local plans are similarly strapped for resources, so delays have become more common than not. Once thought to be the solution to redundancy and high credentialing costs, use of the Council for Affordable Quality Health Care (CAQH) Universal Provider Datasource has not resulted in shorter enrollment turnaround times. The credentialing process remains painfully slow, and an initial plan enrollment can take six months or longer. Credentialing a provider can be completed in a matter of days or weeks, but only if there is motivation to do so. Groups and integrated entities are far more motivated to conduct an expedited credentialing for their own providers, and many do so by pursuing delegated credentialing. We suggest that you develop a comprehensive provider credentialing program to prepare you for delegated credentialing as a natural progression in mature payor relationships. Adopting credentialing standards, establishing a review process, conducting ongoing monitoring, and putting providers on a rigid re-credentialing cycle are part of every quality program adopted by health plans, networks, hospitals, and other facilities and could easily be part of yours. Provided the credentialing program meets the requisite standards, IPAs, ACOs, and similarly integrated delivery models are perfectly positioned to take on the responsibility for credentialing. Everybody Credentials … Why Shouldn’t You? Health plans, networks, government payors, hospitals, and other facilities have always credentialed providers in accordance with standards set forth in bylaws or policies and procedures designed to meet regulatory or accreditation requirements. Specific credentialing measures, primary source verification, sanction monitoring, and the frequency of re-credentialing are just some of the requisite components of all programs developed to review licensed practitioners FEATURE STORY THE JOURNAL OF THE HEALTHCARE BILLING AND MANAGEMENT ASSOCIATION 9 in a standardized and objective manner. PAYORS CREDENTIAL: As discussed, health plans have accepted that credentialing, while a National Commission for Quality Assurance (NCQA) accreditation requirement for ensuring network quality, carries a high administrative price. If they offer Medicare or Medicaid managed care products, they must also follow requirements set forth by the Centers for Medicare & Medicaid Services (CMS) and those of the states in which they operate. Federal Medicare and state Medicaid programs have recently enhanced their credentialing programs and added re-credentialing requirements as required by the Affordable Care Act as a means of combating fraud. FACILITIES CREDENTIAL: Hospital medical staff offices (MSOs), nursing homes, surgery centers, and other facilities conduct provider credentialing programs as mandated by The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and state and federal regulatory bodies. While there are specific components unique to JCAHO requirements, such as peer review and clinical performance, the basic process of assessing a provider’s credentials is similar to those employed by health plans and networks. LARGE GROUPS CREDENTIAL: Large groups, faculty practice plans, and staffing agencies have been developing comprehensive programs for the credentialing of their own licensed providers to prepare for delegation or as part of a comprehensive quality management program. An ACO or similarly integrated model should be no less rigorous when defining and enforcing a standard level of provider quality. In addition to having the right to represent that a group meets industry standards for training, licensure, and the absence of sanctions, forward-thinking groups have taken a meaningful step in preparing for delegation. A comprehensive credentialing program complete with primary source verification of credentials positions the group to take advantage of delegated
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