Thought Leadership

New Perspectives To Improve the Credentialing Industry

Q&A: Is Delegated Credentialing Right For Your Organization?

Allyson Schiff, Vice President of Operations, discusses the role of delegated credentialing and whether it is right for your organization.

Q. What is Delegated Credentialing?

A. Delegated Credentialing is the process that insurance payers go through to delegate the Primary Source Verification process to a provider organization in exchange for changing the provider enrollment process from a paper based process to a roster based process.

Most payers will only enter into a delegated credentialing contract with provider groups that have greater than 150 providers in their group.

Q. What are the primary steps needed to be taken to obtain a Delegated Credentialing Contract?

A. While entering into and successfully running a Delegated Credentialing Contract program is a significant undertaking, the following are a few high level concepts that you will need to consider:

1. Negotiate and enter into a delegated contract with your payer(s). Each contract will need to be individually negotiated and will include the service level agreements / requirements that the provider group and payer(s) need to follow. Fee schedules (if a higher rate is negotiated) will also be included.

2. Build and run (or contract with) a Credentials Verification Organization (CVO) operation within your organization that conducts the Primary Source Verification (PSV) services required by your Delegated Credentialing Contract. While some provider groups have their medical staff services department run their PSV services, there is a growing trend of out-sourcing or conducting the PSV services within the provider enrollment department. The policies and procedures of the CVO will have to be approved in conjunction with the payer(s).

3. Choose the right credentialing software to manage your data and delegated contracts, build your delegated rosters and submit them to your payer(s). Please note, each payer may have a different format pertaining to their delegated credentialing roster.

4. Ensure timely reconciliation of the returned delegated rosters to ensure that the payer(s) have processed all requests correctly.

5. Yearly audits will be performed by the payer(s), and will directly affect the CVO – policies and procedures will be tested to ensure the upkeep of the work is being completed.

Q. What are the benefits of Delegated Credentialing?

The benefits are significant. The primary benefit can be the reduction in the time that it takes for a payer to grant the Provider Identification Numbers (PINs) and Effective Dates for membership into the payer’s panels. Other benefits include roster based enrollment (meaning all providers can be added to a single roster and submitted to the payer instead of sending individual applications for each provider), as well as easier tracking and reconciliation processes.

While entering into a Delegated Credentialing Contract program is a significant undertaking, the benefits can significantly improve your organization’s efficiency, patient satisfaction scores, and profitability.



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