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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. Definitions .

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the complexities of managed care credentialing

The Complexities of Managed Care Credentialing

Mei Ling Christopher, UnitedHealthcare

Sallye Marcus, Anthem Blue Cross

session objectives
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
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
Who are they?
  • Delegates may be:
    • Medical Groups
    • Hospitals
    • Medical Universities
    • Independent Physician Associations (IPA)
    • Physician Hospital Organizations (PHO)
    • Management Service Organizations (MSO)
    • Credentialing Verification Organizations (CVO)
benefits of delegation
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
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
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 continued1
Survey Process (continued)
  • Rosters are required from all delegated groups for submission to NCQA
    • Roster should be in Excel spreadsheet, with two sheets/tabs
    • Include all date ranges of practitioners that have been processed with your organization
    • Do not include hospital based or allied health providers
survey process continued2
Survey Process (continued)
  • For NCQA roster submission the following fields are required:
    • Last name
    • First name
    • Degree
    • Specialty
    • Initial credentialing date
    • Most recent recredentialing date
    • State
    • Name of organization
contents of a file

Application/Signed Attestation

State License Primary source verification (PSV)


Education/Board Certification

Work History

Contents of a File
  • Professional Liability Insurance
  • Malpractice Hx. (or NPDB)
  • License Sanction Review
  • Medicare/Medicaid Sanction review
  • 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
Electronic Audits
  • Many Health Plans are moving to a desktop audit process
    • 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 meeting
electronic audits continued
Electronic Audits (continued)
  • The auditor will request:
    • Policies and Procedures, Evidence of reporting, sub-delegation agreements
    • A full roster to select 30 initial and 30 recredentialing files
      • 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