foundation to formalize a credentialing program in preparation for delegation. What is Delegated Credentialing? Delegated credentialing is the process by which a health plan (or any other entity responsible for credentialing) agrees to turn over a portion of their credentialing review process to a qualified entity; it must provide oversight over the delegate for ongoing adherence to program requirements. The delegated credentialing process is repeated with each plan and involves three key components listed below: • The delegation agreement outlines the responsibilities of Newly Minted (continued on page 12) Members Lydia Bailey Killeen, Texas, Integrated Health Management Dustin Cragun Bountiful, Utah, Alta Billing Service Byrd Evans Austin, Texas, Agnite Health, LLC Joni Grimsley Sioux Falls, South Dakota, eProvider Solutions James John Rockville, Maryland, VitalAxis Inc. Abeer Linton Rancho Cucamonga, California, A Plus Medical Billing Services Omar Perez Miami Lakes, Florida, Intermedix Holden Pierre-Louis Potomac, Maryland, BPOSS, LLC Jesus Rueda New York, New York, CloudRev Medical Adelina Taraborelli Philadelphia, Pennsylvania, Medical Billing Inc. of Delaware Valley Linda Thomas Pittstown, New Jersey, Ambulance Billing Co., LLC
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