Managed care organizations, such as health management organizations (HMOs) and independent provider associations (IPAs), must accredit their providers, which means they must verify the medical provider’s professional history. Due to the dispersed nature of managed care organizations and the resource requirements of the accreditation process, accreditation verification organizations (CVOs) step in to provide these accreditation services.
Accreditation Overview
The two main accrediting organizations for managed care organizations are the National Committee for Quality Assurance (NCQA) and the Utilization Review Accreditation Council (URAC). As part of their accreditation requirements, both URAC and NCQA require managed care organizations to accredit their providers according to their standards.
While it’s less common for preferred provider organizations (PPOs) to accredit their doctors, accreditation reduces risk and liability while improving patient care. As an example of how important these standards can be to PPO quality, more than 10% of NCQA-certified organizations are PPOs.
Credentialing verification requirements for both NCQA and URAC require that the provider’s employment history, disciplinary actions, and malpractice claim history be verified for the previous five years and then reverified every three years. Additional areas that are checked are similar for both organizations, including the following information:
- Postgraduate education and training
- hospital memberships
- Board Certifications
- state licenses
- DEA certificate
- Medicare/Medicaid Penalties
- Adverse actions in NPDB or HIPDB records
The organizations listed above should be contacted and verification 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 review committee.
The type of information the CVO collects can be modified to meet the needs of the managed care group. For example, if a PPO wants to verify that a doctor has the proper licenses and malpractice insurance, but does not need to meet URAC or NCQA standards for credentialing, a CVO will tailor the credentialing process to find that information.
Select a good CVO
Managed care organizations have long relied on CVOs to provide accreditation services because CVOs tend to be faster and less expensive than in-house accreditation. Using CVO helps reduce staff time and training for managed care groups, as well as reduce their liability and lower the risk of penalties for errors during NCQA/URAC audits. CVOs are not only licensed 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 fit the needs of the managed care group, such as verifying with fewer criteria than the NCQA/URAC standards for PPOs or adding verification criteria for other managed care groups.
- The CVO must be certified by NCQA or URAC, preferably both, which means that the CVO meets the practices and standards of the accrediting organization.
- Complete reports, with no unverified data, and supporting documentation must be complete and available on file.
- Response time must be within industry averages; for standard NCQA/URAC accreditation, this is about 30 days.
- Any issue with a provider should be promptly brought to the review committee of the managed care organization.
- The CVO must offer additional services, such as tracking expirations such as license renewals and reaccreditation deadlines, and support through routine NCQA/URAC compliance audits.
- The CVO must have strong customer service practices, including a single designated CVO representative; quality assurance and customer satisfaction practices; and a quick response time to questions.
CVOs offer better response time, lower overhead and expenses, less staff time, and less liability for managed care groups. Even groups, like PPOs, that are not required to meet NCQA/URAC accreditation standards still benefit from choosing better providers, which means better patient care and accountability, by accrediting their providers through of a CVO.