QUESTION: We are in the process of negotiating with insurers to conduct “delegated credentialing.” We would like to use our Medical Staff Credentials Policy to perform delegated credentialing, but during a pre-delegation audit, the insurer informed us that our Policy does not comply with accreditation standards. Why is that and what do we need to do?
ANSWER: By way of background, we are seeing significant interest from hospitals in pursuing delegated credentialing with insurers. Delegated credentialing means that the hospital performs the credentialing that insurers are required to do before accepting individual providers for participation with the insurers’ plans. Since the hospital is conducting the credentialing for the insurer, the regulatory requirements and accreditation standards that control are those to which the insurer is subject. The majority of these requirements and standards come from the Medicare Managed Care Manual, state Medicaid rules (if the insurer has Medicaid managed care plans), and insurer accreditation entities such as NCQA and URAC.
For the most part, these credentialing requirements and standards overlap with those for hospitals. However, there are a few differences that need to be addressed if you plan to use your Medical Staff documents for delegated credentialing. For example, the URAC accreditation requirements instruct that the Credentials Committee is tasked with making a “final determination” on applications. This can be a sticking point for insurers accredited by URAC and which are delegating credentialing to a hospital using its Medical Staff policies for delegated credentialing. The reason for this is because the Medicare Conditions of Participation and hospital accreditation entities, such as the Joint Commission, require the hospital’s board to make final decisions on applications for appointment and clinical privileges.
Nonetheless, this is not a difficult fix and you have a couple of options. The first is to adopt a Credentials Procedures Manual that works in conjunction with your Medical Staff Credentials Policy. You want to be sure that you note in this Manual that the procedures specified are designed to comply with, and for use in, the delegated credentialing process. A second option is to add an appendix to your Medical Staff Credentials Policy, which includes all the provisions needed to comply with the regulatory requirements and accreditation standards for insurers. For example, with respect to the “final determination” issue noted above, the appendix could instruct as follows: “For purposes of delegated credentialing and reporting practitioner effective dates to third-party payors, the date that the Credentials Committee, or chairperson of the Credentials Committee (for those applications that meet the criteria outlined in the Credentials Policy for “clean applications”), approves the practitioner’s credentialing will be used as the practitioner’s effective date.”