Credentialing – To Delegate or Not To Delegate
Monday, May 5th, 2008 The National Committee for Quality Assurance (NCQA) sets the standard for credentialing in managed care. Defined as the “process by which a managed care organization (MCO) authorizes, contracts with, or employs practitioners who are licensed to practice independently to provide services to its members”, credentialing simply means making sure that a practitioner is qualified to render care to patients. Each MCO sets its own qualifications and then structures its processes to ensure that the practitioners meet these qualifications.
This blog entry is intended to provide the reader with an overview of credentialing requirements and the credentialing process, including delegation of some or all of the credentialing activities.
Each managed care organization (MCO) is responsible for establishing the criteria for participation within the health plan. The basic elements for a physician are likely to include the following:
1. Valid and current licensure
2. Appropriate education and training
3. Curriculum Vitae (CV)
4. Clinical privileges at a hospital
5. Valid Drug Enforcement Agency (DEA) certificate
6. Board certification (if required by the MCO or specified by the practitioner)
7. Work history
8. Malpractice insurance
9. History of liability claims
Regardless of the guidelines set, the MCO must put a system in place that ensures that its practitioners meet these standards before they are accepted as an active provider within the health plan. This system or process is commonly referred to as credentialing.
The credentialing process is just that – a process. It consists of a series of activities designed to lead to a decision to accept or reject an individual’s application to participate in the MCO as an active health care provider. A simple credentialing process is outlined below:
Application – Practitioners expressing an interest in participation with the MCO, and/or practitioners who meet the MCO’s organizational needs and administrative requirements, are invited to apply.
Initial Screening – Before proceeding with the next step, the application is reviewed to determine that it is complete.
New Provider Site Visit – The applicant is notified that a new provider facility assessment and medical record keeping process audit must take place.
Primary Source Verification – NCQA stipulates that seven criteria must be verified from the primary source because they identify the legal authority to practice as well as the relevant training and experience. MCOs may choose to use an external agency to collect information from the primary sources. If this is the case, the MCO has delegated this component of the credentialing process and must assume oversight functions. The criteria that require primary source verification include:
1. Valid license to practice
2. Status of clinical privileges at primary admitting facility
3. Valid DEA certificate, if applicable
4. Education and training of practitioners
5. Board certification if the practitioner states that he/she is board certified
6. Current adequate malpractice insurance
7. History of professional liability claims
File Preparation – Immediately following the initial screening, the file is prepared for presentation to a Credentialing Committee.
Data Entry – After all required data elements have been received, the individual practitioner’s credentialing file is entered into the MCO’s credentialing database and prepared for presentation to a Credentialing Committee.
The Decision – The decision to accept or reject an individual’s application is made by a Credentialing Committee.
References:
National Committee for Quality Assurance, The 2007 MCO Standards and Guidelines and Survey Tools
Related Web Site:
http://www.ncqa.org/ (NCQA)
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