How to Implement a Delegated Credentialing Program


The medical industry is a highly controlled and regulated activity. Almost every process is scrutinized to ensure the highest possible patient safety and satisfaction. Among others, clinics and hospitals are obliged to perform heavy credentialing before a new practitioner can work at their facility.

While it has its merits, this long onboarding can be excruciating for everyone involved. Practitioners sometimes have to wait several months until they’re allowed to work. Patients are also forced to wait for new doctors to be onboarded, while clinics have to spend money on paychecks for employees who aren’t working.

Due to the credentialing’s complexity, many healthcare providers eventually decide to hire external CVOs. These are specialized organizations that can streamline the onboarding process and reduce the administrative burden for your business. So, before learning how to create a delegated credentialing program, we suggest you learn more about the process by clicking here.

6 Steps for implementing a delegated credentialing program

Delegated credentialing might sound like a risky endeavor for medical institutions. In the end, you’re hiring an external company to perform a vital service for your business. Choosing the wrong provider can lead to all sorts of trouble and even potential fines. This is why introducing a new program needs to be given appropriate attention.

Here are 6 steps for introducing a delegated credentialing provider:

1.     Facility contract

First off, a medical group must sign a contract with a CVO provider. Keep in mind that this is a long-term venture, so it’s vital to hire a company that you’re confident in. Switching between providers too often will force you to transfer data from one system to another, which can lead to all sorts of errors and inconsistencies.

Keep in mind that a delegated credentialing agreement can’t be signed before you have a facility contract. Furthermore, both sides need to agree upon eligibility criteria so that a facility or group can enter this agreement.

2.     Policies and audit

Before starting full-scale outsourcing, a provider has to perform a full audit. During the process, the health plan will go through the facility’s policies and procedures, thus creating a proper structure for future compliance. Specifically, they need to create a framework that would make it easier for URAC, NCQA, CMS, and other accrediting bodies to easily access the data.

During the evaluation, the provider also needs to ensure that the client was previously adhering to these policies. The health plan needs to ensure there aren’t any gaps that would cause issues down the line.

3.     Credential file audit

Upon reviewing the client’s past policies and creating a new process, the health plan needs to perform the second part of the audit. To be precise, they need to transition to credential file audit. This process includes 10 initial credentialing files and 10 credentialing files, all selected at random. Each one of them needs to be checked for compliance according to the existing industry standards.

If everything seems to be in order, or if there are only negligent issues, the facility can proceed to the next step, which is being reviewed and approved by the health plan.

4.     Credentials Committee

After these audits, the provider network will show the results to the Credentials Committee. If necessary, the group will have to make some fixes that would tackle various issues noticed during the audit. As you can presume, there can’t be any contract signing before these problems are addressed.

5.      Delegated credentialing agreement

At this point, both sides can sign an agreement that outlines both sides’ responsibilities. The agreement needs to be well-structured and cover all the contingencies. Keep in mind that these contracts have some leeway, as both entities can decide on full or partial credentialing.

According to the contract, the client needs to do its best to introduce policies that will help them adhere to current managed care standards. There also need to be clauses that cover the reporting tasks and responsibilities. These reports have to be properly structured, and the contract should define when the reports should be submitted and to whom.

6.     Monitoring

Upon signing the agreement, the organization needs to perform continuous monitoring. Depending on the credentialing body, the provider should present a review each year or every three years. Besides going through procedures and policies, oversight also requires that the CVO performs an audit of random credential files.

How can a CVO improve your internal processes?

While introducing a new delegated credentialing program might look intimidating, it doesn’t carry certain benefits. Most notably, you can outsource the process to an experienced team that performs the same tasks for numerous clients. As such, you can eliminate the common inefficiencies connected to in-house credentialing.

Delegating this process is vital for healthcare providers that have a massive employee turnover. Given that hospitals need to wait for practitioner credentialing to be over so they can fully onboard new staff, they’re obliged to pay salaries until then. This can be a massive burden for clinics and hospitals with many employees, as they effectively have to pay for something they get no value from.

Unlike healthcare providers, CVOs are fully invested in this process. Many hospitals force their nurses, doctors, and other practitioners to do credentialing during work hours, even if they’re fairly unacquainted with the process. As a result, it isn’t common for data to have numerous errors and inconsistencies.

CVOs use well-defined methodology and various tools to simplify the process. They introduce all practitioner data into their systems, ensuring that nothing is omitted. Given that these digital platforms are so advanced, they rarely cause errors such as document duplication. As such, you rarely get fined after hiring CVOs.


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