Leveraging Delegated Credentialing Toward Efficiency and Growth

Credentialing is an essential part of enrolling your providers in new health plans so you can tap into new patient markets. But it also involves many time-consuming verification steps and strict regulatory requirements—and you’re often stuck waiting on payers to handle them.

On average, it can take payers anywhere from three to six months to complete the credentialing process. During that time, your providers aren’t considered in-network, so they can’t see new patients and get reimbursed for rendered services. That means you’re not only missing countless revenue opportunities, you’re unable to deliver life-changing care.

Fortunately, eligible health organizations can credential their own providers on the payers’ behalf, reducing both enrollment time and opportunity costs. This is made possible through delegated credentialing.

For digital health companies and other health systems, delegated credentialing is one of the best ways to support your growing provider network, drive operational efficiency, and generate additional revenue. Next, we explore what delegated credentialing is, why it’s so rewarding, and how an expert credentialing partner can help you enjoy all of the benefits with none of the administrative hassle.

What is Delegated Credentialing?

In the simplest terms, delegated credentialing is when one healthcare organization (usually a health plan or insurance company) allows a healthcare system they work with (usually a hospital group or large digital health company with at least 50 providers on a single contract) to credential their own providers, rather than having to wait and rely on their payer partner for the green light.

How Does Delegated Credentialing Work?

Delegated credentialing can target many different parts of the credentialing process, but it typically involves steps that rely heavily on manual tasks and that are particularly prone to delay—like primary source verifications (PSV).

Organizations can choose to delegate these functions in one of two ways:

• In-house. Establish or expand an internal credentialing committee to tend to primary source verifications and other critical credentialing tasks.
• Through a CVO. Partner with an external credentials verification organization (CVO)—preferably one that is fully automated and NCQA-accredited—to outsource PSV and other administrative needs related to the credentialing process.

If you decide to use an in-house solution, the efficiency of the credentialing process will largely depend on the efficiency and skill of your team. If your committee members have other full-time responsibilities to juggle, you may need to hire additional support to ensure credentialing can be carried out quickly and smoothly.

Keep in mind, if your team uses manual methods—like writing to or calling primary-source institutions to verify a provider’s credentials—this will hold up the process, largely negating the time benefits that made you consider delegated credentialing in the first place.

What Are the Benefits of Delegated Credentialing?

When carried out effectively, the most significant benefits of delegated credentialing can be broken down into four categories: time, cost, administrative relief, and a better provider and patient experience. Let’s dive further into the specifics of each:

1. Time

As mentioned, credentialing providers through a payer can take as long as 6 months, during which time that provider cannot see new patients, deliver treatment, or be reimbursed for care.

Handling credentialing yourself gives you greater control, so you can optimize the process, introduce more efficient workflows, and get your providers in-network faster.

When you partner with an expert CVO like Certify, you can automate your credentialing workflows from end-to-end, completing primary source verifications in minutes and credentialing your providers in a matter of days.

2. Cost

The U.S. healthcare industry wastes upwards of $2.1 billion on inefficient, redundant administrative tasks aimed at verifying and managing provider data. This includes credentialing, which can run your organization between $500 and $1,400 per application.

By taking over and streamlining the credentialing process, you can cut back on needless spending and save considerably on costs.

This doesn’t even account for the additional revenue you stand to gain by allowing your providers to treat new patients sooner. Providers forfeit an estimated $9,000 each day their credentialing is delayed. That means a mere 30-day credentialing delay can cost your organization over $200,000 per provider—or over $10 million annually if you average 50 or so new hires a year.

3. Reduced workloads

Faster credentialing turnaround times and fewer back-and-forths with payers to exchange data and documentation means less paperwork and less of an administrative burden for your team, your partners, and your providers.

If you choose to work with a third-party CVO like Certify, you’ll also benefit from having a single source of truth to store and manage your provider data in real time, so you can ensure the information you’re working with is always accurate and up-to-date.

4. Better experience

Simply put, less time, cost, and work requirements mean a better experience for everyone, from your internal team members and providers to your external partners and patients.

Delays in credentialing can lead to growing frustrations for providers who are anxious to provide services, care for patients, and get reimbursed to generate revenue as quickly as possible. Delegated credentialing can improve their job satisfaction as well as the satisfaction of their patients, who don’t have to experience extended wait times to receive in-network care.

What Are the Eligibility Requirements for Delegated Credentialing?

A healthcare organization must satisfy certain requirements to qualify for delegated credentialing, which are imposed at the discretion of the payer they’re working with. Typically, requirements include having more than 50 providers and meeting a specific threshold of group enrollment applications.

If you’re working with an external CVO, that authorized service must also meet certain criteria to qualify as a credentialing (CR) delegate under the NCQA—like performing delegated functions for at least 70% of your providers.

Additional best practices may include:

• Having a contract in place and/or in negotiation. Ensure that all contractual agreements with external CVOs and payers are in place and clearly outline the responsibilities and obligations of each party.
• Credentialing policies and procedures. Establish credentialing policies, primary source verification (PSV), sanction monitoring, and additional procedures that are compliant with current standards, including CMS, state-specific regulations, and any additional procedures that are compliant with current standards.
• Establishing a dedicated peer review credentials committee. Set up a dedicated peer review credentials committee to oversee the credentialing process and ensure continuous quality improvement.

In addition to these official standards, if you’re tackling credentialing tasks like PSV in-house, your internal team must have the capacity to complete all of the necessary steps, ensure data sets meet compliance and regulatory requirements, and keep up with provider directories regularly to ensure your records are complete and error-free.

How Can a Third-Party CVO Support Delegated Credentialing?

Digital health companies and other health systems can turn to expert third-party CVOs and other credentialing solutions to help with the delegated credentialing process.

Among other advantages, these partners can help you:

• Reach the group enrollment threshold that triggers delegated credentialing eligibility
• Ease administrative burdens, especially when it comes to time-consuming tasks like PSV
• Ensure effortless compliance throughout the credentialing process
• Consult on enrollment negotiations, contracts, reimbursement rates, and key policies and procedures
• Streamline NCQA survey preparations and (in the case of a fully NCQA-certified partner) provide automatic credit toward certain must-pass file review and non-file review elements

To maximize these benefits, we recommend looking for a CVO and/or enrollment solution that not only offers delegated credentialing support but a fully automated provider data platform that ensures efficiency and savings across the board.

How Certify Can Help

In addition to hands-on delegated credentialing support, Certify offers an industry-leading provider intelligence platform. Our API-first, automated data infrastructure can connect to hundreds of primary sources in real time and deliver thousands of verified provider data points in a matter of seconds—so you can get providers in-network and reimbursed for services faster.

Our superior provider data powers everything from one-click credentialing solutions to auto-filled, integrated enrollment applications, abstracting away the administrative details that hold you back from your full scaling potential.

To learn how they work, get in touch with our team at sales@certifyos.com—or request a live demo to see our platform in action.