provider agreement (and sometimes both). Delegation only addresses the credentialing component of the plan participation process. How Does Delegated Credentialing Streamline Plan Participation? Under the traditional credentialing enrollment scenario, a plan receives a provider’s application, an online request for participation, or a form to authorize the use of CAQH to begin the credentialing process. The plan reviews the credentialing documents and verifies data on the application related to training, work history, licensure, and all other aspects of the provider profile using primary sources. Once reviewed and verified, the file will be brought to the plan’s credentialing committee. This process can take three to six months, or longer, depending on the plan’s workload and motivation to add new providers to its network. Delays can occur from credentialing documents expiring in the process and lost or neglected applications. If clarification is needed for any aspect of the application and a response is not received in a timely manner, an application can be rejected or returned. In this case, the onboarding of that sought-after fellowship-trained physician you fought to bring on board is now at risk of a start date delay or of practicing without plan reimbursement. Under delegated credentialing, the group collects all credentialing information and documentation upon hire (or at the start of the program). All information is then reviewed, and primary source verifications are conducted. The provider is presented to the credentialing committee and, once approved, is entered on the plan rosters for the next monthly submission. Depending on the individual plan (and the delegation agreement), following receipt of your roster, the new hire can potentially be considered “participating” THE JOURNAL OF THE HEALTHCARE BILLING AND MANAGEMENT ASSOCIATION 13 as early as the effective date they were approved by committee. The financial and patient access issues around delayed enrollment have been described above, but think of the ease of onboarding for your client’s new hire when information is requested only once for enrollment to be facilitated for nearly all plans. Start Today Take the first step by contacting all of your commercial, Medicare managed care, and Medicaid managed care plans, and request a sample delegation agreement and assessment form. Ask for their process and timeframes. Simultaneously, draft policies and procedures related to the credentialing process and identify a credentialing committee and a communication strategy to prepare group participants for any additional information or attestations that may be required. The group will need to contact NPDB to complete the application to become an approved organization. A cost-effective solution to creating a credentialing program is to contract with an NCQA-certified CVO to review provider application and documents, then perform primary source verifications and return each file for committee review without delay. The CVO will monitor all providers between credentialing cycles for the absence of sanctions. Keep in mind that your credentialing program must meet all NCQA, Medicare, and state Medicaid requirements while remaining cost effective. ■ Jackie Mayer has more than 25 years of experience in the healthcare industry. In 2003, Mayer started the Credentialing and Managed Care Division of Advanced Health Management Services (AHMS), a boutique consulting and practice management company that was acquired by MDeverywhere in 2011. In May of 2010, Mayer oversaw the successful creation of an NCQAcertified CVO.
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