Delegated Credentialing for ACOs and Other Integrated Delivery Models IS DELEGATED CREDENTIALING IN YOUR FUTURE? By Jackie Mayer, MHA As groups merge to create large, clinically integrated delivery models, such as independent practice associations (IPAs), accountable care organizations (ACOs), and patient-centered medical homes, clinical and technological integration to improve outcomes and reporting are at the forefront of discussion. What has been put in place to increase care coordination and reduce costs for Medicare beneficiaries also results in lower costs for the non-Medicare population, providing opportunities for payor-contract negotiations. Large, integrated groups have also found opportunities to leverage size, covered lives, and efficiencies to revisit commercial health plan contract rates. When you revisit reimbursement models and negotiate Replacing the traditional provider enrollment (credentialing) model with delegated credentialing – earning the formal approval of payors to credential your own providers – can decrease denials, practice disruptions, and internal referral roadblocks. group agreements, consider seizing the opportunity to take control of the credentialing process. Replacing the traditional provider enrollment (credentialing) model with delegated credentialing – earning the formal approval of payors to credential your own providers – can decrease denials, practice disruptions, and internal referral roadblocks. To make this work, you will need a program to review and monitor providers’ credentials within your organization. The good news? It does not have to be difficult or expensive. The Cost of Credentialing Delays Credentialing delays are expensive. Once your group has recruited 8 HBMA BILLING • JULY.AUGUST.2014 the very best practice, physician, or midlevel practitioner to add value to your entity, the onboarding process can come to a screeching halt by a three- to six-month wait for plans to complete the credentialing process. Plan enrollment remains labor intensive with few shortcuts. Yet, practices and their larger integrated entities need to maintain participation in a wide range of plans to remain competitive and to facilitate scheduling, coverage, timely payment, and, most importantly, keeping referrals within the entity. Practices have become accustomed to devoting extensive resources to the fragmented process of enrolling providers in health plans or awaiting demographic updates, even when a credentialed provider is simply changing groups. Credentialing delays continue to hamper a group’s ability to quickly onboard a new hire with the seemingly endless wait for their colleague to move through the credentialing process to committee. The price you pay is lost revenue, unhappy patients, delayed payments, out-of-network services, and denials, combined with coverage and referral issues. So, why does the credentialing process take so long? Credentialing, while a necessary quality process for health plans, does little to impact group sales or control medical costs. Pressure to rein in administrative costs has led to centralized credentialing functions and reductions in local market staff. In a large market with a high concentration of providers and mature networks, it is a rare luxury to have your client’s application expedited. Smaller
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