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Actual for You - Benefits of a Credentialing Verification Organization
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Think we live in a tough economy? Think again.Have a look at these up-to-date stats...59% of all Americans are directly or indirectly (via 401K's and pensions) invested in the stock market: an all-time high in percentage of population who, in October, benefited from stock market highs.In fact, a greater percentage of Americans are market-invested than ever before in history, in part thanks to 401K Plans – which, in many cases, have employer matching contributions. For small business, the health of big business is often a predictive facto
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
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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
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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
Put many different people together in one place, day after day after day, and conflicts are bound to happen. Most people work them out on their own, but what happens when the conflict doesn't go away and threatens the productivity of your entire staff or team?We've all seen it – Mary isn't speaking to Susan; Ted and Tom can't be put on the same project; Bill goes behind Karen's back and "forgets" to include her in project discussions. Some days, it's like working in a kindergarten. As the manager, what is your role in resolving workplace conflicts?s.
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
It's an issue faced by business owners worldwide -- having to let go of, or "fire" a client. When I started my business, it's not a situation I ever thought I would face, as I was happy to take on almost anyone that wanted to hire me. However, over time, my client scrutinizing skills became more acute, and I began to realize that not every client is a perfect client for me. In fact, more than 50% of the people I speak with are not a good fit for one reason or another. Just like Donald Trump in "The Apprentice", sometimes you just have to say, "You're fir
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
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