What is it?

When a health plan “delegates” to a third party (us), they are effectively agreeing to allow the third party to verify the credentials of a provider and grant participation in the underlying contract to be paid by the health plan.  The idea is the health plan is giving the task over to a third party and gains reduced overhead but does not give up the right to set the standards by which the third party must comply.

Under delegation, we can:

  • Unify the schedule of effective dates
  • Unify the schedule of re-credentialing dates
  • Re-credential all the delegated plans every two years
  • Use one application process for initial and re-credentialing events (not 20 or 30)
  • Move providers to new tax i.d.’s within a matter of days
  • Best of all, reduce the average enrollment time to under 30 days

Two reasons.

1. It’s in our control. We are incentivized to make it a faster process to meet the needs of our clients. The one thing that differentiates us from the market is our ability to add value to our clients, you.

2. It’s more efficient. Since we are verifying one application that applies to as many as 20 or 30 plans, we get to focus our attention on that one application.

Is there that big of a difference between your timeframes and the industry?

Yes. Yes there is. According to the MGMA, the “ Industry Average Best” credentialing time with health plans is about 90 days. The “Industry Average Worst” credentialing time frame with health plans is about 180 days. Considering the average revenue of an Orthopedic Surgeon.

Surely there is a catch?

There are a couple of issues to remember.

1. Just like with the health plans, we can’t control the provider/administrator getting us a completed application and back up documents. We work feverishly at trying to overcome this communication issue. The “intake” process is troublesome. Once we get the completed application, we can get to work on it; however, we still may not be able to process the application quickly. See 2.

2. Once we have the completed application, we have to verify the data. A more complex application that includes a long and complex work history, overseas education or work, licensure board issues, malpractice claims, can all slow the process down.

3. “Loading”. This is the term we use for explaining the difference between the effective date, and the time the health plan has “loaded” the provider into their system for recognition. You still get the effective date but the health plan may not recognize the provider for days, or even months, depending on the efficiency of their internal process, not ours. You will still need to bill these plans to meet timely filing, but the health plan should pay you according to the contracts effective date.

Can you track this timeline?

Yes. We break the process down into parts that are tracked, monitored, and graphed through a tool on our clients login screen called the Credentialing Performance Summary. It starts with the date we are made aware of the provider’s planned start date. Then we track the Intake process up to the point of a complete application. Then our Data Integrity Management team logs the data and looks for any holes that may require further explanation or slow the process. Our Verification Team then takes over to verify the data according to industry standards. Once the verification is complete, we take the file through a committee of health care providers who will consider any “flags” or approve the file as clean. After committee approval is complete, we notify the health plans of the providers effective date. You can see more on our website functionality here.