Managed Care Credentialing and Delegation Insights 2023

Managed Care Credentialing with a focus on Delegation and Contracting 2023 NYSAMSS May 5, 2023 Diana K. Di Hall CPCS CPMSM FMSP Manager, Provider Data Management Children s Healthcare of Atlanta

How are we going to roll today? Delegation Looking at What is needed for Delegated Credentialing Auditing/Audit Tools Discussing NCQA guidelines for delegation Looking at a sample delegation contract

Delegated credentialing = health care entity (delegator) + another health care entity (delegatee) Delegated Credentialing A Health Plan may delegate licensing verification to another entity via a contracted process that included rules, roles and responsibilities. Delegation may happen at all levels of healthcare, but remember that the final approval of a clinical provider s acceptance into a health plan or other delegator entity lives with the delegator. They act on data provided by the delegate.

Entities that delegate Provider Networks Health Plans(United, Cigna, Aetna, Blue Cross Blue Shield Plans) Preferred Provider Organizations (PPO) Accountable Care Organizations (ACO s) Specialty Provider Networks(Dental, Vision) Independent Physician Associations(IPA s) Who Delegates? Organizations that credentialing is delegated to: Provider Groups(single or multi-specialty, multiple or single location) Independent Physician Associations(IPA s) Hospitals & Hospital Systems Specialty Provider Networks( Dental, Vision)

Collaboration throughout your organization (Managed Care Contracting, Credentialing, Enrollment, Operations and Finance) What s Involved! Is your organization ready? Delagatee: Do you meet the criteria of the delegator (clinical provider types, PSV/Sanctions, credentials committee, Policies and Procedures) Delegator : Know the organization you are delegating to (Network Development, Provider Relations, Credentialing) COMMUNICATION IS KEY!!!

Pre-Delegation Audits: Performed by entity granting delegation(Health Plan). Review of organization s policies & procedures to ensure they meet or exceed entities(CMS,State & Federal, Accrediting organizations) policies & procedures. Review of credentialing files to make sure policies & procedures are actually being put into practice. Review of credentialing committee minutes. Delegated Credentialing Audits

Annual Audits: Performed to ensure that organization continues to meet or exceed entities (accrediting bodies) policies and procedures. Credentialing file review, review of Policies & Procedures to ensure reviewed annually and to review any required revisions( Federal, State, Accrediting Organization, Health Plan specific). Delegated Credentialing Audits Some Health Plans will waive Annual Audit if organization is accredited or certified by NCQA( still annual review of policies and procedures) Corrective Action Plan(CAP): If during Pre or Annual audit findings reveal non-compliance with Health Plans policies & procedures including Primary Source Verification errors a corrective action plan is put in place giving the organization an opportunity to correct/remedy issue(s) within a defined time period. Health Plan will perform review to ensure deficiencies have been put in place and being utilized.

Organization: Surveyor: Review Date: Policies and Procedure Score Notes Initial Credentialing Process Recredentialing Process Role of Medical Director Credentialing Committee Decision Making Process Type of Provider Specialties Example of Delegated Example of Delegated Audit Tool Audit Tool - - P&P/Committee P&P/Committee Minutes Minutes Primary Source Verification Options Verification Time Frames Recredentialing Time Frame Ongoing Monitoring Process Quality Process Complaint/Grievances Process Credentilaing Committee Minutes Score Notes Month 1 Month 2 Month 3

Who is responsible? Does this live in the MSO? Does your entity do this internally or does it delegate to others? DELEGATION!! Why should the MSO be involved with all delegation contracts and decisions? What might happen if the MSO is left out of any decisions made about delegation?

Qualifications vs. Competencies Qualifications* Education and Training Board Certification State Licensure DEA/CDS Privileges from other healthcare entities Competencies* Peer References Observation Procedure Logs Sanctions/Claims History *Documentation of current competence should come from the applicants peers. *Verifications should be from primary or approved secondary sources

So what does NCQA say about Delegation? NCQA HP Credentialing Standards Delegation of Credentialing A written document that is mutually agreed upon and describes - responsibilities of both the delegator and the delegated entity delegated activities

process used by the delegator to evaluate the delegated entity s performance NCQA HP Credentialing Standards Delegation of Credentialing So what does NCQA say about Delegation? delegator s remedies if the delegated entity does not fulfill its obligations delegator must review regular (at a minimum semi-annual) delegate reports

So what does NCQA say about Delegation? NCQA HP Credentialing Standards Delegation of Credentialing Should also include privacy and confidentiality protections. (HIPPA Health Insurance Portability and Accountability Act of 1996) Why is HIPPA important?

So what does NCQA say about Delegation? NCQA HP Credentialing Standards Delegation of Credentialing PHI Protected Health Information! Allows for PHI usage by delegate (if needed!) Delegate safeguards against improper use/release (and what THEIR sub- delegates do as well) Inform delegator of any issues with PHI use/release Return, destruction, protection of PHI at end of delegation agreement

So what does NCQA say about Delegation? NCQA HP Credentialing Standards Delegation of Credentialing The delegator must retain the right to approve new practitioners, providers, and sites - and when necessary to terminate or suspend individual practitioners or providers based on quality issues

So what does NCQA say about Delegation? NCQA HP Credentialing Standards Delegation of Credentialing Evaluation of the delegated agency must occur prior to delegation and at least annually - audit of files (cred/recred) against NCQA standards - audit of processes (verification/security) against NCQA standards - Delegate performance improvement (after one year of delegation)

Delegation Agreement - Sample Elements of an Agreement Obligations Responsibilities Oversight PHI Insurance Compensation/Expenses Delivery of Information

Delegation Agreement - Sample Elements of an Agreement Exculpation (to clear or excuse from blame) Term of Agreement Termination Performance Evaluation Correction Action Plans Mediation/Arbitration Illegality

Delegation Agreement - Sample Elements of an Agreement Assignment Governing Law Certification/Compliance Authority Exhibits/Attachments Pricing Elements for verification Other Services Covered

Questions? THANK YOU!!! Di Hall CPCS CPMSM FMSP Diana.Hall@choa.org 404-785-4571