MAMSS Delegated Credentialing Panel May 19, 2016 Bob DeMayo Director, Medical Staff Affairs and Credentialing, Boston Medical Center Kathleen E. Pollitt Manager, Provider Enrollment, Boston Medical Center Linda M. Campbell, RN-BC, CPHQ System Director, Medical Staff Services, Lahey Hospital & Medical Center Kathleen Marcin Manager, Provider Enrollment & Reporting, Lahey Hospital & Medical Center Sandra Dussault Manager, Provider Analysis & Credentialing, Fallon Health Jacqueline Mitchell, CPCS, CPMSM Credentialing Manager, Senior Whole Health Moderated by: Kate Powers, CPMSM Associate Director, Provider Services, Brigham and Women's Hospital /Brigham & Women’s Faulkner Hospital

MAMSS 2016 Delegated Credentialing Panel Sandra Dussault Manager, Provider Credentialing

Delegated Credentialing A formal process by which an organization gives another entity authority to perform credentialing functions on its behalf

Potential delegates Delegates may be: Hospitals Independent Physician Associations Physician Hospital Organizations

Credentialing – a requirement Fallon Health Credentialing is required to meet the National Committee for Quality Assurance (NCQA) credentialing standards for delegation

Delegation agreement Mutually agreed upon Describes the delegated activities and responsibilities Requires at least semi-annual reporting from delegate entity Describes the process to evaluate performance Specifies that the organization reserves the right to approve, suspend and terminate practitioners, providers and sites Describes the remedies available if the delegated entity does not fulfill its obligations

Pre-Delegation The organization must conduct a pre-delegation audit prior to the effective date of the delegation agreement The presence of a mutual agreement between the delegating organization and its delegate is required The Auditor will request: Your policies and procedures, the evidence of reporting, and sub-delegation agreements A full roster to select 30 initial and 30 recredentialing files The Auditor will request the first 8 initial and 8 recredentialing files from the delegate Additional files will be requested if there is a deficiency with the first 8 elements

Ongoing delegation Annually review delegate policies and procedures Annually audit credentialing and recredentialing files against NCQA standards Annually evaluates delegate performance against NCQA standards

NCQA survey process NCQA and health plans retain the right to request the verification documents as evidence; regardless of certification or accreditation status The “look back period” is 36 months prior to the survey date Once notified by NCQA of the files selected, the timeframe to collect and submit is short

Benefits to delegation Eliminates duplication and reduces cost because practitioners do not have to complete a credentialing application for each health plan Enhances third party payer reimbursement for contracted entities Patients can be seen sooner by new practitioners Effective use of resources

Contact Info Sandra Dussault 1-508-368-9819 sandra.dussault@fallonhealth.org