Delegated credentialing: 12 tips for building effective partnerships

This week, CRC Daily covers credentialing—a critical function across the care continuum.

When it comes to delegated credentialing, communication is key. Strive to share information and be available for any questions or feedback. The ultimate goal is for partners to work together as a team to achieve the maximum benefits of delegation. The following are additional, more targeted recommendations for health plans and delegated entities, respectively.

Health plans

• Predelegation assessment: Understand the entire flow of the potential delegate organization. This is especially helpful for large medical groups that may be part of a healthcare system and used to hospital credential­ing processes.
• Delegation agreement: Involve credentialing management early on in the contracting process to review the activities being considered for delegation. Use the delegated entity to its full potential by including all creden­tialing activities for which the delegated entity is qualified—it’s to everyone’s advantage.
• Accreditation/certification status: If a potential delegate is accredited or certified, less oversight is needed. Elements already reviewed and accepted by an accreditor do not require additional oversight by the health plan. Maintain a copy of the delegate’s current accreditation or certification in the delegate’s file to support surveyors’ review.
• Education: Ensure that credentialing staff are aware of what is included in the delegation agreement to expedite the preassessment and oversight audit. Inform delegates of any policy changes, and provide sufficient time to make necessary updates.
• Assessments: Perform a desktop review of policies, procedures, and committee minutes in advance of an on-site audit to help identify any potential areas of concern. Consider electronic file reviews, if available, to streamline the process. Give delegated entities sufficient notice of audits (e.g., 30 days). This practice may be required in the contract. Be as flexible as possible with the audit date to minimize the impact to the delegate’s schedule. Consolidate audits with other payers when feasible to minimize duplication.
• Surveys: Provide delegates with as much notice as possible about upcoming survey activities and any required involvement, such as a file audit or an interview.

Delegated entities

• Delegation agreement: Review the delegation agreement thoroughly to ensure that credentialing activities can be performed as expected. Maintain a detailed list of requirements for each delegation agreement held with payers, high­lighting the differences to ensure compliance.
• Ongoing quality assurance: Build and maintain credibility by executing a compliant and timely credentialing process. Create a process for files that do not meet clean criteria (i.e., that have red flags) and commu­nicate to the payers as appropriate. Inform health plans of any adverse issues with practitioners in a timely manner.
• Reporting: To promote consistency, create a standard reporting template that outlines all payer requirements.
• Assessments: Routinely audit files and the credentialing database to ensure accuracy of practitioner data. Review and prepare files in advance to facilitate audits.
• Surveys: Be accessible during health plan accreditation surveys.

Source: Credentialing for Managed Care: Compliant Processes for Health Plans and Delegated Entities

Looking for more delegated credentialing insights? 

Click here to read the November 2016 MSP's Voice column. First-time Credentialing Resource Center Journal contributor Laurel J. Yungwirth, CPCS, MHA, shares her hard-earned wisdom on the who, what, why, and how of forging productive delegated credentialing partnerships.