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

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.

Credentialing Spectrum is a complete credentialing profile module

Its features are as below.

Management of Credentialing and Re-credentialing activities and reminders.
Complete Cloud based Documents Management for Credentialing Documents.
Reminders on Expiration of various credentials such as CDS, DEA, License, CAQH, Board Certification, Mal Practice , Hospital Privileges.
Facility Credentialing Management.
Insurance Participation Agreements and/or Contract Management
Auto-fax, Auto-email and Secure Messaging Capability.
Extensive Report and/or analytics Module.