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Why Delegated Credentialing Matters in Healthcare? An Overview for Providers

what is delegated credentialing and their uses

What is Delegated Credentialing in Healthcare

Healthcare organizations must maintain high standards when credentialing providers, ensuring they meet all qualifications before delivering care. One effective method is delegated credentialing, a process that allows certain entities to handle credentialing responsibilities on behalf of healthcare organizations. This system improves efficiency but requires adherence to stringent standards and oversight.

What is Delegated Credentialing?

Delegated credentialing refers to the process by which healthcare organizations, insurers or networks authorize another entity to handle the verification and review of a provider’s qualifications, such as their licenses, certifications and professional background. Essentially, the credentialing authority is delegated to a third party vendor or another healthcare provider group. Delegated credentialing programs are becoming an essential part of healthcare organizations’ credentialing strategies, as they allow third-party vendors or healthcare groups to manage credentialing responsibilities, ensuring compliance and speeding up the process.

What is a Delegated Credentialing Entity

What is a Delegated Credentialing Entity?

Who Can Delegate Credentialing and Be Delegated?

Credentialing can be delegated by healthcare organizations, insurance companies, or managed care organizations (MCOs). Commonly, delegated credentialing is passed on to delegated providers, delegated entities, or third-party credentialing companies. The primary delegator must oversee and audit the delegated entity’s processes regularly to ensure compliance with accreditation and regulatory requirements.

Examples of Delegated Credentialing Programs

Examples of delegated credentialing include hospitals outsourcing credentialing to a third-party vendor or a health plan allowing a large physician group to conduct credentialing internally for its members. National Committee for Quality Assurance (NCQA) often oversees these processes to ensure compliance.

What is a Delegated Provider in Credentialing?

A delegated provider is an individual or group that has been authorized to perform credentialing on behalf of a healthcare organization. For example, a large healthcare system may conduct its own credentialing for its providers under a delegated agreement with an insurance company.

What is an Authorized Agent?

An authorized agent is an entity that receives responsibility of performing credentialing tasks on behalf of the delegator. The authorized agent could be a third party credentialing service or a large healthcare provider group capable of performing extensive background checks, primary source verification (PSV) and maintaining compliance with national standards.

What is a Delegated Entity in Healthcare?

Delegated entity is an organization that has been given authority to perform credentialing activities. This could be a healthcare provider network, third party administrator (TPA) or credentialing vendor that handles entire credentialing process, from application to verification, on behalf of another entity.

What is a Delegated Credentialing Agreement?

Delegated credentialing agreement is a formal contract between two parties, typically a healthcare organization or insurance company and a third party vendor or provider group, outlining the responsibilities of each party regarding credentialing. This agreement ensures the delegation adheres to regulatory requirements and that both entities remain compliant with oversight audits.

Delegated vs Non-Delegated Provider in Medical Management

In healthcare, there are two distinct credentialing processes: delegated and non delegated. A non delegated vendor must follow the traditional credentialing route, in which they provide all necessary documentation directly to the healthcare organization or insurance company for review. Conversely, a delegated provider manages their own credentialing, making process faster but subject to regular audits.

Delegated Credentialing vs Credentialing by Proxy

Credentialing by proxy allows one entity to rely on another’s credentialing decisions without repeating entire credentialing process. While similar to delegated credentialing, credentialing by proxy may not require a formal delegation agreement, though it still involves oversight to ensure accuracy and compliance

Regulatory Bodies Involved in Delegated Credentialing

Several regulatory bodies oversee delegated credentialing to ensure proper compliance, security, and data accuracy.

1. NCQA (National Committee for Quality Assurance)

NCQA sets standards for delegated credentialing programs, ensuring that the process remains transparent and compliant. Organizations are required to meet stringent NCQA criteria if they engage in delegation. For more detailed and authoritative content on credentialing standards and practices, visit the NCQA website.

2. CMS (Centers for Medicare & Medicaid Services)

CMS also plays a role in credentialing, particularly for entities serving Medicare and Medicaid populations. CMS ensures that providers meet federal standards before delivering care.

3. Local Government and Verification Processes

Local health authorities and state governments often have specific credentialing requirements. They can audit healthcare organizations to ensure that delegated credentialing complies with both federal and local laws.

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Delegated Credentialing Requirements for Time

Delegated credentialing typically allows providers to be credentialed more quickly than in non delegated processes. However, providers and credentialing entities are required to conduct timely re credentialing, usually every two to three years, depending on state and federal guidelines.

Understanding the Delegated Credentialing Process, How It All Works

The delegated credentialing process is streamlined and broken down into several key steps:

  • Develop an Internal Credentialing Program: Before delegation occurs, a healthcare organization must first establish its internal credentialing policies and ensure they align with regulatory standards.
  • Complete Pre-Delegation Assessment: Healthcare organizations perform an assessment to determine if potential delegated entity has capabilities to manage credentialing processes.
  • Negotiate Delegated Agreement: Formal delegated credentialing agreement is drawn up and signed by both parties, outlining responsibilities and terms of the delegation.
  • Conduct Credentialing: Once agreement is in place, delegated entity can begin conducting credentialing processes, including primary source verification (PSV) and background checks.
  • Participate in Annual Oversight Audits: Regular audits ensure that delegated entity continues to meet all required credentialing standards. These audits can be internal or performed by external accrediting bodies.

Pros and Cons of Delegated Credentialing

Benefits of Delegated Credentialing

  • Efficiency: Delegated credentialing speeds up the process, allowing providers to start work faster.
  • Resource Management: Organizations can allocate fewer resources to internal credentialing.
  • Scalability: Large provider groups can manage their own credentialing, reducing administrative burdens.

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Downsides of Delegated Credentialing

  • Oversight Burden: Delegated entities must undergo regular audits and maintain compliance, which can be resource intensive.
  • Compliance Risk: Any lapses in credentialing compliance can lead to penalties or loss of accreditation.
  • Cost: Delegated credentialing agreements can come with high costs, especially for smaller healthcare providers.

Conclusion

Delegated credentialing offers a fast and efficient way for healthcare providers to get credentialed but it comes with responsibilities and risks. By understanding the differences between delegated and non-delegated processes and ensuring compliance with regulatory bodies like NCQA and CMS, healthcare organizations can leverage delegated credentialing to streamline operations while maintaining high standards of care. Delegated credentialing programs are integral to this process, offering both speed and scalability, but requiring careful management and regular audits to ensure compliance and quality.

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