Delegated Credentialing: Speed Up Enrollment and Reimbursement Faster

Course Description:

The payor enrollment process can take six months or longer for commercial payors. It is a time-consuming process that creates barriers to practitioner onboarding and revenue generation. Payor enrollment can delay the onboarding process for months, especially with commercial payors. These delays create issues with provider satisfaction, patient satisfaction, revenue generation, access to care and, ultimately, patient safety.

Delegated credentialing can simplify the enrollment process by allowing health care organizations to accept responsibility for credentialing their own providers. There are several steps involved in becoming delegated with health plans. Organizations must complete a pre-delegation process, including a file audit and review of their policies and procedures in order to become delegated with a payor. Once the organization is delegated, they are able to control the credentialing and approval process for the payor and greatly reduce the timeline for payor credentialing.

This presentation will review how payor enrollment and delegated credentialing affect revenue cycle. Focus will be given to the benefits of delegated credentialing and steps to successfully complete a pre-delegation audit and implement a delegation agreement with payors.

Learning Objectives:

Define payor enrollment, delegated credentialing and revenue cycle
Explain the difference between payor enrollment and delegated credentialing
Discuss payor enrollment and delegated credentialing’s impact on revenue cycle
Compare payor enrollment turnaround times
Determine the feasibility of delegated credentialing for your organization
Understand the steps to become delegated with health plans

Areas Covered in the Session:

What is Revenue Cycle?
The Effect of Onboarding Delays on Revenue Cycle
Payor Enrollment
- What is Payor Enrollment?
- Government Payor Enrollment
- Federal & State Plans
  - Medicare (PECOS)
  - Railroad Medicare
  - Tricare
  - Medicaid
  - CHIP
- Commercial Payor Enrollment and Timelines
Common Denial Reasons
- Uncredentialed Provider
- Timely Filing
What is Delegated Credentialing?
Delegated Credentialing Timeline
Delegated Credentialing – Impact on Revenue Cycle
Delegated Credentialing – Determining the Feasibility
Compliance
- Credentialing Plan
- NCQA Guidelines CR8
NCQA CR8: Element A-Delegation Agreement
NCQA CR8: Element B – Pre delegation Evaluation
NCQA CR8: Element C – Review of Delegate’s Credentialing Activities
Element D – Opportunities for Improvement
Staffing Levels
- Determine Adequate Staffing Levels
- Specialist To Provider Ratio
SBAR Analysis
- Situation
- Background
- Assessment
- Recommendation
Credentialing Turnaround Times
- What is your current turnaround time?
- Does it meet payor requirements?
- Track and trend TAT
Software
- Software Compliance
- Secure Environment
- Audit Reporting
- No Surprises Act
Delegated Credentialing – Software Comparison Grid
Review Guidelines for Credentials Committee & File Approval
- What would your approval process look like?
  - MSO
  - CVO
  - Medical Practice
CR 2: Credentialing Committee
Delegated Credentialing – How?
- Determine Eligibility Requirements
- Document Review
- Credentialing Plan
- Initiate Pre-delegation Process
Credentialing Software
- Audits
- Practice Information
- System Security and Access
Preparation for Pre-Delegation Audit
- Perform Self-Audit of Potential Files
- Virtual vs. Onsite Audits
- Staff Education
Next Steps
- Delegation Agreement
- Legal Review
- Fee Schedule Negotiation/ Acceptance
- Contract Execution
Credentialing Process
- Quality Issues/ Complaints
- Ongoing Sanctions Monitoring
- Medicare Opt-Out
- Credentialing System Control/ Audit Log
Approval Process
Reappointments
Reporting and Rosters

Suggested Attendees:

Authorized officials
Delegated officials
Revenue cycle directors
Credentialing
Enrollment
Office Manager
Revenue Cycle
Operations
Billing Team
In and Out of Network Providers
Medical Billing Companies
Providers’ Office Staff
Physician
Hospitals and Facilities
Insurance Companies
Healthcare Attorneys
Executive and Administrators
Front Desk
Scheduling
Authorizations Staff
Medical Assistants
Certified nursing assistants
Credentialing and Enrollment Specialists
Practice Administrators
Revenue Cycle Managers
Provider Enrollment Managers and Directors
CVO Managers and Directors

About the Presenters:

Tammy West is Director Professional Services for The Hardenbergh Group. She brings 25 years of experience in healthcare administration and 16 years in Medical Staff Services. Tammy specializes in CVO operations, provider credentialing, provider enrollment, quality analysis, quality improvement, quality auditing, delegation audits, and policy and procedure creation and implementation. She has extensive experience with CMS, TJC and NCQA requirements for provider credentialing and medical staff services.

Prior to joining The Hardenbergh Group, Tammy was a consultant and independent contractor for hospitals, health systems, CVOs, locum companies and private practices across the United States. She has vast experience as an MSP, including credentialing specialist, provider enrollment specialist, medical staff coordinator, Medical Staff Manager, and CVO Director.

Tammy was a CVO Manager where she was responsible for creating and implementing policies and procedures for a new corporate CVO for a large health system. During her tenure, the CVO achieved NCQA accreditation and delegated credentialing status with commercial payors. Additionally, Tammy worked as a quality auditor for an NCQA certified managed care company and an Adjunct Instructor teaching medical office systems classes.
Tammy has a BS in Human Services Management and a master’s in healthcare administration with a minor in Education. She is a member of the North Carolina Association Medical Staff Services and the National Association Medical Staff Services.

Additional Information:

System Requirement:

Internet Speed: Preferably above 1 MBPS
Headset: Any decent headset and microphone which can be used to hear clearly
For more information, you can reach out to the below contact:
Toll-Free No: 1-302-444-0162
Email: care@skillacquire.com

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