How to establish delegated agreements for efficient enrollments

In a time when health care is changing fast, with new services and more chances to grow, adding new providers to health plans can be a tough task. 

And when we're all focused on keeping patients safe and making health care affordable, the credentialing and enrollment process for providers can often feel like more of a problem than a help. 

This essential, yet highly regulated process can take up to six months to complete, resulting in delayed payer reimbursements and limited patient access.

And this prolonged timeline can lead to late payments from payers and less access for patients. It can also make providers feel frustrated. Some studies even show that providers spend about 17% of their working hours on manual collection of the required information and documentation. 

Then it’s a waiting game.

Yet, there's a strategy that can change the game: delegated agreements. When properly executed, these agreements can significantly expedite the credentialing process, speed up provider onboarding and fast-track reimbursements.

What are delegated agreements?

Embracing delegated agreements as a strategy could give your provider group the competitive edge it needs to thrive in the modern health care landscape.

Before diving into the benefits, it’s important to understand what delegated agreements are.

To accept insurance, provider groups must enroll their providers with payers. We already know that the enrollment process — while a key component ensuring health care professionals meet the necessary qualifications to deliver safe, high-quality health care — is time consuming and labor intensive. 

However, there's an alternative: delegated credentialing. 

This is when the payer delegates the credentialing responsibility to the credible and proven provider groups they work with — a shift that forms the basis of a delegated credentialing agreement.

Instead of payers managing credentials and applications, the responsibility lies with provider groups. 

The benefits of delegated agreements

Delegated credentialing agreements flip the script and quicken the decision-making process for insurance companies to add a provider to their panel, and set a start date for membership. Other benefits include: 

Speed

Because credentialing requirements vary from payer to payer (as well as from state to state), delegated agreements allow provider groups to accelerate the credentialing process, bypassing the delays that come with the involvement of payers who may be managing numerous providers simultaneously. In such cases, primary source verification takes days, not weeks or months.

For instance, to credential 100 providers with a payer like Aetna in Texas without a delegated agreement would entail submitting 100 separate payer enrollment applications. 

Control

During the enrollment process, provider groups must send a large volume of information to payers, often leading to a lack of transparency and control. Once the information is sent, it's challenging to track its status. 

Has it been received? Is the payer working on the credentialing? There are instances where provider groups can track updates via portals, but often they resort to calling or emailing the payer to gather information or expedite the process.

Moreover, without a delegated agreement, there's little room for expediting a specific provider or a group of providers, especially during expansion or growth. Provider groups are essentially at the mercy of payers to advance their providers through the process. 

Payers also typically work on applications in the order they receive them and each payer might have thousands of provider applications to review simultaneously. Waiting for a provider's turn in this massive queue could extend the credentialing process by weeks, or even months. This delay effectively freezes both patient care delivery and the billing process.

Financial gain

Closely tied to speed, quicker credentialing means faster reimbursement. As soon as providers are credentialed, they can begin accepting payments for their services, enhancing the financial health of the provider group. The quicker the credentialing, the quicker the revenue stream begins.

Why aren’t more organizations taking advantage of delegated credentialing and agreements?

Given the advantages, one might assume that delegated credentialing would be the go-to method for provider credentialing. However, there are barriers that discourage widespread adoption.

Risk avoidance

Payers, while delegating the credentialing process, still bear risk if issues arise with the credentialed providers. Hence, they tend to be cautious.

Time and resources

The delegation process is detailed and requires significant documentation, resources, and audits to prove competency. This process can be time-consuming and might distract from your primary focus - delivering health care services.

Reporting and auditing

Delegated provider groups must have strong record-keeping and reporting systems in place to meet payer auditing requirements. Delegation entails rigorous audits of your credentialing processes, requiring high standards and regular audits.

Expertise

Setting up a compliant delegated credentialing program requires specific industry knowledge, which can be a hurdle for those unfamiliar with the intricacies of the process.

Compliance certification

Though not mandatory, certifications such as NCQA or URAC help demonstrate compliance, speeding up the delegated credentialing process. You must meet all relevant compliance requirements, which can be intricate and demanding.

Provider group size

Payers usually require provider groups to meet certain size criteria for delegation, ensuring the groups have enough providers, sufficient experience in credentialing and can provide a substantial sample for auditing.

Despite the potential for increased speed and efficiency, smaller provider groups may find the initial requirements for delegated credentialing too daunting. Consequently, they may stick with traditional credentialing and enrollment processes until they have the capacity and infrastructure for delegated credentialing.

Exploring delegated agreements on your own

While securing delegated agreements independently offers direct control and potential cost savings, it's not without its challenges (see above). The process is complex, requires substantial resources, and involves strict audits and quality checks.

Here's a general example of what’s involved:

Preparation: Understand the process, its requirements, and evaluate your organization's capacity to manage credentialing.

Identify payers: Determine the payers with whom you wish to establish agreements based on business volume or growth opportunities.

Initiate contact: Express interest in a delegated agreement to the provider relations department of each payer and inquire about the application process.

Complete applications: This step can be complex and typically requires detailed information about your organization, including policies, staffing, and performance metrics.

Audit preparation: Be ready for potential audits, site visits, or virtual verifications of your credentialing processes and record-keeping practices.

Negotiate the agreement: If approved and audits are passed, establish the agreement's terms including credentialing timeframes, reporting requirements, and dispute resolution procedures.

Sign and implement: Once satisfied with the terms, sign the agreement and commence delegated credentialing tasks.

Maintain compliance and reporting: Regularly report credentialing activities to the payer, uphold agreement compliance, and be ready for periodic audits to ensure compliance.

While securing delegated agreements independently is viable, it demands significant investment in terms of time and resources. 

The winning advantage: securing delegated agreements with Medallion

Working with a credentials verification organization (CVO) like Medallion guides provider groups through establishing a delegated credentialing process. Medallion assists with the initial setup, audit preparation and setting up relationships with payers. 

Here's how we tackle four out of the five barriers listed in our earlier discussion:

Simplifying the delegation process: Medallion shoulders the bulk of the setup for the delegation process. We prepare the essential documentation, freeing your team to focus on preparing your providers for the process.

Meeting audit reporting requirements: Medallion provides built-in reporting and upholds credentialing documentation standards, ensuring you meet all requirements for payer audits.

Leveraging industry expertise: Our credentialing experts bring over a century of collective experience, offering guidance and support. This enables you to achieve compliant credentialing without adding headcount. 

Compliance certifications: We're NCQA certified, which payers often accept on behalf of the provider groups we work with. Our team has experienced 15-plus NCQA audits, with staff members who manage delegated audits for payers.

As for having enough providers to credential – while we can't directly influence this, we can potentially link to licensing to assist with recruitment efforts.

From barriers to credentialed and enrolled

Achieving delegated credentialing agreements is a complex process with stringent requirements. But with Medallion, you're not alone in this journey. We're here to turn those barriers into bridges, making the process of securing delegated agreements more efficient and less stressful.

Our comprehensive services, backed by industry expertise and dedicated support, empower you to focus on what you do best – providing quality health care. While we handle the administrative complexity, you can ensure your providers are ready to provide the best patient care.

What you should do now

When you’re ready, here are three ways we can help your organization move faster:

1. Book time with Medallion. Schedule a live demo with one of our experts and SMEs to see how Medallion can help your team reach their revenue goals. 
2. If you’d like to learn how to credential providers faster, visit our blog. It’s full of resources to help scale your efforts. 
3. If you know another provider operations specialist who’d enjoy reading this page, share it with them via email, LinkedIn or Twitter.