1. Diana K. “Di” Hall, CPCS CPMSM – Sr. Director, Compliance & Quality
Managed Care Challenges and Opportunities -- Credentialing, Provider Enrollment & Delegated Credentialing
Diana K. “Di” Hall, CPCS CPMSM – Sr. Director, Compliance & Quality

2. How are we going to roll today?
Managed Care Credentialing
Expectations of Regulatory Bodies
Differences from traditional “hospital” credentialing
Provider Enrollment
Responsibility
Making Delegation work for your facility
Delegation
Discussing NCQA guidelines for delegation
Looking at a sample delegation contract
Examining Compliance Measures

3. Who are you and where are you from?
Di Hall – MSP since 1993
Married to Ike, who is the Radiation Safety Officer at Emory University Hospital (Atlanta)
We like penguins
Dually Certified by NAMSS
Have worked at MDA/CREDENT since 2006. 
CREDENT is certified by the National Committee for Quality Assurance (NCQA) for 10 out of 10 elements through September 2017.

4. Managed Care
“A system of health care in which patients agree to visit only certain doctors and hospitals, and in which the cost of treatment is monitored by a managing company.”

5. What is Credentialing?
The collection, verification and review process used to determine current professional qualifications of a provider.
Does the clinical provider meet pre-established criteria for participation in a health care setting (hospital medical staff/managed care network)?

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

7. Managed Care Credentialing
Public Regulatory Bodies
CMS – Medicare Managed Care
Private Regulatory Bodies
NCQA: Health Plan; Managed Behavioral Health Organizations; Credentialing Verification Organization
URAC: Credentials Verification Organization; Health Plan; Health Network

8. Accredited Managed Care Entities must follow similar guidelines for other healthcare Accreditation
Organized to deliver healthcare
In compliance with all local/state/federal laws
Have a representative population of the entity’s clinicians on the Credentials Committee
Be ethical and non-discriminatory in making decisions
Have secure and confidential handling of all documentation

9. At a minimum for Managed Care:
Credentialing Basics
At a minimum for Managed Care:
Appropriate Licensure
Appropriate DEA/CDS Certification
Appropriate training/Board Certification
Appropriate Malpractice Coverage
Appropriate review of sanctions/claims activity
Appropriate review of application packet

10. CVOs must follow their Client’s Credentialing Guidelines
URAC/NCQA have straightforward rules of what must be verified, how it must be verified and for how long that verification is valid before Credentialing Committee review. CVOs are contracted to by healthcare entities to take off the burden of qualification verification from their staff.

11. Provider Enrollment
Contracting and credentialing oversight with healthplans by physicians, advanced practice clinicians, and healthcare entities (e.g. hospitals).
State Medicare Plans
Medicare
Insurance Companies

12. Other types of Provider Enrollment
CAQH Account Set-up & Maintenance
DEA/CDS registration
Licensure application
Billing
IPA or Physician Groups

13. DELEGATION!! Who is responsible? Does this live in the MSO?
Does your entity do this internally or does it delegate to others?

14. Delegation – what is it good for?
Why do it?
Who allows it?
How do we do it?

15. 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

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

17. 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?

18. 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

19. 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

20. 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)

21. So what does NCQA say about Delegation?
NCQA HP Credentialing Standards Delegation of Credentialing The delegator must review five percent or fifty of the delegated entity’s credentialing files, whichever is less, as evidence if its oversight. A minimum of 10 initial credentialing and 10 recredentialing files must be reviewed. (Audit requirement is eliminated if CVO/delegated entity is NCQA certified.)

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

23. Delegation Agreement - Sample
Elements of an Agreement
Exculpation
Term of Agreement
Termination
Performance Evaluation
Correction Action Plans
Mediation/Arbitration
Illegality

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

25. Compliance Measures - Delegator
What are your expectations?
Format of Data
Format of Delivery
Timeliness of Data Delivery
Verifications
Copy of verification
Provider profile of element/date/verifier
Other

26. Compliance Measures - Delegate
Reporting Outliers
Measuring internal compliance
Completeness
Accuracy
Timeliness
Other

27. Auditing – friend or foe?
Set up a calendar
Make a formal request
Date/Time
Number of files
What is being audited
Provide immediate feedback

28. Auditing Tips & Tricks Be comfortable!! Be friendly!
Make expectations/needs known before date of audit.
Prepare audit tools/files.
Communicate, communicate, communicate!
What are your tips?

29. Questions?
Di Hall, CPCS CPMSM Sr. Director, Compliance & Quality Improvement Medical Doctor Associates LLC CREDENT Verification & Licensing Services LLC Phone: