Provider credentialing plays a critical role in improving patient outcomes and shielding providers from costly risks, such as delays in reimbursement, liability, and non-compliance. But to perform credentialing correctly, organizations (be it providers, payers, or credentialing verification organizations) need to employ the correct processes and right data sources.
One way of showing that is by following the standards set by accreditation agencies, like the National Committee for Quality Assurance (NCQA).
The NCQA is a private, non-profit accrediting agency that offers a number of certification options to credentialing organizations. These programs are aimed at helping organizations achieve their goals, especially: efficiently credentialing/recredentialing practitioners without delays, accelerating payer enrollment, and delivering safe, high-quality care to patients.
Moreover, the NCQA’s accreditations are recognized in the healthcare space and trusted by payers as well as state and federal regulators. Organizations with NCQA accreditation show that they’re applying best practices in their credentialing processes, be it in terms of primary source verification to moving through applications with efficiency and accuracy. The NCQA’s recognition helps these organizations attain and maintain their compliance with payers and government programs like Medicare and Medicaid.
Thus, NCQA accreditation helps generate significant return-on-investment by streamlining credentialing efforts, shielding provider organizations from costly risks, and maintaining the trust of key stakeholders – i.e., patients, major payers, regulators, and practitioners.
NCQA accreditation refers to a set of certifications or programs that organizations can attain to demonstrate their compliance with best industry practices and standards. When it comes to credentialing, the NCQA offers several programs, notably:
With both programs, the NCQA evaluates the operations and processes of organizations that are engaging in credentialing. It reviews everything from how credentialing is done within the organization to data management to ongoing monitoring and more.
Though a rigorous and lengthy process, attaining NCQA accreditation is a prudent step. Not only does it strengthen an organization’s credentialing processes so that it mitigates risk, but it builds reputability with key stakeholders (like payers) and makes compliance easier.
NCQA accreditation helps every stakeholder involved in the provision of medical care. For example, it helps health plans reduce the risk of a provider not meeting credentialing rules and, in turn, assists them in maintaining a strong network of quality providers with sufficient credentials. It also reduces the amount of work a practitioner must do to join a network and access reimbursement.
Likewise, provider organizations benefit from NCQA accreditation by improving their own credentialing processes. They can carry out primary source verification (PSV) quicker and with high accuracy; enroll practitioners faster so that they deliver care sooner; reduce the administrative burden on their medical staff, hence freeing them to focus on delivering high-quality care to patients; and align with payer and regulatory compliance rules.
NCQA accreditation also helps regulators by setting clear standards for providers and other stakeholders to follow. It makes compliance easier while also ensuring that funds from public programs like Medicare and Medicaid are solely used by credentialed providers.
For CVOs – which provide credentialing services on behalf of providers, payers, and others – NCQA accreditation helps across many areas, such as: delivering more efficient services to contracted healthcare organizations, improving the CVO’s reputation, aligning closer to state regulations, expanding revenue streams and more.
> Hot Tip: NCQA Accreditation is an important step on the road to delegated credentialing, which brings significant efficiencies to care delivery organizations wanting to get their providers enrolled into payer networks faster.
Ultimately, the NCQA offers both programs as a framework improving credentialing and re- -credentialing capacities. However, there are some differences between the two programs as they’re meant for distinct credentialing groups.
The NCQA Credentialing Accreditation program is for organizations performing full-scope credentialing. They’re aiming to deliver better care, elevate their reputation, closely align with regulatory requirements, receive a delegated agreement from a health plan, and secure new revenue streams.
To attain NCQA Credentialing Accreditation, the NCQA will evaluate the organization in the following areas:
> Hot Tip: Verifiable helps organizations achieve NCQA accreditation through reliable automation technology and guidance to ensure standards are met. This allows orgs to bring credentialing entirely in-house, reducing dependencies on 3rd party CVOs and streamlining in-house operations. Orgs who make this move can save millions in operational costs.
The CVO Certification is for “organizations that work on behalf of healthcare organizations to service the process to fulfill credentialing requirement duties.” Instead of solely managing the credentialing work internally, some healthcare organizations outsource this work to CVOs as the latter may be better equipped to carry out the work efficiently and accurately.
To attain NCQA CVO Certification, the NCQA will evaluate CVOs in the following areas:
>Hot Tip: If you’re not ready to go completely in-house and get accredited by the NCQA, you can outsource some or all of your credentialing to Verifiable’s certified CVO.
There’s no doubt that NCQA accreditation creates a pathway for improved credentialing, compliance and many other benefits. However, acquiring NCQA accreditation isn’t easy or quick. It involves a rigorous and extensive evaluation process of your organization. In fact, the NCQA states that the evaluation time frame can take up to 12 months from the date of submitting your application.
Not every healthcare organization can afford that time – they still need to carry out their credentialing/recredentialing work and, potentially, deal with issues like enrollment and payment delays, claims rejections, and liability challenges. Moreover, organizations also need to weigh if it’s an efficient use of their internal resources to manage credentialing – or, alternatively, if they’re better served working with a third-party partner.
The fastest way to align with NCQA standards is to work with an existing NCQA-certified CVO. This will give you access to the industry best practices, compliant processes, and robust toolsets to rapidly improve your provider credentialing. In effect, you don’t have to wait 12 months nor undergo the NCQA’s extensive evaluation process.
Verifiable, for example, is NCQA certified in 11 out of 11 verification services, including:
You’ll gain a direct pathway to rapidly improving your credentialing needs, complying with major payors and state/federal compliance requirements, and accelerating payor enrollment so that you can focus on improving patient outcomes.
>Hot Tip: With Verifiable you can combine NCQA-Certified CVO services with the technology and expertise necessary to bring credentialing in-house over time and achieve NCQA Accreditation.
Healthcare organizations that provide full-scope credentialing services, including verifying practitioner credentials, recredentialing, and credentialing committee reviews, are eligible to apply for NCQA Credentialing Accreditation.
The process can take up to 12 months from the time of application submission. This period includes rigorous evaluations and assessments of the healthcare organization's credentialing processes.
There's no official expedited process for NCQA accreditation. However, organizations can streamline their efforts by thoroughly preparing in advance and ensuring that all criteria are met before applying.
While both programs evaluate an organization’s credentialing processes, Credentialing Accreditation is for organizations offering full-scope credentialing services. CVO Certification is specifically for organizations that manage the credentialing process on behalf of healthcare providers.
Maintenance involves regular monitoring and compliance checks, as well as undergoing re-accreditation at intervals specified by NCQA.