The Increasing Importance of
High-Quality Primary Source Verification
By: Mary Reichert, CPA and 
Susan Prior, CHC  

Lack of proper credentialing can negatively impact patient care, decrease revenue and raise compliance concerns.

As efforts to boost program integrity are increased, Medicare is clamping
down on physicians without proper credentials or who have sanctions
against them. A week does not go by without reading about a health  care facility or provider that is being charged with Medicare fraud.  Some commercial payers are considering stricter guidelines applicable  to those providers with hefty malpractice settlements. These actions by  government and commercial payers are all about enforcing credentialing  standards. Healthcare facilities and medical practices must have reliable  processes in place that will capture providers and their staff who are not  properly credentialed.

As the healthcare industry is transforming how it delivers patient care  and how it gets paid for delivering the care, the chances of errors in the  credentialing process rise. Errors occur when practitioners are practicing  at multiple organizations and also when there is a failure to:
  • continuously monitor sanctions and licensure restrictions, 
  • re-verify information over time,
  • understand the many nuances in coverage requirements of insurance plans,
  • identify high-risk providers,
  • and dedicate sufficient resources to the credentialing function.
Adding to the confusion, the credentialing process varies by payer, by plan  and by state.

When providers can't bill for services rendered as a result of credentialing  failures, patient care and revenue are impacted. To maintain a consistent  cash flow, medical practices and hospitals must have an expert and  experienced credentialing staff in place with a refined and organized
work process.

Overview of Credentialing, Primary Source Verification  and the NCQA

Credentialing, also called Privileging, is the process of obtaining, verifying,  and assessing the qualifications, background, and legitimacy of the  licensure, education and training of physicians and other practitioners.  It basically is the validation that the practitioner is qualified and competent  to provide quality healthcare services and receive reimbursement for those
services. Because quality improvement and patient safety are the focus of  every healthcare organization, whether it is a hospital, ACO, FQHC or  medical practice, the only way to ensure that the information received for  credentialing purposes is accurate is to employ a process called Primary  Source Verification ("PSV").

PSV is verification from the original source of a specific credential  (education, training, and licensure) in order to validate the accuracy of the  qualifications of an individual practitioner. Such a level of verification is  time-intensive and also requires continuous monitoring as a sanction or  some other issue can occur at any time.

For example, the risk of not realizing that a disqualifying incident has  occurred can be greater when a provider is working for multiple  organizations. The practitioner may have a malpractice claim or settlement  that involves another organization resulting in an Office of Inspector
General ("OIG") exclusion or removal from a payer panel. The only way a  credentialing process would identify this incident in a timely manner would  be to continually monitor this provider's credentialing data and information.  If such an incident is missed and this provider continues seeing and treating  patients, quality patient care and reimbursement may be in jeopardy.

Because health plans use the National Committee of Quality Assurance  ("NCQA") credentialing standards when contracting with practitioners and  facilities, it is advantageous to use credentialing services that are also  certified by NCQA. NCQA requires that the credentialing process verify the  practitioner's claimed qualifications against the primary sources, such as
ensuring the practitioner is licensed to practice medicine; validating  his/her education and training (including board certification), work history,  history of professional liability claims; and ensuring the provider is licensed  by the Drug Enforcement Agency ("DEA"). Also, NCQA requests that health  plans re-credential practitioners at least every three years and requires  frequent monitoring of provider sanctions and complaints in between the  re-credentialing cycle.


* Education and Training
* Malpractice Claims History
* DEA Certification
* Medicare/Medicaid  Sanctions
* License to Practice
* Ongoing Monitoring of  Sanctions
* CVO Application and  Attestation Content
* Medical Board Sanctions
* Work History

What is a CVO?

A CVO, or Credentialing Verification Organization, is an entity that offers  to verify the credentials of practitioners as a service. When a CVO is  certified by NCQA that means they have passed a rigorous quality  assessment program and have met NCQA's strict standards. It is  important when healthcare organizations evaluate CVOs and other  credentialing organizations that they understand the distinction that  NCQA certification brings.

PSV under a CVO presents the opportunity for an organization to have  delegated agreements with the insurance carriers. A delegated agreement  shifts the burden of PSV from the payer to the organization. Delegated  agreements with insurance carriers can reduce the timeline for the
practitioner to be approved for participation in the network. If the  organization wants to participate with the insurance carriers under a  "delegated" agreement, then aligning with a CVO gives them the option to  do this without taking on the challenge of becoming NCQA certified. The  insurance carrier then does not need to audit the organization because  NCQA will do that every two years. 

The value added by utilizing a CVO is the "ongoing monitoring" of the  practitioner to issue alerts for any sanctions on medical license,  malpractice claims and placement on the OIG Exclusion List. Many CVOs  will query at both the Federal and State level for issues that can lead to a  compliance risk for the organization. These notifications protect the  organization as well as the patients.

What is the cost and risk?

Lack of an organized, diligent and precise credentialing process can lead  to decreased revenue (inability to bill for services rendered), increased  expenses (liability and penalties), and compliance issues that may result in  substantial penalties. Typically, while providers and facilities experience  delayed reimbursement as the result of the failed credentialing process,  more serious issues and increased costs may also occur. 

Having a comprehensive credentialing program that includes primary  source verification will improve patient satisfaction, reduce unnecessary  expenses related to legal issues, ensure best practice revenue cycle  management, and support your compliance efforts. Using an NCQA  certified CVO should be an integral part of a sound compliance plan.

  • State licensing boards for medical license and DEA/CDS
  • Medical Specialty Boards
  • Office of the Inspector General (OIG)
  • National Practitioner Databank and healthcare Integrity and Protection Databank (NPDBHIPDB)
  • American Medical Association (AMA) Physician Master File
  • Federation of State Medical Boards (FSMB)
  • Applicable Medical Staff Offices
  • Medical Schools
  • Residency Programs
  • Education Commission for Foreign Medical Graduates (ECFMG)
  • List of Excluded Individuals/Entities (maintained by OIG)
  • Medicare and Medicaid Sanctions and Reinstatement Report, distributed to federally contracted organizations
  • State Medicaid agency or intermediary and the Medicare intermediary
  • Malpractice data via website or with malpractice carrier

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VantagePoint HealthCare Advisors is certified by the NCQA as a CVO (Credentialing Verification Organization) and has provided credentialing  and enrollment services for over 10 years to hospitals, physician practices, PHOs,  MSOs, IPAs and ACOs. We have experience credentialing all practitioner types  and specialties. Our in-depth knowledge of regulatory credentialing standards  enables us to efficiently verify physician credentials for hospital medical staff,  physician practices, and commercial and government payers.

VantagePoint is an informational news article series produced by VantagePoint Healthcare Advisors.
With each edition we strive to bring vital information
to the healthcare industry on topics of policy, finance, compliance and business management.


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