Important things about a Credentialing Verification Organization

Managed care organizations like health management organizations (HMO) and independent provider associations (IPA) must credential their providers, meaning they should verify the medical provider's professional history. Because of the dispersed nature of managed care organizations as well as the resource requirements on the credentialing process, credentialing verification organizations (CVO) step up to deliver these credentialing services.

Summary 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) Within their accreditation requirements, both URAC and NCQA require managed care organizations to credential their providers based on their published standards.

While it's 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, greater than 10% with the organizations certified by NCQA are PPOs.

Credentialing verification requirements both for NCQA and URAC require how the work history, disciplinary actions, and malpractice claims good the provider be checked for that previous several years, and then rechecked every three years. The excess areas which can be verified are the same both for 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 above listed organizations have to be contacted and verifying documents, including copies of certificates, provided for the CVO. This data is utilized to make the credentialing state that the CVO submits on the managed care group's review committee.

The kind of information that this CVO collects can be modified to meet the requirements the managed care group. By way of example, if a PPO desires to verify that your physician gets the appropriate licenses and malpractice insurance, but does not need to adhere to URAC or NCQA standards for accreditation, a CVO will adapt the credentialing strategy to discover that information.

Deciding on a Good CVO

Managed care organizations have long been dependent on CVOs to produce credentialing services because CVOs are generally faster and cheaper than credentialing in-house. Using CVOs help in reducing staff a serious amounts of education for managed care groups, together with lowering their liability and lessening the risk of penalties for errors during NCQA/URAC audits. CVOs not merely credential physicians, but various medical personnel, for instance midwives, respiratory therapists, nurses, and physiotherapists.

There are certain characteristics which will 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 must be certified by either NCQA or URAC, preferably both, this means the CVO complies with the accrediting organization's practices and standards.
The completed reports, without any unverified data, and supporting documentation should be complete and positioned on file.
Turnaround time must be within industry averages; for NCQA/URAC standard credentialing, that is about 1 month.
Any difficulty with a supplier needs to be brought quickly on the managed care organization's review committee.
The CVO should offer extra services, for instance tracking expirables like license renewals and recredentialing deadlines, and support through routine NCQA/URAC compliance audits.
The CVO needs to have solid customer care practices, along with a single, named CVO representative; customer care and quality assurance practices; as well as a quick response time and energy 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, that are not needed 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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