Managed Care Credentialing: Compliance Strategies for Health Plans, CVOs, and Delegated Entities

The role of the MSP is expanding to include payer enrollment and delegated credentialing responsibilities for managed care organizations. Traditionally siloed, MSPs are now beginning to take on both responsibilities, which means they must learn the nuances of managed care credentialing as well as the regulatory and accreditation requirements of NCQA, CMS, and URAC.

Managed Care Credentialing: Compliance Strategies for Health Plans, CVOs, and Delegated Entities provides the answers to MSPs’ inevitable questions as they begin to manage the tasks of payer enrollment and delegated credentialing. Author Amy M. Niehaus guides readers through each payer’s requirements, the differences between hospital and managed care credentialing, and how to help their organization establish delegated credentialing agreements and prepare for audits.

As new and existing MSP responsibilities begin to collide, this resource also outlines ways MSPs can modify their current processes to reduce duplication of efforts and develop a comprehensive and compliant managed care credentialing program. Whether you are new to managed care credentialing or are taking on delegated credentialing responsibilities, this book will help you:

• Learn the regulatory and accreditation requirements related to managed care credentialing
• Streamline the provider enrollment process through delegation
• Meet your organizational goals of compliance, operational efficiency, cost savings, and practitioner satisfaction
• Identify the differences between hospital and managed care credentialing

For bulk/group order please contact us at 855-225-5341 ext. 2715 or books@decisionhealth.com

Amy M. Niehaus, MBA, CPMSM, CPCS, is a credentialing and medical staff services consultant with over 25 years’ experience in the industry. She advises clients in the areas of accreditation, regulatory compliance, credentialing, privileging, process simplification/redesign, credentialing technology, CVO development and certification, enrollment, and delegation. Niehaus has worked in multiple environments throughout her career, including acute care hospitals, CVOs, and managed care organizations, which have provided her with unique and diverse insight into all facets of the medical staff services and credentialing profession. She has held numerous management roles culminating as a director of credentialing for a national health benefits organization. Since 2014, she has utilized her knowledge and experience as a consultant to support numerous clients within the healthcare industry.

Chapter 1: Overview of the Managed Care Environment

Chapter 2: Accreditation and Regulatory Requirements         

Chapter 3: Verification Requirements            

Chapter 4: The Credentialing Process             

Chapter 5: Delegated Credentialing

Chapter 6: Credentials Verification Organization (CVO)          

Chapter 7: NCQA Accreditation

Chapter 8: Test Your Knowledge

Appendix