Credentialing in healthcare is a vital process that verifies the qualifications of healthcare providers, ensuring they meet the standards set by insurance companies and regulatory agencies. However, as healthcare organizations grow, managing the credentialing process in-house can become overwhelming. This is where delegated credentialing comes into play. By allowing third-party entities to manage credentialing, healthcare organizations can streamline the process and focus on providing quality care.
In this post, we’ll explore the ins and outs of delegated credentialing, how it works, and why it matters. Plus, we’ll explain the difference between delegated and non-delegated credentialing. And if you’re looking for the best medical credentialing services, consider Medical Credentialing Services by Streamline Billing Group, a trusted partner for healthcare organizations looking to optimize their credentialing process.
What is Delegated Credentialing in Healthcare?
Delegated credentialing is a process in which a healthcare organization transfers the responsibility of credentialing its providers to a third-party entity, often a medical group, health plan, or credentialing service. This means that instead of each provider undergoing credentialing individually through an insurance company, the delegated entity takes charge of verifying provider qualifications on behalf of the payer.
For instance, if you work with an insurance company that allows delegated credentialing, your organization can submit its credentialing data for approval rather than relying on the insurance company to credential each provider one by one.
Delegated Credentialing Meaning
Delegated credentialing allows the healthcare organization (also known as the delegated entity) to act as a liaison between the provider and the insurance companies. The delegated entity ensures that all required documents are up-to-date, including the provider’s qualifications, certifications, and licensure. In return, this saves time and effort for the insurance company.
What is a Delegated Network?
A delegated network refers to a group of healthcare providers who are credentialed through a third-party entity, rather than going through the insurance company directly. This network is responsible for ensuring that its members meet the credentialing standards set by health plans or other payers. When the network or group is delegated, it manages all aspects of the credentialing process internally.
Delegated vs. Non-Delegated Credentialing
Understanding the difference between delegated and non-delegated credentialing is essential for healthcare providers seeking to streamline their credentialing process.
- Delegated Credentialing: In this model, a healthcare organization (delegated provider) or network manages the credentialing process on behalf of a payer, allowing for more streamlined onboarding of new providers. The delegated entity is responsible for ensuring the accuracy and completeness of the credentialing process. This saves time and helps ensure that providers can see patients sooner.
- Non-Delegated Credentialing: Here, each provider must undergo credentialing directly with each payer or insurance company. This process can be more time-consuming, as it requires multiple submissions of the same documentation to different payers.
In most cases, delegated credentialing is the preferred method for larger healthcare organizations because it allows for greater control over the process and ensures timely onboarding of new providers. Smaller organizations or independent practitioners may opt for non-delegated credentialing if they do not have the resources to manage the process internally.
Delegated Providers vs. Non-Delegated Providers in Healthcare
A delegated provider is a healthcare professional who is credentialed through a delegated network or entity. In contrast, a non-delegated provider must go through individual credentialing processes with each payer.
For example, in a delegated system, a large healthcare network could credential its providers and submit the information to multiple payers at once. A non-delegated provider, on the other hand, would have to apply individually to each insurance company, prolonging the onboarding process.
Why Is Delegated Credentialing Important?
Delegated credentialing offers several key benefits for healthcare providers and organizations:
- Faster Provider Onboarding: Delegated credentialing accelerates the process of getting new providers approved by payers, allowing them to begin seeing patients sooner.
- Cost Savings: Managing credentialing internally reduces administrative costs. It eliminates redundant work, as providers do not need to apply for credentialing multiple times with different insurers.
- Improved Accuracy: When a single entity manages credentialing, it can ensure consistency and accuracy across all providers. This reduces errors, such as missed documentation or incorrect credentialing status.
- Increased Efficiency: Delegated credentialing streamlines the credentialing process, freeing up time and resources that healthcare organizations can use to improve patient care.
Challenges of Delegated Credentialing
While delegated credentialing offers many benefits, it’s important to be aware of potential challenges:
- Compliance: The delegated entity must follow strict compliance standards set by the payer. Failure to meet these requirements can result in the loss of delegated status, forcing the healthcare organization to return to non-delegated credentialing.
- Audits: Payers may periodically audit the delegated entity to ensure that the credentialing process meets their standards. Healthcare organizations must be prepared to undergo these audits and maintain thorough documentation.
- Resource Allocation: Delegated credentialing requires significant resources and expertise. Healthcare organizations must ensure they have a dedicated team to manage the credentialing process effectively.
Tips for Successful Delegated Credentialing
To ensure that your delegated credentialing process runs smoothly, follow these tips:
- Establish a Dedicated Credentialing Team: Assign experienced staff to manage the credentialing process and ensure compliance with payer requirements.
- Regularly Update Provider Information: Make sure all provider documentation is up to date, including licensure, certifications, and background checks.
- Prepare for Audits: Keep detailed records of all credentialing activities, and be ready to provide documentation to payers during audits.
- Outsource Credentialing Services: If managing the credentialing process internally seems too complex, consider outsourcing it to a trusted partner like [Streamline Billing Group](https://streamlinebillinggroup.com/credentialing-services-2/). They have the expertise to handle both delegated and non-delegated credentialing, ensuring compliance and efficiency.
Testimonial: Satisfied Customer from Elizabethtown, Kentucky
“As the manager of a growing medical practice in Elizabethtown, Kentucky, credentialing our providers was becoming overwhelming. After contacting Streamline Billing Group, they took over the entire process. Their team handled both delegated and non-delegated credentialing with ease, ensuring all our providers were credentialed quickly. We are now able to focus more on patient care, and I couldn’t be happier with the results. Streamline Billing Group is a game-changer for our practice!” — John D., Elizabethtown, Kentucky
Delegated Credentialing Codes
When discussing delegated credentialing, it’s important to understand how CPT and ICD codes relate to the services offered by healthcare providers. While credentialing itself does not use CPT or ICD codes, these codes are essential for the services that credentialed providers offer.
For example:
- CPT 99213: This is the code for an office visit, and providers must be credentialed to offer these services to patients covered by insurance.
- ICD-10 Z00.00: This is the diagnosis code for a general health check-up, which is commonly billed by credentialed providers.
Conclusion
In conclusion, delegated credentialing simplifies the credentialing process for healthcare organizations, allowing them to onboard new providers more efficiently and ensure compliance with payer requirements. By partnering with a trusted entity like Streamline Billing Group and use their Medical Credentialing Services, healthcare providers can save time, reduce administrative costs, and focus more on patient care.
Whether you’re managing a small practice or a large healthcare organization, delegated credentialing can provide significant benefits. Consider outsourcing your credentialing services to professionals to ensure a smooth and compliant process.
External Resources:
1. NCQA Credentialing Guidelines
2. CMS – Credentialing and Privileging
Streamline Billing Group is ready to assist you in simplifying the credentialing process, whether delegated or non-delegated. Contact them today for expert help!