Benefits Of A Credentialing Verification Organization

Benefits Of A Credentialing Verification Organization

Managed care organizations like health management organizations (HMO) and​ independent provider associations (IPA) are required to​ credential their providers, meaning they have to​ verify the medical provider’s professional history. Because of​ the dispersed nature of​ managed care organizations and​ the resource requirements of​ the credentialing process, credentialing verification​ organizations (CVO) step in​ to​ provide these credentialing services.

Overview of​ Credentialing
The two major accrediting organizations for​ managed care organizations are the National Committee for​ Quality Assurance (NCQA) and​ Utilization​ Review Accreditation​ Council (URAC) as​ part of​ their accreditation​ requirements, both URAC and​ NCQA require managed care organizations to​ credential their providers according to​ their published standards.

While it​ is​ less common​ for​ preferred provider organizations (PPO) to​ credential their practitioners, credentialing lowers risk and​ liability, while improving patient care. as​ an​ example of​ how important these standards can be for​ PPO quality, more than 10% of​ the organizations certified by NCQA are PPOs.

Credentialing verification​ requirements for​ both NCQA and​ URAC require that the work history, disciplinary actions, and​ malpractice claims history of​ the provider be checked for​ the previous five years, and​ then rechecked every three years. The additional areas that are verified are similar for​ both organizations, including the following information:
  • Education​ and​ post-graduate training
  • Hospital affiliations
  • Board certifications
  • State licenses
  • DEA certificate
  • Medicare/Medicaid sanctions
  • Adverse actions in​ NPDB or​ HIPDB records

The above listed organizations must be contacted and​ verifying documents, such as​ copies of​ certificates, sent to​ the CVO. this​ information​ is​ used to​ create the credentialing report that the CVO submits to​ the managed care group’s review committee.

The type of​ information​ that the CVO collects can be modified to​ meet the needs of​ the managed care group. for​ instance, if​ a​ PPO wants to​ verify that a​ physician has the appropriate licenses and​ malpractice insurance, but does not need to​ comply with URAC or​ NCQA standards for​ accreditation, a​ CVO will adapt the credentialing process to​ find that information.

Selecting a​ Good CVO
Managed care organizations have long depended on​ CVOs to​ provide credentialing services because CVOs tend to​ be faster and​ less expensive than credentialing in-house. Using CVOs help reduce staff time and​ training for​ managed care groups, as​ well as​ lowering their liability and​ lessening the risk of​ penalties for​ errors during NCQA/URAC audits. CVOs not only credential physicians, but all types of​ medical personnel, such as​ midwives, respiratory therapists, nurses, and​ physical therapists.

There are certain​ characteristics that can help distinguish a​ good CVO:

  • CVOs should adapt their credentialing criteria to​ accommodate the managed care group’s needs, such as​ verifications with fewer criteria than NCQA/URAC standards for​ PPOs or​ adding verification​ criteria for​ other managed care groups.
  • The CVO should be certified by either NCQA or​ URAC, preferably both, which means the CVO complies with the accrediting organization’s practices and​ standards.
  • The completed reports, with no unverified data, and​ supporting documentation​ should be complete and​ available on​ file.
  • Turnaround time should be within​ industry averages; for​ NCQA/URAC standard credentialing, this​ is​ about 30 days.
  • Any problems with a​ provider should be brought quickly to​ the managed care organization’s review committee.
  • The CVO should offer extra services, such as​ tracking expirables like license renewals and​ recredentialing deadlines, and​ support through routine NCQA/URAC compliance audits.
  • The CVO should have solid customer service practices, including a​ single, named CVO representative; customer satisfaction​ and​ quality assurance practices; and​ a​ quick response time to​ questions.

CVOs offer better turnaround time, lower overhead and​ expense, reduced staff time, and​ lowered liability to​ managed care groups. Even groups, like PPOs, which are not required to​ meet NCQA/URAC standards for​ accreditation​ still benefit by making better provider choices, meaning improved patient care and​ liability, by credentialing their providers through a​ CVO.

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