Transcript Complexities of Managed Care Credentialing

CAMSS
The Complexities of Managed
Care Credentialing
Mei Ling Christopher, UnitedHealthcare
Sallye Marcus, Anthem Blue Cross
Session Objectives
CAMSS
What are the benefits of delegated credentialing
Regulatory/Accreditation Survey process
Electronic audit process
Definitions
CAMSS
• 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.
Definitions (continued)
CAMSS
• 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.
Delegation
CAMSS
• 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.
Who are they?
CAMSS
• Delegates may be:
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Medical Groups
Hospitals
Medical Universities
Independent Physician Associations (IPA)
Physician Hospital Organizations (PHO)
Management Service Organizations (MSO)
Credentialing Verification Organizations (CVO)
Benefits of Delegation
CAMSS
• 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
Survey Process
CAMSS
• 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?
Survey Process (continued)
CAMSS
• 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.
Survey Process (continued)
CAMSS
• 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
Survey Process (continued)
CAMSS
• For NCQA roster submission the following fields
are required:
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Last name
First name
Degree
Specialty
Initial credentialing date
Most recent recredentialing date
State
Name of organization
Contents of a File
•Application/Signed Attestation
•State License Primary source
verification (PSV)
•DEA or CDS
•Education/Board Certification
•Work History
CAMSS
• 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.
Electronic Audits
CAMSS
• 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
Electronic Audits (continued)
CAMSS
• The auditor will request:
— Policies and Procedures, Evidence of reporting, subdelegation 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