PSV is a crucial step in the provider credentialing process as it is the first line of defense to ensure patient safety. Verifying a provider’s professional background must be done correctly and efficiently to filter bad actors as well as avoid delays, claim denials, and other costly risks.
Likewise, accreditation agencies like the National Committee for Quality Assurance (NCQA) and others require PSV. This is important because payers and other key stakeholders utilize the standards set by the NCQA and others as part of their credentialing process. They won’t work with providers who don’t comply with those standards. Similarly, state licensing boards and others also require PSV before engaging a provider.
If you’re going to work with a CVO it’s important to ensure that they are NCQA-certified (like Verifiable), which gives you reassurance that PSV is being done to their standards. For organizations that want to keep their credentialing entirely in-house, a reliable method of obtaining PSVs (like automation software) is essential to getting NCQA-certified.
You Need PSV for Provider Credentialing
Healthcare organizations and payers alike will not work with a practitioner until they verify their qualifications and competencies. Consulting the original issuing bodies of the practitioner’s education or training is a critical way of verifying that information.
It’s important to verify that information as discrepancies and gaps can put patients at risk, result in payment delays, and lead to liability issues. Provider organizations like hospitals want to avoid those risks.
Likewise, payers – be it private sector or government-supported – will not reimburse or issue payments to providers who aren’t properly credentialed. Lack of PSV could result in denials or delays in payments, which can lead to revenue loss for the provider.
Regulators Care About Primary Source Verification
Government bodies also require healthcare organizations to perform PSV when validating their practitioners’ licenses. It’s important to establish robust PSV processes at the start of the credentialing process and afterwards via continuous monitoring. The latter is important for ongoing compliance and re-credentialing approximately two years later.
Accreditation Agencies Value Primary Source Verification
Payers use an accreditation agency’s standards to measure a provider’s ability to deliver safe and high-quality care to patients. In turn, these accreditation agencies generally require PSV as part of their compliance guidelines. Failure to meet these standards can lead to payment delays or denials.
Payer organizations use the NCQA’s standards for PSV when credentialing. Thus, when a provider complies with the NCQA’s PSV standards, they’ll be able to apply for support from multiple payers more efficiently.
The Centers of Medicare & Medicaid Services (CMS)
The CMS is a federal agency that provides healthcare coverage to millions of Americans. CMS requires healthcare organizations that take part in its programs to verify the credentials of their providers through PSV.
State Licensing Boards
State licensing boards are responsible for licensing healthcare providers in each state. Many state licensing boards require healthcare providers to have their credentials verified through PSV before they can be licensed to practice.
The Joint Commission
Organizations seeking accreditation from The Joint Commission must perform PSV for their practitioners. In fact, The Joint Commission places the responsibility for PSV on the provider organization, not the licensed individual practitioner.
Utilization Review Accreditation Commission (URAC)
URAC is a voluntary but widely recognized accreditation among payers. Like the NCQA, complying with URAC’s PSV requirements gives providers the flexibility to readily apply for reimbursements from multiple payers in an efficient way.