Delegated Credentialing: What It Is and When It Makes Sense 

Delegated Credentialing: What It Is and When It Makes Sense 

A healthcare organization working closely with the patient doesn’t have much time to waste on in-house credentials. The best way is to hand over this responsibility to a trusted party or organization. Delegated credentialing is perfect for this. Here is everything you need to know about the process of delegated credentialing in healthcare.  

Taking the help of any other trusted party like credentialing verification organization (CVO) or managed care organization (MCO) for credentialing its own healthcare providers falls under the category of delegated credentialing. The party which is held responsible for performing the credentialing is called a delegated entity or client.  

In 2025, NCQA has made new rules in response to the challenges brought to light by recent market insights. The tendency towards delegated credentialing has changed as a result of revised policies that emphasize the drawbacks of manual approaches.  

Using the recent data analysis, the delegated credentialing has helped both the payer and provider group. 

Consider a large hospital which is working in collaboration with the MSO (Management services organization. MSO is best known for dealing with the non-clinical services for patient care like finances management, IT issues, HR services and quality assurance programs. Appointing a third-party for dealing with the credentialing issues of healthcare providers relieves the burden off their shoulder. Dealing with the accreditation bodies and credentialing committee is no longer a concern for them to worry about.  

How Delegated Credentialing Works?  

Where do your healthcare providers stand? If you are the one who does not compromise on the quality of healthcare services and reputation of organization, delegated credentialing is the best way to get rid of these worries. The question is how to start and how does it proceed. Following is the step-by-step guide showing how delegated credentialing program works: 

Delegation Agreement: One of the prerequisites is the delegation agreement, which is a mutual agreement made between a credentialing organization and a payer organization. Outlining the responsibilities, performance metrics and services in accordance with the policies considering the terms and conditions of the regulatory bodies like NCQA, CMS, URAC and laws of the state ensure the smooth processing.  

Collecting Data: The next step is to collect all the data from the healthcare providers regarding their personal information, employment history, licensures, and professional recommendations.  

Verifying the Authenticity of Data: The credentialing body looks for the authenticity of provided information by contacting the educational institutes to healthcare organizations for progressing the error-free credentialing. 

Provision of Credentials: Once data verification is complete, the healthcare organization provides credentials to the healthcare providers depending on the outcomes of data verification and recommendations of provider group.  

Monitoring and Re-credentialing: Monitoring is essential once delegated credentialing is completed to ensure that healthcare providers align with the optimum standards and updated qualifications.  

Who Qualifies (Operational and Compliance Requirements)  

Let’s have a look at the basic requirements for qualifying for the credentialing programs in accordance with the compliant clauses.  

NCQA delegation standards adhere to different compliance requirements, the most important of which is specific time lapse for primary source verifications (PSV). The following table shows the list of operational requirements along with their PSV time frame. 

Requirements	PSV Time Limit
License	180 days
Board certification:  In case the member is board certified, expiry date from the certificate is documented.	180 days
Work history: Healthcare workers have to give the reason for the employment gap if it is more than six months. The reason for the employment gap is included in the credential file.	365 days
Malpractice history: The delegated organization looks for the previous five years malpractice from the national practitioner bank.	180 days
Note:   Regarding education and CDS or DEA certification, no time limit is present. However, it is advised to take it before the day the committee decides.

The provider must know about the regulations of different operating regions to adjust their policies in due course. One must know the types of credentialing bodies to have a better understanding of delegated credentialing program requirements.  

Types of Delegated Credentialing Bodies:  

Credentialing Accreditation	Provider group  Have complete authority for credentialing along with the committee approval process.
CVO certification	Healthcare group No complete authority and also needs committee approval for the process.

Oversight, Audits and Quality Metrics 

The surveillance of delegated authorities is essential to keep a check whether the responsibilities assigned by the delegated group have been fulfilled or not. Shared delegation compliance audits can work for the required field. Main aspects to focus during the audit of delegated group are given below:  

• Reviewing of delegated agreements and appointment letters.  

• Assessment of risk management framework for streamlining delegated functions.  

• Reviewing the customer feedback section to assure that the delegated party is doing its work with honesty.  

• One of the main concerns is assessing how the delegated organization deals with conflict of interest without disrupting the basic code of conduct.  

• The computation of financial records including billings, invoices, payment processing and transaction is the task of auditor to ensure fair financial account management.  

• Assessment for credentialing and enrollment services of the delegated staff to estimate their worthiness of working in the healthcare organization.  

• The shared delegation audit identifies the areas of improvements to improve the shortcomings of organization and improve the efficacy.  

Hence, the audit group makes sure to control the risks, enhance efficacy, create room for improvement and assess whether the delegated entities are performing their duties according to the demands of healthcare organization or not.  

Pros and Cons for Receiving Groups  

Pros

Cons

Time saving: Handing over the process of credentialing to the professional saves both the time and effort of administrative staff.  Improved efficiency:  When administration do not have to spend time and efforts on credentialing provider enrollment maintenance service, utilization of that manpower and time for patient care and other important functions help in improving the efficiency of organization.  Faster Onboarding:   The healthcare organizations looking for a good turnover can rely on delegated credentialing companies. The expertise techniques will help them to fill the staff gap as early as possible.  Consistent Quality Providence: Credentialing by the third party works under strict protocols ensuring the maintenance of standardized procedures to keep going with the error-free credentialing.  Cost reduction: Outsourcing the credentialing process saves expenses required to hire and train the staff for in-house credentialing. Moreover, the cost spent on the operations for credentialing process is also saved. Good For Large Scale Organizations:  Delegated credentialing is ideal for large healthcare companies. A large organization means a greater number of employees and more accuracy for the credentialing. Third-party credentialing knows how to deal with the varying workload and without burdening the organization.   Risk-free Credentialing:  The professionals of the delegated credentialing team know all the necessary standards and protocols that can carry out an accurate delegated credentialing.  Enhanced Compliance with Accreditation Standards:  The National Committee for Quality Assurance (NCQA) has specific standards for dealing with the legit credentialing process. Third-party fulfilling all the accreditation standards is of prime importance for streamlined credentialing without any sanction.

Privacy Issues:  Sharing private information with a third-party raises the concerns regarding privacy. Personal information of healthcare providers is at stake if the third party does not have any precautionary measure for data protection. There is the need to adhere to regulatory bodies for data protection like the Health Insurance Portability and Accountability Act.  Dependency on Third Party:  If the organization is going through any crisis, the dependency on external body dealing with credentialing makes it difficult for the people to deal with in-house problems.  Chances of Miscommunication:  The working relationship between both parties speaks a ton about the smoothness of work. Miscommunication can lead to delays in the functional operations related to credentialing programs. It not only affects the staff but also affects the efficacy and patient care of healthcare organizations.  Lack of Credentialing Knowledge:  When the healthcare organization knows that an outside party is controlling the credentialing process, they do not pay much attention to details of the process and hence are deprived of the basic information about in-house credentials.  Legal Challenges:  With the delegation agreement, there comes the legal clauses that need to be followed. In case any one of the parties wants to terminate the agreement, legal action is taken or sometimes they must deal with the penalties.

Pros and Cons for Provider Group 

Pros	Cons
The provider group has excessive control over the credentialing process.  They have the authority to quickly add high-performing individuals ensuring better patient care in healthcare organizations.	Responsibility comes with the challenges. Sometimes, it is difficult to meet the complex compliance audits for the credentialing process.  The delegated entity has to make sure that they have professionals with updated and authorized knowledge to keep up with the credentialing program.  They may face issues regarding timely submissions and regular audits.

Getting Ready: Data, Policies, Team  

Delegated credentialing is best for running a healthcare organization effectively. Before getting ready for the process make sure to tick the following boxes: 

• Know the basics of delegated credentialing. 

• Completion of pre-delegated requirements. 

• Sustaining compliance with state regulations and industry principles.  

• Securing expert support for long time run.   

The provider group can take help from the experienced delegated credentialing consultant to assess the compliance with state regulations, make an effective credentialing committee, form new policies or review the old ones.  

Frequently Asked Questions:  

1. What is the difference between delegated credentialing and non-delegated credentialing?  

Delegated credentialing refers to handling the verification of credentials of healthcare provider to the third-party while non-delegated credentialing or credentialing involves performing the credential verifying process by in-house staff. 

2. How much time does delegated credentialing take?  

Delegated credentialing takes on average a few weeks to months. The duration depends on the scale of healthcare organization and the volume of data.  

3. What is the average cost of the delegated credentialing program?  

The cost depends on the agreement between the payer and the delegated party. However, it depends on the extent of services the organization receives and the duration for which the agreement is valid.  

4. Do payers accept delegated credentialing?  

No, not every payer can accept delegated credentialing. The payer agreement put forward from the paying group lists the necessary requirements depending on the company and region.  

Final Verdict:  

Delegated credentialing is not everyone’s cup of tea. However, educating yourself regarding the credentialing and its requirements is beneficial for both healthcare providers and provider groups. Make sure the organization is eligible to participate in the credentialing process. Both parties should be clear about what the delegated credentialing means. 

Don’t burden yourself with the ifs and buts of delegated credentialing. Still confused about payer delegation? Get help from our credentialing experts at Credex Healthcare. At Credex, we value delegation oversight.