1. 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

2. MAMSS 2016 Delegated Credentialing Panel
Sandra Dussault
Manager, Provider Credentialing

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

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

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

6. 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

7. 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

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

9. 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

10. 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

11. Contact Info
Sandra Dussault