“NCQA Credentials Verification Organization (CVO) Certification helps improve verification operations and protect consumers by ensuring a consistent, effective and diligent verification process.”

A Credentialing Verification Organization (CVO) performs third party payer enrollment and primary source verification (PSV). This is not new news. However, here are some thoughts to consider regarding in-house vs. outsourced enrollment/credentialing and why NCQA thinks it so important to work with vetted CVOs to optimize care delivery and business performance.

1. Worker shortages are rampant. Healthcare is not immune. In fact, studies indicate it is even worse in healthcare due to COVID-related stressors resulting in staff burnout/departure and early retirement. Becker’s hospital review just released a brief article echoing sentiments we have all felt in terms scheduling challenges and regular provider availability. It is not just doctors and ancillary clinical staff, business offices are struggling to get things done with a remote and shrinking workforce. Credentialing and enrollment for most organizations has always been an afterthought; i.e., duties performed by not necessarily seasoned professionals. Today, credentialing and enrollment services are an avoidable burden best done by external experts who perform this work all day, every day. 

2. Patient Safety. Provider and staff shortages result in pressure on HR to fill empty seats as quickly as able. How do you make certain you hire qualified professionals who not only have necessary credentials but a blemish-free track record or very few, explainable incidents? Short answer: Primary Source Verification (PSV) before the provider starts seeing patients. Aside from verifying med school and residency graduation requirements, a review of the National Practitioner Data Bank is telling and it alone could mitigate a new hire from seriously harming a trusting patient. 

3. Mergers & Acquisitions (M&A). COVID, ACO/MSSP growth, and small practices struggling to keep up have resulted in fewer self-employed practices as more an more become employees of healthcare conglomerates. Regardless of the reason, changes in tax or employer identification numbers (TIN/EIN) results in volumes of work around credentialing and/or third party payer enrollment. If not done well/correctly, delayed payments and/or inappropriately filed claims create avoidable risks mitigated if the credentialing/enrollment process is done well by seasoned/skilled professionals. 

4. Management Service Organizations (MSOs) focus. MSOs do an exceptional job of helping providers groups reduce costs by centralizing business activities like HR, Finance, and IT. After M&A, it is common to see business functions centralized. Some also offer third party payer enrollment and credentialing. If done well, that’s great. However, it is never easy nor realistic to be great at everything. Things to consider when evaluating capabilities: 

• What are Key Performance Indicators (KPI) used to assess success (e.g., percentage of applications are accepted on first pass)?

• What is turn-around-time (TAT) (MSO to payer) for request/return of missing data?

• What Service Level Agreements (SLAs) in terms of advising a practice/provider of challenges/issues with a payer application or credentialing process?

A company focusing exclusively on credentialing/enrollment typically outperforms companies with multiple business lines.

If you are lucky enough to have a CVO partner who performs exemplary credentialing and enrollment, be grateful and let them know you appreciate the solid performance. If not so lucky, contact PMG Credentialing today to learn more about CVO status and how we help clients succeed.