Complexities of Managed Care Credentialing

The Complexities of Managed
Care Credentialing
Mei Ling Christopher, UnitedHealthcare
Sallye Marcus, Anthem Blue Cross
Session Objectives
What are the benefits of delegated credentialing
Regulatory/Accreditation Survey process
Electronic audit process
• Delegation occurs when an organization gives
another entity the authority to carry out a function
that it would otherwise perform.
• Sub-delegation occurs when the organization’s
delegate gives a third entity the authority to carry
out a delegated function.
• For example, the organization may delegate credentialing (CR)
activities to a provider hospital organization (PHO), who then
delegates some of those activities to an Management Services
Organization (MSO). In this case, the MSO is the sub-delegate.
Definitions (continued)
• Annual Audit: A health plan must conduct an audit
at least every 12 months; 2-month grace period
allowed (14 months).
• Documented Process: Policies and procedures,
process flow charts, protocols, and other
mechanisms that describe the methodology used by
the organization to complete a task.
• The delegate has been given the power to carry out
a specific function, within the parameters agreed to.
• The organization gives a delegate the authority to act
on its behalf, but it remains responsible for the
function to be carried out properly.
• The organization must conduct annual oversight
activities of the delegate.
• NCQA requires the presence of a mutual
agreement between the delegating organization and
its delegate.
Who are they?
• Delegates may be:
Medical Groups
Medical Universities
Independent Physician Associations (IPA)
Physician Hospital Organizations (PHO)
Management Service Organizations (MSO)
Credentialing Verification Organizations (CVO)
Benefits of Delegation
• Reduce duplicate credentialing efforts
• Allow practitioners to become effective with the
organization sooner
• Patients can be seen sooner by new practitioners
• Cost Savings – Better use of resources
Survey Process
• Please ensure the health plan knows your
organizations correct status:
– Is your organization NCQA certified or accredited?
– Does your organization sub-delegate to a NCQA
certified CVO?
– Is your organization delegated for Organizational
Providers/Health Delivery Organizations?
Survey Process (continued)
• NCQA and the health plans retain the right to
request the verification documents as evidence,
regardless of certification or accreditation status.
• The look back period is 36 months prior to the
survey date.
• Once notified by NCQA of the files selected the
timeframe to collect the files and submit to NCQA
is short.
Survey Process (continued)
• Rosters are required from all delegated groups for
submission to NCQA
– Roster should be in Excel spreadsheet, with two
– Include all date ranges of practitioners that have been
processed with your organization
– Do not include hospital based or allied health
Survey Process (continued)
• For NCQA roster submission the following fields
are required:
Last name
First name
Initial credentialing date
Most recent recredentialing date
Name of organization
Contents of a File
•Application/Signed Attestation
•State License Primary source
verification (PSV)
•Education/Board Certification
•Work History
• Professional Liability
• Malpractice Hx. (or NPDB)
• License Sanction Review
• Medicare/Medicaid Sanction
• Cred. Committee Date
• (CMS Audits) - Hospital Privileges, Medicare Opt-Out and
Performance Review for recredentialing
The copies should either be dated/signed or initialed, or a checklist
should be dated/signed.
Electronic Audits
• Many Health Plans are moving to a desktop audit
– Reduces health care costs
– Frees up time you would normally spend during the
onsite audit
– Notification well in advance of the audit outlining
which files are needed, allowing time to gather and
send the files
– Provide electronic copies of the files via secure email
or website, or conduct audit live via a webex/web
Electronic Audits (continued)
• The auditor will request:
— Policies and Procedures, Evidence of reporting, subdelegation agreements
— A full roster to select 30 initial and 30 recredentialing
— The auditor will request the first 10 initial and 10
recredentialing files from the delegate
— Additional files will be requested if there is a deficiency
within the first 8 elements

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