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 weather resistant verify the medical provider's professional history. Due to the dispersed nature of managed care organizations and the resource requirements on the credentialing process, credentialing verification organizations (CVO) step in to supply these credentialing services.

Overview of Credentialing

The two major accrediting organizations for managed care organizations include the National Committee for Quality Assurance (NCQA) and Utilization Review Accreditation Council (URAC) In their accreditation requirements, both URAC and NCQA require managed care organizations to credential their providers according to their published standards.

Though it may be more uncommon 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 might be for PPO quality, in excess of 10% in the organizations certified by NCQA are PPOs.

Credentialing verification requirements either way NCQA and URAC require the work history, disciplinary actions, and malpractice claims history of the company checked for that previous five years, then rechecked every three years. The excess areas which can be verified resemble either way organizations, for example 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 aforementioned listed organizations has to be contacted and verifying documents, like copies of certificates, brought to the CVO. This data is accustomed to build the credentialing report that the CVO submits for the managed care group's review committee.

The information that this CVO collects may be modified to meet the requirements of the managed care group. For example, if your PPO really wants to verify that a physician provides the appropriate licenses and malpractice insurance, but does not need to conform to URAC or NCQA standards for accreditation, a CVO will adapt the credentialing strategy to learn that information.

Selecting a Good CVO

Managed care organizations have long relied on CVOs to supply credentialing services because CVOs tend to be faster and less costly than credentialing in-house. Using CVOs lower staff some time to working out for managed care groups, as well as lowering their liability and lessening the risk of penalties for errors during NCQA/URAC audits. CVOs not merely credential physicians, but all types of medical personnel, such as midwives, respiratory therapists, nurses, and physical therapists.

A number of characteristics that can help distinguish a great CVO:

CVOs should adapt their credentialing criteria to accommodate the managed care group's needs, for instance verifications with fewer criteria than NCQA/URAC standards for PPOs or adding verification criteria for other managed care groups.
The CVO ought to be certified by either NCQA or URAC, preferably both, this means the CVO matches the accrediting organization's practices and standards.
The completed reports, without any unverified data, and supporting documentation really should be complete and on file.
Turnaround time really should be within industry averages; for NCQA/URAC standard credentialing, this is about 1 month.
Any problems with a service provider should be brought quickly for the 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 ought to have solid customer support practices, with a single, named CVO representative; customer care and quality assurance practices; plus a quick response time for it 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 needed to meet NCQA/URAC standards for accreditation still benefit by designing better provider choices, meaning improved patient care and liability, by credentialing their providers by way of a CVO.

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