Managed care organizations like health management organizations (HMO) and independent provider associations (IPA) are necessary to credential their providers, meaning weather resistant verify the medical provider's professional history. Due to the dispersed nature of managed care organizations and the resource requirements in the credentialing process, credentialing verification organizations (CVO) step in to offer these credentialing services.
Introduction to Credentialing
Both major accrediting organizations for managed care organizations include the National Committee for Quality Assurance (NCQA) and Utilization Review Accreditation Council (URAC) Within their accreditation requirements, both URAC and NCQA require managed care organizations to credential their providers according to their published standards.
Though it may be less frequent for preferred provider organizations (PPO) to credential their practitioners, credentialing lowers risk and liability, while improving patient care. As one example of how important these standards is usually for PPO quality, in excess of 10% from the organizations certified by NCQA are PPOs.
Credentialing verification requirements either way NCQA and URAC require that the work history, disciplinary actions, and malpractice claims reputation the company be investigated for your previous five years, after which rechecked every 3 years. The extra areas which are verified are similar equally for organizations, including the following information:
Education and post-graduate training
Adverse actions in NPDB or HIPDB records
The above mentined listed organizations need to be contacted and verifying documents, for example copies of certificates, delivered to the CVO. This post is used to build the credentialing say that the CVO submits on the managed care group's review committee.
The sort of information that the CVO collects can be modified to fulfill the needs of the managed care group. For example, in case a PPO would like to verify that a physician has got the appropriate licenses and malpractice insurance, but does not need to stick to URAC or NCQA standards for accreditation, a CVO will adapt the credentialing tactic to see that information.
Choosing the Good CVO
Managed care organizations have long relied on CVOs to produce credentialing services because CVOs are usually faster and less expensive than credentialing in-house. Using CVOs help reduce staff serious amounts of training for managed care groups, in addition to lowering their liability and lessening the risk of penalties for errors during NCQA/URAC audits. CVOs not merely credential physicians, but all sorts of medical personnel, for instance midwives, respiratory therapists, nurses, and physical therapists.
There are actually certain characteristics which can help distinguish an excellent CVO:
CVOs should adapt their credentialing criteria to fit 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 needs to be certified by either NCQA or URAC, preferably both, which implies the CVO matches the accrediting organization's practices and standards.
The completed reports, without having unverified data, and supporting documentation ought to be complete and available on file.
Turnaround time must be within industry averages; for NCQA/URAC standard credentialing, that is about Thirty days.
Any difficulty with a carrier should be brought quickly to your managed care organization's review committee.
The CVO should offer extra services, including tracking expirables like license renewals and recredentialing deadlines, and support through routine NCQA/URAC compliance audits.
The CVO needs to have solid customer satisfaction practices, such as a single, named CVO representative; customer care and quality assurance practices; and a quick response time for you 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 aren't instructed to meet NCQA/URAC standards for accreditation still benefit by looking into making better provider choices, meaning improved patient care and liability, by credentialing their providers via a CVO.
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