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
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
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
'S CREDENTIALING VERIFICATION ORGANIZATION
PROGRAM REQUIRES THAT THE FOLLOWING CREDENTIAL
ELEMENTS BE VALIDATED FOR EACH PROVIDER:
* Education and Training
* Malpractice Claims History
* DEA Certification
* License to Practice
* Ongoing Monitoring of
* CVO Application and
* Medical Board Sanctions
* Work History
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.
* * * * *
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.