The Complexities of Managed Care Credentialing

1. The Complexities of Managed Care Credentialing Mei Ling Christopher, UnitedHealthcare Sallye Marcus, Anthem Blue Cross

2. Session Objectives • What are the benefits of delegated credentialing • Regulatory/Accreditation Survey process • Electronic audit process

3. Definitions • Delegation occurs when an organization gives another entity the authority to carry out a function that it would otherwise perform. • Sub-delegation occurs when the organization’s delegate gives a third entity the authority to carry out a delegated function. • For example, the organization may delegate credentialing (CR) activities to a provider hospital organization (PHO), who then delegates some of those activities to an Management Services Organization (MSO). In this case, the MSO is the sub-delegate.

4. Definitions (continued) • Annual Audit: A health plan must conduct an audit at least every 12 months; 2-month grace period allowed (14 months). • Documented Process: Policies and procedures, process flow charts, protocols, and other mechanisms that describe the methodology used by the organization to complete a task.

5. Delegation • The delegate has been given the power to carry out a specific function, within the parameters agreed to. • The organization gives a delegate the authority to act on its behalf, but it remains responsible for the function to be carried out properly. • The organization must conduct annual oversight activities of the delegate. • NCQA requires the presence of a mutual agreement between the delegating organization and its delegate.

6. Who are they? • Delegates may be: • Medical Groups • Hospitals • Medical Universities • Independent Physician Associations (IPA) • Physician Hospital Organizations (PHO) • Management Service Organizations (MSO) • Credentialing Verification Organizations (CVO)

7. Benefits of Delegation • Reduce duplicate credentialing efforts • Allow practitioners to become effective with the organization sooner • Patients can be seen sooner by new practitioners • Cost Savings – Better use of resources

8. Survey Process • Please ensure the health plan knows your organizations correct status: • Is your organization NCQA certified or accredited? • Does your organization sub-delegate to a NCQA certified CVO? • Is your organization delegated for Organizational Providers/Health Delivery Organizations?

9. Survey Process (continued) • NCQA and the health plans retain the right to request the verification documents as evidence, regardless of certification or accreditation status. • The look back period is 36 months prior to the survey date. • Once notified by NCQA of the files selected the timeframe to collect the files and submit to NCQA is short.

10. Survey Process (continued) • Rosters are required from all delegated groups for submission to NCQA • Roster should be in Excel spreadsheet, with two sheets/tabs • Include all date ranges of practitioners that have been processed with your organization • Do not include hospital based or allied health providers

11. Survey Process (continued) • For NCQA roster submission the following fields are required: • Last name • First name • Degree • Specialty • Initial credentialing date • Most recent recredentialing date • State • Name of organization

12. Application/Signed Attestation State License Primary source verification (PSV) DEA or CDS Education/Board Certification Work History Contents of a File • Professional Liability Insurance • Malpractice Hx. (or NPDB) • License Sanction Review • Medicare/Medicaid Sanction review • Cred. Committee Date • (CMS Audits) - Hospital Privileges, Medicare Opt-Out and Performance Review for recredentialing The copies should either be dated/signed or initialed, or a checklist should be dated/signed.

13. Electronic Audits • Many Health Plans are moving to a desktop audit process • Reduces health care costs • Frees up time you would normally spend during the onsite audit • Notification well in advance of the audit outlining which files are needed, allowing time to gather and send the files • Provide electronic copies of the files via secure email or website, or conduct audit live via a webex/web meeting

14. Electronic Audits (continued) • The auditor will request: • Policies and Procedures, Evidence of reporting, sub-delegation agreements • A full roster to select 30 initial and 30 recredentialing files • The auditor will request the first 10 initial and 10 recredentialing files from the delegate • Additional files will be requested if there is a deficiency within the first 8 elements