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

Bookmark and Share

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

Product Code: CFMC2

Availability: In stock

Your Price:
Add Items to Cart

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

Amy M. Niehaus, MBA, CPMSM, CPCS

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

Published: July 2022

Page count: 170
Dimensions: 8.5” X 11” perfect bound
ISBN: 978-1-68308-965-0

About the Authors

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 been a member of the National Association Medical Staff Services (NAMSS) since 1991 and is dual-certified as a Certified Professional Medical Services Management (CPMSM) and a Certified Provider Credentialing Specialist (CPCS). She has served as a NAMSS Instructor from 2010-2021, presenting CPCS and CPMSM certification programs and developing new content for NAMSS education programs. She has served in other NAMSS roles, including chair of its MCO Task Force, chair and member of the Education Committee, and independent study program editor. She was awarded the Joan Covell-Carpenter award in 2003 for her Synergy article entitled “Physician Credentialing Guide.” She is also a former president of the Missouri Association Medical Staff Services and the Greater St. Louis Area Chapter.

Niehaus has been a speaker and educator since 2000. She has developed and presented various programs to state and national audiences on credentialing and privileging processes; The Joint Commission, NCQA, and URAC accreditation standards and survey preparation; CVO certification; provider enrollment; and delegation. She has authored and contributed to a variety of industry-related publications, including NAMSS Synergy, The Greeley Company, Credentialing Resource Center, AHLA MedStaff News, and Becker’s Hospital Review.

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. She holds a Bachelor of Science degree from the University of Missouri and a Master of Business Administration from Maryville University in St. Louis.

Table of Contents

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