Delegated Credentialing: How It Can Impact Your Revenue

 In Articles, Credentialing, Provider Notes

What is Delegated Credentialing?

As health systems grow larger, more and more providers are being credentialed with insurance carriers under what is known as Delegated Credentialing. This is a process where an organization, most often a large health system, is given authorization by a specific insurance carrier to perform credentialing in-house.

The authorization includes an agreement by that carrier to accept all claims from any provider credentialed in-house as in-network, provided the service(s) were performed at a location also owned and operated by the same health system. While the provider may be “fully credentialed,” the in-network status of the provider with the insurance carrier only applies to the health system that performed the Delegated Credentialing.

How does it affect credentialing my providers?

This Delegated Credentialing status affects a provider when they turn to an independently owned private practice for employment, whether they are leaving the larger health system altogether or simply joining a practice part-time. A provider who is under Delegated Credentialing with a large health system is not considered credentialed for private practice. The traditional credentialing process needs to take place, which takes on average 60-90 days once the insurance carrier has all of the required documentation.

In some cases, the Delegated Credentialing status can be hard to break. We have had instances where a provider has left the position and facility that held their Delegated Credentialing with United Healthcare, but have been unable to credential that provider in the traditional manner until the health system that put the Delegated Credentialing in place formally contacts the insurance carrier and breaks the bond.

What should I do?

When seeking to add a provider to your practice, their CV is the best place to start. If there is work history for a major health system or entity in your local area (UNC, Duke, & Novant are just some examples in North Carolina), then ask about Delegated Credentialing. You should not assume that any provider who is accepting patients from all insurance carriers is credentialed for private practice.

If you are a provider that has worked for a large system, ask about your credentialing status now! It’s good to know and understand your credentialing status with the insurance carriers you are contracted with and who are paying for your services. Your current credentialing status is information you are entitled to, along with all of your I.D. numbers, and the credentialing department should readily provide them to you.

Can a provider have both Delegated and Traditional Credentialing?

Yes, there are many providers who keep their position that assigned them Delegated Credentialing status and also choose to work for a private practice. There is a process in place that allows Delegated providers to work for a private practice. However, if at any time the provider terminates their employment with the health system that put their Delegated credentialing in place, ALL credentialing will be terminated and the provider will need to go through the traditional credentialing status from the beginning. This is just another reason why it is very important to know your credentialing status, and keep your practice administrator/credentialing department informed of all changes to your employment.

The Revenue Effect

Delegated Credentialing affects the time and process it takes to credential a provider for work in a private practice.  Likewise, leaving the employment of an organization that applies Delegated Credentialing can cause a provider to suddenly be out of network with all commercial carriers. Lapses in network participation can be avoided if you know how you are credentialed and by keeping all of your current (and future) employers of any change in employment status.

Summary

Delegated Credentialing is not a road block to becoming a credentialed provider with a private practice; it is more of a detour. The steps needed to put traditional credentialing in place are slightly different and can be more easily maneuvered if the Delegated Credentialing is known about from the start. Likewise, lapses in participating provider status can be avoided by keeping your practice administrator/credentialer informed about any changes to your employment status, even if those changes occur outside their organization. Every change in your work status can affect your credentialing status with all of the organizations you provide services

For more information on Delegated Credentialing, contact us at info@msochealth.com.

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