1. CAMSS The Complexities of Managed Care Credentialing Mei Ling Christopher, UnitedHealthcare Sallye Marcus, Anthem Blue Cross

2. CAMSS Session Objectives What are the benefits of delegated credentialing Regulatory/Accreditation Survey process Electronic audit process

3. CAMSS Definitions Delegation occurs when an organization gives another entity the authority to carry out a function that it would otherwise perform. Sub-delegation occurs when the organization’s delegate gives a third entity the authority to carry out a delegated function. For example, the organization may delegate credentialing (CR) activities to a provider hospital organization (PHO), who then delegates some of those activities to an Management Services Organization (MSO). In this case, the MSO is the sub-delegate.

4. CAMSS Annual Audit: A health plan must conduct an audit at least every 12 months; 2-month grace period allowed (14 months). Documented Process: Policies and procedures, process flow charts, protocols, and other mechanisms that describe the methodology used by the organization to complete a task. Definitions (continued)

5. CAMSS The delegate has been given the power to carry out a specific function, within the parameters agreed to. The organization gives a delegate the authority to act on its behalf, but it remains responsible for the function to be carried out properly. The organization must conduct annual oversight activities of the delegate. NCQA requires the presence of a mutual agreement between the delegating organization and its delegate. Delegation

6. CAMSS Who are they? Delegates may be: –Medical Groups –Hospitals –Medical Universities –Independent Physician Associations (IPA) –Physician Hospital Organizations (PHO) –Management Service Organizations (MSO) –Credentialing Verification Organizations (CVO)

7. CAMSS Benefits of Delegation Reduce duplicate credentialing efforts Allow practitioners to become effective with the organization sooner Patients can be seen sooner by new practitioners Cost Savings – Better use of resources

8. CAMSS Survey Process Please ensure the health plan knows your organizations correct status: –Is your organization NCQA certified or accredited? –Does your organization sub-delegate to a NCQA certified CVO? –Is your organization delegated for Organizational Providers/Health Delivery Organizations?

9. CAMSS NCQA and the 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 the files and submit to NCQA is short. Survey Process (continued)

10. CAMSS Survey Process (continued) Rosters are required from all delegated groups for submission to NCQA –Roster should be in Excel spreadsheet, with two sheets/tabs –Include all date ranges of practitioners that have been processed with your organization –Do not include hospital based or allied health providers

11. CAMSS Survey Process (continued) For NCQA roster submission the following fields are required: –Last name –First name –Degree –Specialty –Initial credentialing date –Most recent recredentialing date –State –Name of organization

12. CAMSS Contents of a File Application/Signed Attestation State License Primary source verification (PSV) DEA or CDS Education/Board Certification Work History Professional Liability Insurance Malpractice Hx. (or NPDB) License Sanction Review Medicare/Medicaid Sanction review Cred. Committee Date (CMS Audits) - Hospital Privileges, Medicare Opt-Out and Performance Review for recredentialing The copies should either be dated/signed or initialed, or a checklist should be dated/signed.

13. CAMSS Electronic Audits Many Health Plans are moving to a desktop audit process –Reduces health care costs –Frees up time you would normally spend during the onsite audit –Notification well in advance of the audit outlining which files are needed, allowing time to gather and send the files –Provide electronic copies of the files via secure email or website, or conduct audit live via a webex/web meeting

14. CAMSS Electronic Audits (continued) The auditor will request: — Policies and Procedures, Evidence of reporting, sub- delegation agreements — A full roster to select 30 initial and 30 recredentialing files — The auditor will request the first 10 initial and 10 recredentialing files from the delegate — Additional files will be requested if there is a deficiency within the first 8 elements