Why Delegated Credentialing Reduces the Time it Takes to Enroll a Provider

Provider enrollment and credentialing takes attention to detail, patience, and most of all, time. The process can take anywhere between 60 and 120 days, and as we all know, time is money. If a busy provider bills approximately $10,122/day and it takes 90 days to enroll a provider, you’re at risk of losing $900,000+ in revenue. That’s less than ideal, and the results of our 2021 Annual Report on Provider Enrollment proves that medical professionals want to see that change. In fact, reducing the time to enroll a provider was the single highest rated item on our survey at 88.2%.

So, how can organizations achieve their goal of reducing the time it takes to enroll a provider? Delegated payer contracts, or delegated credentialing, is one way to do so.

What is Delegated Credentialing?

Delegated Credentialing is when an organization, most often a large health system, is given authorization by a specific payor to perform credentialing in-house. Delegated credentialing is more than just verifying credentials. This is because the delegated health care entity (e.g. the health system) is responsible for evaluating practitioners' qualifications and making credentialing decisions on behalf of another delegating health care entity (e.g. the payor). In this arrangement, the responsible delegated entity does all the work necessary to complete the credentialing process, but at the end of the day, the accountable delegated entity still has the authority to veto any decision made by the delegated party.

Delegated Credentialing requires there to be a mutually agreed-upon arrangement that provides an explanation of obligations in keeping with regulatory bodies, like the NCQA, URAC, CMS, and federal and state laws. Delegation agreements can be a separate agreement or an amendment to an existing parent contract/agreement.

How does Delegated Credentialing work?

Before delegation is possible, the delegate must implement a foolproof ‘in-house’ credentialing process. The delegating organization, like a health plan, must perform a full evaluation of the delegate’s ability to perform credentialing tasks. This includes a written review of the delegate’s understanding of standards and delegated tasks, a review of the delegate’s policies, procedures and files, and assessment of the delegate’s staffing and performance levels.

Most, if not all, health insurers will require that a delegate’s processes and procedures be compliant with relevant NCQA Standards and Guidelines before they agree to delegate credentialing and recredentialing. NCQA Credentialing Accreditation means your medical group practice has an efficient and accurate process in place that:

• Verifies practitioner credentials through a primary source, a recognized source, or a contracted agent of the primary source.
• Has a designated credentialing committee in place to review practitioner credentials and make credentialing recommendations.
• Aligns with state requirements.

Once that is complete, you must then execute a delegation agreement outlining the responsibilities of each party involved. Note: Every single delegated credentialing contract you engage in will have to be negotiated individually. Every contract will have a handful of organization-specific requirements, but standard contracts will all include specifics on:

• Roles and responsibilities of each party and the activities being delegated
• Reporting frequency
• A performance evaluation process
• Use of Protected Health Information (PHI)
• Remedies for non-compliance
• The right of the plan to make final decisions

After these steps have been completed, the delegate will then be in charge of credentialing for the delegating organization. They will be responsible for sending the health plan an updated provider roster on a regular basis (often monthly). A provider roster is used to associate or disassociate a provider with an organization. Rosters include information on:

• Changes of status
• Address
• Billing information
• New or terminated providers

When the delegating party receives an updated provider roster, any new provider listed can be considered "Participating" and, therefore, eligible for reimbursement.

What are the benefits of Delegated Credentialing?

The time savings are undeniable when delegated credentialing is done correctly. For most medical groups, delegated credentialing can shave off weeks from the process. And in some instances, and with the right tools in place, the entire process can be done in just 7-10 days. Faster turnaround times means timelier reimbursement from payers, which is always good. Better yet, depending on the agreement terms, it may lead to a reduced amount of time and resources dedicated to provider enrollment. Finally, and this may be the biggest benefit, delegated credentialing increases both practitioner and patient satisfaction, as new providers can more quickly put their expertise to work and patients are able to more readily benefit from their care.

What organizations can receive delegated status?

In most instances, qualified healthcare organizations, including CVOs, can achieve delegated status with health plans/insurance companies, like UnitedHealth Group, Cigna, Aetna, etc., as well as The Centers for Medicare & Medicaid Services. However, not all organizations in the medical services industry can use delegated credentialing. According to this year’s annual report, 43% of respondents indicated they were not able to obtain delegation status because they were unable to meet provider threshold requirements.

If you want to see other ways organizations are reducing the time it takes to enroll a provider, we recommend checking out the full 2021 Annual Report on Provider Enrollment. We’re certain the report is chock full of tips and insights that will help your organization save time and money. Download the report today.