Leveraging Delegated Credentialing to Enhance Revenue Cycle Management

Healthcare organizations must ensure that the providers they hire to render services have the appropriate training, skills, and licenses. In every organization that offers healthcare services, this healthcare professional evaluation process called credentialing, is undertaken. This process has several stages to ensure that the critical qualifications are satisfied. Delegating the workload in completing the healthcare provider credentialing may relieve the challenge of this labor-intensive and complex process.
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What is Delegated Credentialing?

Credentialing by Delegation is a situation in which a specific payor permits an organization, normally a larger health system, to complete the credentialing process in its own right. However, it is not enough to simply check the credentials. The health system, which takes up the role of the delegated authority, assesses the suitability of healthcare practitioners and makes the credentialing decisions for the payor. Although the health system performs all necessary steps to complete the credentialing process, the payor retains the right to veto any decisions made by the delegated entity.

For Delegated Credentialing to function, there must be a mutually agreed-upon arrangement outlining the obligations of each party, ensuring compliance with regulatory bodies such as the NCQA, URAC, and CMS, as well as federal and state laws. These delegation agreements can be standalone documents or amendments to existing contracts. The entity granted permission to perform credentialing is commonly referred to as the Delegated Entity, Delegate, or Client.

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Navigating Regulators and Delegated Credentialing

Several regulatory bodies are involved in or have a vested interest in delegated credentialing:

1. The National Committee for Quality Assurance (NCQA): The National Committee for Quality Assurance stands out as the foremost organization promoting accreditation in the health sector. Its primary purpose is improving healthcare delivery systems. The NCQA shows an evidence-based program for case-management accreditation that all payer, provider, and community-based organizations can use. Due to the importance placed on these standards, particularly in delegated contracts, comprehensive review by relevant entities is essential.
2. The Centers for Medicare & Medicaid Services (CMS): The Centers for Medicare and Medicaid Services (CMS) within the Department of Health and Human Services (HHS) supervises programs such as Medicare, Medicaid, Children’s Health Insurance Program (CHIP), and some elements of the Affordable Care Act (ACA). It is important to note that any organization rendering healthcare services as per these federal programs especially those wishing to outsource the credentialing process should be aware that CMS requires more than what the National Committee for Quality Assurance (NCQA) standards call for.
3. Local State Governments: In addition to federal and national standards, certain state governments may impose supplementary credentialing process requirements. These potential additions include mandated applications, the utilization of a designated organization for primary source verification, and the enforcement of specific turnaround times for completing the credentialing process.

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Ongoing Credentialing Responsibilities

Delegated credentialing can be achieved through two main methods:

1. A vital component of the credentialing process that can be delegated, is the outsourcing of the process to a Credentials Verification Organization (CVO). These entities are an arm of a healthcare unit's credentialing department but specialize in performing primary source verifications for their clients. 
2. Another form of delegated credentialing is setting up an internal Credentials Verification Organization CVO. This CVO would take charge of the verification process for every healthcare provider within the institution regardless of their location. This centralized structure would be responsible for conducting primary source verifications, and streamlining the credentialing process for the organization.

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Benefits of Delegated Credentialing

Leveraging an internal or external CVO to manage and centralize the provider credentialing process offers below strategic benefits:

1. Accelerated Payer Enrollment Timelines: Pursuing contractual agreements for delegated credentialing provides health plans with the ability to expedite the physician enrollment process. Traditionally credentialing of a provider would take a healthcare payer between 90-120 days, however, in using delegated agreements, such time issued can reduce to a mere 30-60 days. This shifts the gears to the quick onboarding of new providers hence they get to attend to patients and cut costs due to timely reimbursements. 
2. Medical Staff Efficiency: Beyond streamlining payer enrollment, delegated credentialing offers substantial benefits for an organization's medical staff. Currently, providers practicing at multiple facilities within the same healthcare system face the redundancy of undergoing credentialing at each location, essentially duplicating the verification effort. By centralizing the credentialing process through delegation, this burden is lifted from individual providers, allowing them to dedicate more time to crucial tasks such as privilege and board approvals. This improved efficiency translates to a more focused and productive medical staff.
3. Provider Availability: When there is no delegated credentialing, providers working in many healthcare organization facilities face a considerable amount of administrative work. Conventionally, each facility requires them to fill in the credentialing verification documents, which means that a lot of time and effort is wasted on a needless repeat of work. Consolidation of the activities of the centers through delegation of the credentialing process further removes this duplication and saves precious time of providers that can be utilized in more productive ways such as attending to patients and other critical activities.
4. Effective revenue cycle and reimbursements: Delegated credentialing offers a clear financial benefit for healthcare organizations by reducing the administrative burden on providers. By eliminating the need to complete separate credentialing paperwork for each facility, delegation frees up valuable provider time. This translates directly into an increased capacity to see more patients, which in turn leads to a higher volume of patient encounters. This growth in patient interaction directly correlates with increased organizational revenue and ultimately translates to faster reimbursements.
5. Increased Patient Satisfaction: The practice of delegated credentialing contributes to the enhancement of patients’ satisfaction levels since it assists in moving the processes of onboarding new providers. This process of credentialing can be time-consuming and thus slows down the provider’s ability to see patients. In a delegated agreement as opposed to asking each facility to complete individual credentialing tasks, the processes are coordinated and simplified; hence there is a reduction in the time taken for a new provider to get credentialed and start working. This translates to shorter wait times for patients seeking appointments, ultimately enhancing their overall satisfaction with the healthcare organization's efficiency.

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Conclusion

For healthcare establishments, there is an added perk of efficiency with the use of office credentialing that is faster and less costly. In this case, all the credentialing functions may be carried out within the organization or through outsourcing to task-specific organizations known as Credentials Verification Organizations, which would enable the healthcare entity to fasten the time taken to enroll with a payer, Physician practice management, and improve the access to providers. This method simplifies the process of getting providers on board, which in turn improves the satisfaction levels of the patients and also assists in sound revenue cycles and prompt payments. Complying with the regulation and as well realizing the importance of delegated credentialing in the management of an organization, a healthcare organization will concentrate more in offering health services to its patients rather than engaging in management issues hence better results are registered for both the patient and the provider.

If you are a healthcare provider and wish to learn more about delegated credentialing, feel free to write to us at partnerships@homrcm.com.
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