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.