Setting the Stage for Delegation for Your Practice

Many large groups, IPAs, and ACOs are considering taking control of the credentialing process by replacing the traditional provider enrollment (credentialing) model with delegated credentialing—earning the formal approval of payors to credential their own providers. Delegated credentialing can mean decreased denials and quicker, more predictable cash flow. But preparing for delegation requires careful planning and thoughtful execution.

There are key requirements for a successful delegation program, many of which can be met by tweaking and enhancing your existing processes.

First, groups need standardized information gathering from their provider members (application and attestation), primary source verification of credentials, policies and procedures for all aspects of the program, and a credentialing committee. Formal communication to group members on committee decisions is also required.

The group will credential all providers at the start of the program (initial credentialing) in accordance with approved policies and procedures and will credential all new providers as they join the group. They will then need to be re-credentialed no later than 36 months from each provider's committee approval data. Between credentialing cycles, each provider is monitored to ensure they have not been sanctioned by Medicare, Medicaid, or any state medical board.

Once the credentialing program is operational, it is time to approach all payors and request a review of the program for delegation.

The eMDs credentialing team is often asked whether a group must have specific language related to credentialing in their participant contracts in order to bind group members to the credentialing program. The response is that they most likely do not. Most agreements are vague in detailing the obligations of each party, yet all will likely require that members comply with the group's administrative requirements. ACO contracts most likely require that participants:

  • Adhere to policies and procedures
  • Remain free of sanctions throughout their affiliation
  • Remain licensed to practice without restrictions

Depending on the level of information the group collects from its members, some form of an application—a consent for the group to access primary sources such as the National Practitioner Data Bank (NPDB) on their behalf and an attestation to the integrity of the self-reported information—will be required. An existing governing body or a subset of a board of directors, which is representative of the group's specialty composition, can provide the structure for a credentialing committee. The group's policies and procedures will need to be enhanced to add credentialing policies and procedures, and they will have to be reviewed and periodically modified to meet the changing needs of the group. This includes a process for the group to take action when members do not meet the organization's standards. If your group has the ability to bind members to the program, adding some structure and processes will create the foundation to formalize a credentialing program in preparation for delegation.