Credentialing is a vital process for healthcare providers, ensuring they meet the necessary standards to deliver quality care to patients. However, not all credentialing processes are created equal. Two common methods are delegated credentialing and standard credentialing. While both aim to verify a provider’s qualifications, they differ significantly in their approach, timeline, and impact on healthcare organizations.
In this blog post, we’ll explore the key differences between delegated credentialing and standard credentialing, helping you understand why a provider who has undergone delegated credentialing at a large health system may still need an initial standard credentialing at a private practice.
What Is Standard Credentialing?
Standard credentialing is the process by which individual healthcare providers submit their credentials to each insurance company or payor for verification. The payor then conducts a thorough review of the provider’s education, training, licensure, work history, and other relevant qualifications.
Key Features of Standard Credentialing:
- Individual Review: Each payor conducts its own review of the provider’s credentials, leading to multiple, potentially redundant verification processes.
- Time-Consuming: Standard credentialing can be a lengthy process, often taking 60 to 120 days or more, depending on the payor and the completeness of the application.
- Consistency: Because each payor reviews credentials independently, there is a standardized, albeit slow, approach to ensuring all necessary qualifications are met.
- Limited Control: Providers have little control over the timeline or process, as they are subject to each payor’s internal procedures.
What Is Delegated Credentialing?
Delegated credentialing is a more streamlined process where a healthcare organization, such as a hospital or large medical group, is authorized by insurance payors to credential their own providers. Instead of each payor conducting its own review, the healthcare organization takes on the responsibility of verifying credentials according to the payor’s standards.
Key Features of Delegated Credentialing:
- Centralized Verification: The healthcare organization handles the credentialing process for all payors with which it has agreements, creating a single, unified process.
- Faster Processing: Credentialing is managed internally, making the process typically much quicker than regular credentialing. The organization can verify credentials and submit documentation to payors more efficiently.
- Increased Control: Organizations with delegated credentialing have greater control over the timeline and process, allowing for quicker onboarding of new providers.
- Accreditation Requirements: To engage in delegated credentialing, organizations must meet specific accreditation standards set by bodies like the National Committee for Quality Assurance (NCQA). This ensures that the organization has the necessary systems and processes in place to perform credentialing accurately and reliably.
Why Does My Provider Need Standard Credentialing If They Have Been Through Delegated Credentialing?
When a provider leaves a health system or large organization that operates under delegated credentialing, their credentialing status does not transfer with them. Delegated credentialing is tied specifically to the organization that holds the delegation agreement with insurance payors. Once a provider departs from that organization, they are no longer covered under its delegated credentialing agreement.
As a result, the provider’s credentialing information is effectively removed from the payor’s active records. Insurance payors have no existing file or recognition of the provider in their system when they join a new practice. This necessitates the submission of an initial standard credentialing application to re-establish the provider’s qualifications and re-enter them into the payor’s network under the new practice.
This initial credentialing process is crucial not only for reinstating the provider’s ability to bill for services but also for ensuring that all necessary verifications—such as licensure, certifications, and work history—are up-to-date and aligned with the standards of the new practice and the payors. Without completing this step, the provider would be unable to see patients under the new practice or receive reimbursement from insurance payors.
Conclusion
Understanding the differences between delegated credentialing and standard credentialing can help your practice make informed decisions during the hiring process. When hiring a provider or considering one, it’s important to know where they are currently employed. If they are employed at a large health system such as Essentia or St. Luke’s, they have likely undergone delegated credentialing. This means the timeline for their credentialing at your private practice may take longer due to the need for an initial application.
At Integrity Health Network, we specialize in guiding healthcare providers through the standard credentialing process. We are focused on helping independent private practices that don’t have the privileges of larger health systems. Our streamlined systems remove the burden of credentialing from your hands.
If you’re looking for assistance with credentialing your providers or want to learn more about your options, don’t hesitate to reach out. We’re here to help you navigate the complexities of credentialing with confidence.
