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Delegation Agreements – The Win-Win for Everyone in Credentialing

Are you frustrated yet? That big box health plan has been credentialing your provider for almost a year, and you just keep giving away free healthcare services waiting for that retro to take effect. Yes, you are. So are they. They, the health plans, are overwhelmed with volumes. And, also overwhelmed with trying to perform delegation audits in a timely fashion. Let’s face it. Most of us credentialing professionals love our jobs and would hate for them to disappear due to the latest technology or sweeping legislation to eliminate redundancy. That is why we keep pressing on in our separate entities. Because, in the interim of those significant changes occurring, we need to be as efficient as possible. How do I propose we do this? You already know the answer, but just in case you didn’t here goes. The answer is delegation agreements, the smart way. How’s that? Through accreditation, that’s how.

If you are a health care entity, such as a large group practice or a group of hospital staff represented by an independent practice association, or any entity with a formal credentialing process and needs to enroll its providers in a health plan, you want to pursue either NCQA Credentialing Accreditation or CVO Certification. Getting one of those designations will make it as easier for both the health plan and your organizations to get those doctors from contracting to actively contracted. Since a delegation agreement defines the responsibilities of the entity who wants to enroll and the health plan who is going to grant the authority to credential on its behalf, you will immediately know what is expected as evidence of your formal credentialing program. Once that hurdle is met though, accreditation alleviates the need for full-blown delegation surveys on an annual basis. And at the very least, no file review to show evidence that your organization, the delegated entity has met guidelines. However, that portion of the audit could get a bit tricky with additional Medicaid and other state requirements. But, don’t despair. The elements of the agreement are what keeps the required credentialing activities flowing in the right direction and in the right timeframe. If your organization is credentialing your provider within 60 days and the health plan is adding those providers to your contracted roster within 30 days of receipt, I call that a win-win. Of course, every health plan is different and so is every eligible healthcare organization, but I would say 90 days is a lot better than six months to a year. You may want to raise your hand at the next meeting with your executive team and say, "Hey, let’s get accredited."

Dilsa S. Bailey, CPMSM is the owner and principal consultant for The Right Credentials Network. If you are interested in maintaining or applying for NCQA Credentialing Accreditation or CVO Certification, contact her for more information. Dilsa helps to build and repair credentialing programs and trains staff to perform efficiently and productively.

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