The Complexities of Managed Care Credentialing

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The Complexities of Managed Care Credentialing

• Mei Ling Christopher, UnitedHealthcare
• Sallye Marcus, Anthem Blue Cross

2
Session Objectives

• What are the benefits of delegated credentialing
• Regulatory/Accreditation Survey process
• Electronic audit process

3
Definitions

• 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 organizations
  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.

4
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.

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Delegation

• 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.

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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)

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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

8
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?

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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.

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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

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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

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Contents of a File

• Application/Signed Attestation
• State License Primary source verification (PSV)
• DEA or CDS
• Education/Board Certification
• Work History

• 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.
13
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

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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