Delegated Credentialing: Overview and FAQ
Delegated credentialing occurs when one healthcare entity gives authority to another to perform the process of credentialing providers. For example, a private insurance group might choose to delegate the provider-credentialing process out to a hospital. At best, these agreements can streamline the process of onboarding providers, like doctors and NPs, and cut down on redundancies.
However, each case is unique and this process may not always work out as planned. Some hospitals and facilities aren’t fit for taking on credentialing responsibilities or don’t have the proper procedures in place.
What might becoming a delegate look like for your organization, and is it even the right move? We’ll provide a general overview of this often complex process and answer some frequently asked questions.
An Overview of the Delegated Credentialing Process
So, what’s this process like and how will it affect your organization? Here’s a quick overview.
Credentialing Providers Involves Many Steps
Credentialing is a thorough process that must take place before a provider, like a doctor or NP, can begin seeing patients. The formal credentialing process includes many steps; here are the main ones:
- Gather information about the provider.
- Verify primary sources (such as diplomas and certificates) and search for any history of malpractice.
- Approve employment.
There is the potential for errors, and several administrative duties are involved in this process. That’s why it’s so important that care providers who work without supervision are properly credentialed through a rigorous process with high standards.
Delegated vs. Non-Delegated Provider Healthcare: Who Is Responsible for Credentialing?
In some instances, insurance companies and other payers control the credentialing duties. This is referred to as non-delegated credentialing, meaning that the payer is responsible for the onboarding process and all decisions involved. For example, an insurance company may determine that a healthcare facility lacks the resources to safely and successfully take over credentialing responsibilities.
Other times, the payer might delegate the credentialing responsibilities to a healthcare facility. This happens only if the facility can prove they’re capable of the work involved. They will have to establish an internal credentialing program and pass a pre-delegation assessment. If successful, then the payer and facility would typically enter into a delegated credentialing agreement. Each agreement will be unique and complex, touching on topics like:
- Types of providers covered
- Specific credentialing functions to be performed
- Notification and reporting deadlines
- Sub-delegating
- Audits
- Record keeping
- Veto power
Once an agreement is in place, the facility has the authority to onboard staff, either in-house or in partnership with an outside agency.
Delegating the Credentialing Process: FAQs
This type of agreement between two organizations shifts the credentialing responsibilities from one entity to the other. Typically, an insurance company or government program transfers the responsibility over to a hospital.
Credentialing staff is a burden in terms of administrative duties, record-keeping, and liabilities, but it also comes with significant rewards. Here are answers to some common questions about assuming credentialing duties.
What is delegated credentialing in healthcare?
Delegating the credentialing process is when one healthcare agency gives authority to another agency to credential providers. An example is when a Paid Provider Organization (PPO) delegates the task of credentialing individual providers to a hospital.
When can your facility delegate the credentialing process?
Your facility might be a good fit if you employ many providers. You should also have the staff and resources available to make sure the provider-credentialing process is completed safely and thoroughly.
How does this process work?
It’s common for facilities (large hospitals, in particular) to contract with multiple payers, like private insurance groups and government programs. When a hospital doesn’t have agreements set up with these payers, individual providers need to apply with each payer. For example, a doctor or NP who wants to work at a hospital with 30 hospital-insurer contracts would have to go through a formal credentialing process with 30 different entities.
Given this redundancy, insurance companies and other healthcare entities may request (or even require) a hospital to take on these credentialing responsibilities. The hospital will have to prove that they have the resources and measures in place to safely take on this duty.
A facility may choose to go through an accreditation process with an agency, like the National Committee for Quality Assurance (NCQA) or the Utilization Review Accreditation Commission (URAC), to get credentialing accreditation. After proving they’re able to safely credential providers, the payer will work with the facility to define the terms of the delegation.
When an agreement is in place, the facility takes over specific responsibilities. The payer will usually require their delegates to submit reports and provider rosters on a regular basis. If a delegate has been accredited by an organization like NCQA, they’ll also need to be prepared for NCQA audits.
What are the advantages and disadvantages of assuming credentialing duties?
Becoming a delegate has advantages and disadvantages. Facility managers and hospital administrators will need to consider both before entering into agreements about credentialing.
| Advantages | Disadvantages |
|---|---|
| Efficient onboarding, or “loading” of providers: When a facility/group takes on the responsibility for credentialing their providers, they typically streamline the process, which can help a hospital avoid having a low census.
Improved revenue cycles: Efficient onboarding cuts down on the delay between hiring and seeing patients, bringing in revenue that would otherwise be lost. Increased patient satisfaction: Efficient, thorough onboarding typically results in a higher number of qualified caregivers within an organization and increased patient satisfaction. |
Administrative burden: Credentialing providers requires ongoing work, including the maintenance of accurate records on each provider and re-credentialing duties.
Confusing reporting: Payers often expect monthly reports and provider rosters according to specific formats that differ from one payer to another. Inconvenient audits: Your organization may be audited at an unexpected or inconvenient time. |
What does this process require?
There are standards that determine which facilities can use delegated credentialing, meaning a healthcare agency will need to meet certain criteria. If they fail to meet those criteria, the payer will keep all credentialing responsibilities.
Each situation is unique and every delegating entity has specific preferences. However, a facility may be a good fit for entering into an agreement with a payer if it:
- Employs a large number of providers.
- Passes the payers’ pre-assessment audit.
- Has a plan in place for submitting monthly reports and rosters to payers.
- Has enough resources to handle the administrative burden of credentialing or works with a Credentials Verification Organization (CVO).
Keep Your Facility in Compliance With the Latest Healthcare Updates
Staying on top of current issues in healthcare is vital. If you have more questions about delegated credentialing, or other important procedures, we’ve got you covered. Don’t miss out on our latest facility management insights, tips, and resources.