How to create a delegated credentialing program?

Credentialing Services

This is part two of a two-part post that evaluates what is delegated credentialing and why healthcare provider organizations should consider it.

As explained in the first post of this two-part series, delegated credentialing is an opportunity for large provider organizations to take matters into their own hands, streamline processes and realize substantial benefits. These include getting providers credentialed quicker so they can generate revenue and expand clinical bandwidth.

So, how do organizations create a delegated credentialing services process? It entails establishing processes, as well as implementing tools to assist with workflow and manage the flow of data.

Key processes to implement include:

  • Adopting Credentialing Standards — The National Committee for Quality Assurance (NCQA) has already established standards for payers, as has the Joint Commission for providers. Standards from both organizations should be adopted, as well as any specific standards from regional payers.
  • Establish a Review Process — Create a committee to define processes and review provider credentialing.
  • Conduct Ongoing Monitor — Develop processes to continually monitor work quality.
  • Re-Credentialing — Create processes to easily re-credential providers on an ongoing basis.
  • Create Agreements with Payers — Delegated credentialing agreements need to be established, clearly stating structure and metrics, including:
    • Outlining the responsibilities of the payer and delegated entity.
    • Detailing metrics of how the payer can define and assess performance.
    • Developing ongoing oversight processes.

Accomplishing these processes requires sophisticated credentialing software that includes:

  • Analytics and reporting
  • Dashboard presentations and milestone tracking
  • Demographic import features
  • Document management
  • Reminders and notifications
  • Task management and assignment features

A key resource to assist with delegated credentialing programs is the Healthcare Billing and Management Association (HBMA). The organization has a number of useful resources that expound on the above in further detail.

Author Julia Solooki is a board member of the HBMA Education Committee.

Advertisements

Outsourcing Provider Credentialing = Gaining Specialization

It makes so much sense that doctors do this all the time. So, why then, isn’t it best practice to provide specialization for the critical tasks in physician offices, such as provider credentialing? It seems as if such a necessary task so vital to protecting a practice doesn’t get the respect or staff resources that it deserves. Instead, credentialing work is simply absorbed by various members of the back-office staff. As a result, the accuracy of credentialing work is often compromised, exposing the organization to financial and patient safety risks.

But rest assured, credentialing specialization does exist, and can be obtained. The answer: Outsourcing. By outsourcing an organization’s credentialing function, physician offices can better focus their staff on revenue-generating tasks, such as billing and collections.

A primary benefit of outsourcing is that it allows provider organizations to access industry-leading expertise on the nuances of physician credentialing, enabling them to get the work done, quicker, better, faster. Experienced credentialing professionals have spent years learning about information resources to verify credentials, which helps them avoid potential pitfalls, and enhance their work through best practices.

Working in harmony: It’s important to note that outsourcing doesn’t necessarily mean that provider organizations have to completely relinquish their control over the function. Rely on the specialization, while keeping the tasks that are easier to manage within the office. This also keeps costs in check. For instance, many organizations choose to retain control over certain aspects, while outsourcing the labor-intensive processes of conducting background and reference checks, or the tedious processes of verifying schools, licensure, employment, malpractice carriers, and more. Experienced outsourcing professionals have the tools, resources and knowledge to perform these tasks faster and more accurately.

With the right outsourcing arrangement and leveraging specialized experts, organizations can remain better focused on their core competencies to improve performance and profitability.

How to Select Credentialing Software

Whether you’ve done it just once, or hundreds of times, you know that physician credentialing is a labor- and time-intensive task. On the flip side, it’s also mandatory if you want to earn reimbursement from payers while also minimizing risks for your practice. Fortunately, there is a silver lining. Software solutions are available to help manage the process. Here are some key features to look for when selecting physician credentialing software.

Cloud-Based. It’s important to look for a cloud-based solution as opposed to traditional software that must be physically purchased on a disc, manually installed and then maintained. Cloud-based solutions can be easily accessed via a browser, are available on a pay-as-you-go subscription basis, and upgrades can be done quickly and nearly effortlessly from any location.

Automated reminders and alerts. Reminders and alerts are critical to notify users when tasks need to be completed. For example, credentialing software can remind users in advance when physicians require re-credentialing. Alerts help notify of important upcoming dates, such as when physician certifications and licenses are about to expire. These reminders and alerts, combined with reports listing upcoming tasks, help facilitate greater efficiency so organizations can always stay on top workloads.

Convenience features. Credentialing software solutions should also provide numerous other conveniences. Once physician demographic and other information is entered, the system should be able to reuse that information to pre-populate forms and other materials. In other instances, some software can also remove the need for data entry by pre-populating the physician data. Look for a system with import tools that allow for the seamless extraction of provider information from various forms, including insurance company forms and the PDF documents from the Council for Affordable Quality Healthcare (CAQH). Then, once imported, this information can be used auto-populate other forms. This eliminates the lengthy and time consuming process of re-entering information.

Document management. Systems should include document management capabilities to store forms, correspondence, credential verification materials, and more. This saves time by properly organizing documents into a logical order that can be easily navigated for quick reference, and rids office staff of the stacks of folders with hard copies.

With the right software solution, credentialing can be a more streamlined and consistent effort throughout any organization. With the right software, you just might welcome the new staff physician who needs to be credentialed.

Red flags in the credentialing process

When I think of a process, I think of clear steps that one follows to consistently achieve the same end result. Whether it’s the Blog-Red-Flag1process for making cookies, mailing a package, or boarding a plan, there is a series of events that are followed and at the end we reach the same result each time.  For credentialing,  however, the  process is not as clear cut. There are many nuances and details, not to mention changes in healthcare policies that can make even the most diligent healthcare management professional have a slipup. But, unlike resulting in a soggy or over-crunchy batch of cookies, a slip-up in credentialing is far more serious.

While this isn’t fully encompassing, there are some “red flags” of the physician credentialing process that can be invaluable to know and keep an eye out for.

Certain indicators that can raise concern include:

  • Gaps in time between residencies, employment or training that are not explained or verified
  • Mismatched or missing information between the application and CV
  • Professional references that are vague, missing needed information or in any way negative

While these indicators do not account for all red flags that should be investigated prior to making a recommendation regarding appointment or clinical privileges, they are certainly some of the most predominant and frequently seen.

To take the safety and assured accuracy of your credentialing one step further, and to hopefully avoid these red flags, consider working with a vendor to handle the process for you.

Qualified, knowledgeable staff, and technology offerings are available to help with credentialing assignments. Expert vendors can offer tools that give you credential expiration reminders, templates for applications, task management and milestones to lead you through the process; all for easy workflow management.

Putting this important task in the hands of subject matter- experts can help alleviate the risk and save office staff time to focus on other equally important day-to-day business operations.

Credentialing Issues and Resolution

Credentialing Issues and ResolutionWhile it’s imperative that each and every physician is properly vetted and credentialed prior to practicing for numerous reasons, the tedium that goes into the process can steal valuable time away from patient care, scheduling and billing – also tasks incredibly important to overall business operations. Compound all of this with the explosion of credentialing requirements and paperwork, staff can take up to 3-5 hours each day on credentialing.

Today’s healthcare industry offers numerous challenges that lend to strapped staff time. Requirements for hospitals and healthcare organizations continue to grow with Meaningful Use and HIPAA. As of January 2013, only credentialed medical assistants have been permitted to enter medication, radiology, and laboratory orders into the EHR to count toward meeting the Meaningful Use thresholds under the Medicare and Medicaid EHR Incentive programs.

With the growing complications and tediousness of credentialing, the risk of error exists, and the ramifications of incorrect or insufficient credentialing can cost practices and hospitals dearly. Payer processes can be slowed, patient-risk is increased and organizations can pay hefty fines in malpractice situations if proper paperwork is not produced.

A resolution? To best manage this oftentimes complicated task of physician credentialing, practices and hospitals can look to vendors well-versed in the space that can securely manage the process for credentialing and re-credentialing. Vendors should have the ability to manage profiles and documents for physicians, help monitor for expiring credentials and have a dedicated, knowledgeable staff to answer any questions about the process in general. Save time, save money, save the legal headaches.