delegated credentialing: achieving success for your ... · delegated credentialing: achieving...

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Delegated Credentialing: Achieving Success for your Organization

Amy M. Niehaus, CPMSM, CPCS, MBAOctober 7, 2014

Objectives

• Name the key components of a delegated credentialing program under NCQA standards

• Outline the various elements of a delegated credentialing agreement

• Summarize the required steps of the delegation audit process

• Identify the benefits of delegated credentialing to both parties

Sources

• NCQA 2014 Health Plan (HP) Standards and Guidelines - Effective for Surveys Beginning On or After July 1, 2014 (CR 9: Delegation of CR)

• NCQA Frequently Asked Questions• NCQA Corrections, Clarifications and Policy

Changes• ncqa.org

Copyright 2014 The Greeley Company, Inc. All rights reserved. These materials may not be duplicated without the express written permission of the Greeley Company, Inc.

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What is Delegation?

• Merriam Webster Dictionary: to give (control, responsibility, authority, etc.) to someone: to trust someone with (a job, duty, etc.)

• NCQA: delegation occurs when an organization gives another entity the authority to carry out a function that it would otherwise perform

Why Delegate from Organization’s Perspective?

• Reduces turnaround time for network participation

• Helps manage significant volume of providers

• Reduces resources (staff, budget, time)

• Accommodates network growth

• Supports contracting efforts

• Increases practitioner satisfaction

Why Become Delegated fromEntity’s Perspective?

• Reduces turnaround time for network participation

• Timelier reimbursement from payers

• Reduces resources for provider enrollment– Depends on terms of agreement– May still have other non-delegated payers, i.e. CMS– Further reduction if integrated with MSSD

• May provide contracting leverage

• Increases practitioner and patient satisfaction


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What Entities Can Be Delegated To?

• The organization can delegate credentialing activities to a variety of entities, including– IPAs– PHOs– CVOs– Medical societies– Other health plans– Hospitals

What Can Be Delegated?

• Portion of the credentialing process, such as primary source verification (PSV)

• Multiple credentialing processes, such as collection and review of the application and PSV

• All credentialing activities

• Organizations vary in the amount of delegated activities that occur, if any

• Organizations may not delegate overall responsibility for credentialing

What is Subdelegation?

• Subdelegation occurs when a delegated entity contracts with a third party to perform a delegated function

• Examples– Payer to PHO to Hospital– PHO to Hospital to CVO– Payer to IPA to CVO

• Organization must receive results of delegate’s oversight assessment or perform the oversight assessment directly


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Pre-Delegation Assessment

• Evaluation of the potential delegate’s ability to perform required PRIOR to signing an agreement– Written review of delegate’s understanding of standards and

delegated tasks• Policies & procedures, file review

– Staffing levels– Performance records

• NCQA Accreditation or Certification a plus!

• Onsite visit not required

Discussion Point

Is there value in performing a site visit during the pre-delegation assessment, even though it is not required by NCQA?

Verification Timeframes under Delegation

• Timeliness determined based on date of credentialing decision

• Full Credentialing Process - timeframes for each credentialing element mirror those required of the organization under NCQA– Example: provider organization (PHO, IPA)– License (180 days)

• Partial Credentialing Process – timeframes are 60 days less– Example: CVO– License (120 days)


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Delegation Agreement

• Must include the following elements:– mutually agreed upon– responsibilities of each party/activities being delegated– reporting frequency, at least semiannually– performance evaluation process– use of Protected Health Information (PHI)– remedies for non-compliance– right of the plan to make the final decision

• NCQA will review up to 4 delegated agreements during survey

Annual Assessment

• Annual reviews are performed to ensure that standards continue to be met

• Similar to pre-delegation review process– Policies and procedures – NCQA standards and Plan’s own requirements– File Review; NCQA audit process required

• 5% or 50, minimum of 10 each, OR• 8/30 methodology

• Semiannual review of reports

• NCQA Accreditation or Certification a plus!

Discussion Point

What is the NCQA 8/30 Rule and how does it impact the file audit?


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Annual Assessment

• Onsite visit not required

• Performance improvement opportunities identified and followed up on, if applicable

• Corrective actions required if issues identified– Education– Corrective Action Plan– Terminate agreement if non-compliant

• Files processed by a delegated entity are viewed by NCQA in the same manner as if they were processed by the organization

Termination of Delegation

• Recredentialing must still occur at least every 3 years

• Organization may obtain files from the delegate and continue with established timeframes; OR

• Perform initial credentialing within 6 months of termination

Credentials Verification Organization (CVO)

• An organization that conducts verification of practitioner credentials and other related activities on behalf of its clients

• Must comply with applicable federal, state and local laws and regulations, including any requirements for licensure or registration

• Maintain the necessary credentials information, policies and procedures


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CVO Certification

• NCQA offers CVO Certification program• Evaluates:

– Policies & Procedures

– Quality Improvement

– Customer Satisfaction

– Confidentiality/Security

– Scope of Services• CVO cannot delegate NCQA standards to other

organizations

NCQA Certified CVOs

• As of 5/31/2014, NCQA has certified 70 CVOs• 2 year certification• Standards address Policies & Procedures, Quality

Improvement and Confidentiality• 10 verification elements available for certification• www.ncqa.org

NCQA CVO Certification Elements

– Application and Attestation Content

– Practitioner Application Processing

– DEA or CDS Certification

– Education and Training

– License to Practice

– Malpractice Claims History

– Medicare/Medicaid Sanctions

– Medical Board Sanctions

– Ongoing Monitoring of Sanctions

– Work History


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Discussion Point

How does CVO certification impact delegation oversight audits?

DELEGATION ACTIVITY

Case Scenario #1

An NCQA-accredited health plan has signed a contract with a large physician group that includes delegated credentialing. As the manager of the plans’ credentialing department, you received a copy of the contract today but notice that the agreement was effective on October 1, 2014. What do you do?


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Case Scenario #2

During the course of an annual review for an existing delegated entity, you identify a trend in the file review results. A particular staff member is using the ABMS Certified Doctor Verification Program, a non NCQA-approved source, for verifying board certification. What do you do?

Case Scenario #3

Your organization has enjoyed a successful, long-term delegation agreement with a large IPA. Recently, there was a change in leadership at the IPA, staffing reductions, and rumors of financial difficulties. What do you do?

Case Scenario #4

Your physician group has grown significantly and you are looking to streamline the provider on-boarding and payer enrollment processes. You are considering delegation with your 14 commercial payers. What are your first steps to determine if you are eligible and ready for this type of arrangement?


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Disadvantages of Delegation

Organization

• Loss of control• Potential impact to

accreditation survey results• Resources to perform

oversight audits

Delegate

• Additional responsibilities based on health plan’s requirements

• Resources to support oversight audits

• Does not fully eliminate provider enrollment activities

Achieving Success – the Organization

• Delegation Agreement:– Contracting should involve Credentialing early on in the

process– Be as inclusive as possible of all activities and expectations

• Education:– Ensure both parties understand what is required per the

agreement– Know the standards and share updates with delegates– Inform delegates of any policy changes

Achieving Success – the Organization

• Assessments:– Perform desktop review of P&P and minutes in advance of

onsite audit– Consider electronic file reviews, if available– Give 30-day notice of audit; be flexible with date– Review only necessary file elements– Send audit results in a timely manner

• Surveys:– Involve delegates in upcoming survey activities– Recognize delegate’s role and contributions


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Achieving Success – the Delegate

• Keep detailed list of requirements for each agreement, highlighting differences to ensure compliance

• Create process for issue files (red flags)

• Inform organization of any adverse issues with practitioners

• Audit every file and database

• Prepare/tab files to facilitate audits

• Build and maintain credibility

• Be accessible and flexible

Delegation Collaboration

• Opportunities to create synergies and efficiencies by collaborating within the industry

• Examples:– ICE

– MUCH

– CAQH

– WCSG


ICE (Industry Collaborative Effort, Inc) - CA• http://www.iceforhealth.org/home.asp• Credentialing Shared Audit Policy Team

– Standardized audit tool and training

– Completion of oversight audits is divided among organization and results shared


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MUCH (Michigan United Credentialing Healthcare Forum)

• Original goal to create a common delegated credentialing process

• Expanded to include other mutual topics of interest, such as NPI, CAQH, legislative activities

• Share responsibility for oversight audits using standard tools and processes


CAQH Universal Provider DataSource• www.caqh.org• v2.0 to be released Q1 2015• Delegation Workgroup representing health plans,

hospitals and delegated groups– Developing standard list of data elements requested by

payers that delegate credentialing

– Eliminate duplicative and organization specific reporting requirements

– Streamline data reporting between payers and delegated entities


WCSG (Washington Credentialing Standardization Group)

• www.wamss.org• State-wide representation from multiple health care

entities• Created Washington Practitioner Application• Developed Shared Delegation Audit (SDA) Team

– Completes collaborative annual credentialing assessments of 25 medical groups


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Keys to Success

TEAMWORK

TEAMWORK

TEAMWORK

Questions?


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