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Learn MoreOne of the things most people look for today, regardless of industry, is how to perform a task accurately and quickly. The need to be efficient is paramount, and when it comes to provider enrollment and credentialing, it’s essential. When done poorly, the process can be time-consuming and inefficient, resulting in revenue loss for busy healthcare providers. However, an approach to gaining success is delegated credentialing. In this blog post, we'll delve into what delegated credentialing is, its benefits for both the organization delegating and the organization being delegated to and how the process works.
Delegated credentialing is a process where a healthcare entity grants another healthcare entity the authority to credential its providers. For example, a preferred provider organization (PPO) may delegate credentialing responsibilities to a hospital or medical group. This goes beyond credentials verification, as the delegated entity is responsible for evaluating qualifications and making credentialing and appointment decisions on behalf of the delegating entity.
When organizations step into a delegated credentialing agreement, there must be a mutually agreed upon arrangement that outlines all the necessary obligations as they pertain to different regulatory bodies, like the National Committee for Quality Assurance (NCQA), Utilization Review Accreditation Commission (URAC), Centers for Medicare & Medicaid Services ( (CMS), and federal and state laws. Delegation agreements can be a separate agreement or an amendment to an existing parent contract/agreement.
When done properly, delegated credentialing can save organizations significant time, enabling patients to access care more quickly. The benefits vary based on the organization.
From a Health Plan's Perspective
From a Healthcare Organization's Perspective
A healthcare organization must have a robust 'in-house' credentialing process to participate in delegated credentialing. Ensuring this involves a comprehensive evaluation of the process.
The first step lies in ensuring the organization meets accreditation standards, which means the organization has a process in place that:
Now, every delegated contract will have organization-specific requirements, but standard contracts should include:
Once this has been done, the delegate will be authorized to complete credentialing for the delegating organization. As part of this agreement, the delegate will be required to share a provider roster with the delegating entity about once per month. This roster will then be used to either associate or disassociate a provider with an organization and provide high-level information on a provider, including their change of status, address, and billing information. When the delegating party receives an updated provider roster, any new provider listed can be considered "Participating" and, therefore, eligible for reimbursement.
Organizations should think carefully about what organization they partner with as a delegated credentialing entity. When considering this partnership, consider these criteria:
The NCQA permits delegating several activities, including credentialing, re-credentialing, case management, utilization management, disease management, and health promotion. However, certain activities, such as those involving member experience, privacy and confidentiality, and marketing information, cannot be delegated.
By embracing delegated credentialing, healthcare organizations can unlock a win-win solution for providers, plans, and ultimately, patients. Streamlined processes, quicker enrollment, and enhanced provider satisfaction make delegated credentialing the future of efficient and effective healthcare administration. Partnering with the right NCQA-accredited delegate empowers medical organizations to focus on what they do best – delivering high-quality care – while leaving credentialing in the hands of experienced experts.
Take the first step towards a faster, more efficient future for healthcare – find out how CredentialStream® can help with all your credentialing needs, including delegated credentialing. Arrange a demonstration with one of our experts today.
When you enact HealthStream's quality compliance solutions, you can do so with the confidence your healthcare organization will meet all standards of care.
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View All ProductsHealthStream works with healthcare organizations to create engaging and high-quality training videos for your staff and management.
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View All ProductsUtilize patient access solutions and advanced reimbursement solutions to manage clinical denials and improve your organization’s reimbursement strategy.
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View All ProductsOur competency development solutions personalize learning for clinicians to bridge the gap between theory and practice for your nurse residents.
View All ProductsEnhance maternal & child nursing care with solutions focused on improving the quality of care for mothers, infants, and children.
View All ProductsAddress staffing orientation challenges to easily achieve and maintain certification with our emergency and acute care training solutions.
View All ProductsAs a premier provider of healthcare education, we are committed to promoting safer, more successful surgical and sedation outcomes for each and every patient.
View All ProductsOur solutions are designed to cater to the needs of patients, healthcare professionals, and organizations dealing with illnesses or chronic conditions.
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