Delegated Credentialing: Achieving Success for …

1 1 Delegated credentialing : Achieving Success for your OrganizationAmy M. Niehaus, CPMSM, CPCS, MBAO ctober 7, 2014 Objectives Name the key components of a Delegated credentialing program under NCQA standards Outline the various elements of a Delegated credentialing agreement Summarize the required steps of the delegation audit process Identify the benefits of Delegated credentialing to both partiesSources NCQA 2014 Health Plan (HP) Standards and Guidelines - Effective for Surveys Beginning On or After July 1, 2014 (CR 9: Delegation of CR) NCQA Frequently Asked Questions NCQA Corrections, Clarifications and Policy Changes 2014 The Greeley Company, Inc.

2 All rights reserved. These materials may not be duplicated without the express written permission of the Greeley Company, is Delegation? Merriam Webster Dictionary: to give (control, responsibility, authority, etc.) to someone: to trust someone with (a job, duty, etc.) NCQA: delegation occurs when an organization gives another entity the authority to carry out a function that it would otherwise performWhy Delegate from Organization s Perspective? Reduces turnaround time for network participation Helps manage significant volume of providers Reduces resources (staff, budget, time) Accommodates network growth Supports contracting efforts Increases practitioner satisfactionWhy Become Delegated fromEntity s Perspective?

3 Reduces turnaround time for network participation Timelier reimbursement from payers Reduces resources for provider enrollment Depends on terms of agreement May still have other non- Delegated payers, CMS Further reduction if integrated with MSSD May provide contracting leverage Increases practitioner and patient satisfactionCopyright 2014 The Greeley Company, Inc. All rights reserved. These materials may not be duplicated without the express written permission of the Greeley Company, Entities Can Be Delegated To? The organization can delegate credentialing activities to a variety of entities, including IPAs PHOs CVOs Medical societies Other health plans HospitalsWhat Can Be Delegated ?

4 Portion of the credentialing process, such as primary source verification (PSV) Multiple credentialing processes, such as collection and review of the application and PSV All credentialing activities Organizations vary in the amount of Delegated activities that occur, if any Organizations may not delegate overall responsibility for credentialingWhat is Subdelegation? Subdelegation occurs when a Delegated entity contracts with a third party to perform a Delegated function Examples Payer to PHO to Hospital PHO to Hospital to CVO Payer to IPA to CVO Organization must receive results of delegate s oversight assessment or perform the oversight assessment directlyCopyright 2014 The Greeley Company, Inc.

5 All rights reserved. These materials may not be duplicated without the express written permission of the Greeley Company, Assessment Evaluation of the potential delegate s ability to perform required PRIORto signing an agreement Written review of delegate s understanding of standards and Delegated tasks Policies & procedures, file review Staffing levels Performance records NCQA Accreditation or Certification a plus! Onsite visit not requiredDiscussion PointIs there value in performing a site visit during the pre-delegation assessment, even though it is not required by NCQA?

6 Verification Timeframes under Delegation Timeliness determined based on date of credentialing decision Full credentialing Process - timeframes for each credentialing element mirror those required of the organization under NCQA Example: provider organization (PHO, IPA) License (180 days) Partial credentialing Process timeframes are 60 days less Example: CVO License (120 days)Copyright 2014 The Greeley Company, Inc. All rights reserved. These materials may not be duplicated without the express written permission of the Greeley Company, Agreement Must include the following elements.

7 Mutually agreed upon responsibilities of each party/activities being Delegated reporting frequency, at least semiannually performance evaluation process use of Protected Health Information (PHI) remedies for non-compliance right of the plan to make the final decision NCQA will review up to 4 Delegated agreements during surveyAnnual Assessment Annual reviews are performed to ensure that standards continue to be met Similar to pre-delegation review process Policies and procedures NCQA standards and Plan s own requirements File Review; NCQA audit process required 5% or 50, minimum of 10 each, OR 8/30 methodology Semiannual review of reports NCQA Accreditation or Certification a plus!

8 Discussion PointWhat is the NCQA 8/30 Rule and how does it impact the file audit?Copyright 2014 The Greeley Company, Inc. All rights reserved. These materials may not be duplicated without the express written permission of the Greeley Company, Assessment Onsite visit not required Performance improvement opportunities identified and followed up on, if applicable Corrective actions required if issues identified Education Corrective Action Plan Terminate agreement if non-compliant Files processed by a Delegated entity are viewed by NCQA in the same manner as if they were processed by the organizationTermination of Delegation Recredentialing must still occur at least every 3 years Organization may obtain files from the delegate and continue with established timeframes.

9 OR Perform initial credentialing within 6 months of terminationCredentials Verification Organization (CVO) An organization that conducts verification of practitioner credentials and other related activities on behalf of its clients Must comply with applicable federal, state and local laws and regulations, including any requirements for licensure or registration Maintain the necessary credentials information, policies and proceduresCopyright 2014 The Greeley Company, Inc. All rights reserved. These materials may not be duplicated without the express written permission of the Greeley Company, Certification NCQA offers CVO Certification program Evaluates.

10 Policies & Procedures Quality Improvement Customer Satisfaction Confidentiality/Security Scope of Services CVO cannot delegate NCQA standards to other organizationsNCQA Certified CVOs As of 5/31/2014, NCQA has certified 70 CVOs 2 year certification Standards address Policies & Procedures, Quality Improvement and Confidentiality 10 verification elements available for certification CVO Certification Elements Application and Attestation Content Practitioner Application Processing DEA or CDS Certification Education and Training License to Practice Malpractice Claims History Medicare/Medicaid Sanctions Medical Board Sanctions Ongoing Monitoring of Sanctions Work HistoryCopyright 2014 The Greeley Company, Inc.