Hospitals, health systems, and delegated credentialing
Editor note: The following is an excerpt from Managed Care Credentialing: Compliance Strategies for Health Plans, CVOs, and Delegated Entities by Amy M. Niehaus, MBA, CPMSM, CPCS. For more information, click here.
The healthcare industry continues to evolve, and many healthcare systems and hospitals are seeking opportunities to become more fully integrated and achieve greater efficiencies among their various facilities, departments, and functions. For example, integration between medical staff services and enrollment for a hospital’s employed practitioners is increasing due to the similarity in information required for both processes. A growing trend to further streamline provider enrollment is for hospitals and health systems to seek delegated credentialing from commercial payers on behalf of their medical groups or other provider organizations, such as a physician hospital organization or independent practice association.
Hospitals and healthcare systems that obtain delegated credentialing from health plans have the opportunity to gain more efficiency and improve their revenue cycles. Establishing credentialing policies and procedures that are also compliant with NCQA, URAC, and/or CMS provides healthcare organizations with a mechanism to streamline the provider enrollment process for their employed practitioners. Most often, the employed practitioner’s approval date with the organization becomes the participation start date with the plans, allowing reimbursement for services much earlier than with a traditional enrollment process. Delegation can positively affect an organization’s revenue cycle by reducing the uncollectable accounts receivable or claim holds that stem from delays incurred while health plans perform their own credentialing process after the practitioner has already been credentialed at the hospital.
There are many components that hospitals need to evaluate when considering whether to pursue delegated credentialing with commercial payers. Medical staff bylaws and credentialing policies are not typically designed to meet the accrediting and regulatory requirements of health plans and may require updates to achieve compliance. Although there are many similarities between hospital and health plan verification processes, such as elements verified and sources used, there are other requirements that are unique to managed care accreditation standards that must be documented, such as specific verification time frames, practitioner notifications and rights, nondiscrimination, and methods to monitor and prevent discrimination.
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