Verifying board certification during your provider enrollment process

Board certification is a voluntary achievement by a practitioner to further demonstrate his or her knowledge and skills in a particular specialty. Although it is not required by any accrediting or regulatory body, many health plans do require as part of their credentialing criteria either board certification or obtainment of board certification within a specific time frame after completing training or being approved for participation. Regardless of an organization’s requirements, the expectation is that, for any practitioner that holds board certification, that certification is verified. NCQA does not require verification of board certification for nurse practitioners or other healthcare professionals unless board certification status is included in the health plan’s member directory or on its website. That is, if a non-physician is board certified within his or her specialty but it is not displayed in the member directory, then the certification does not require verification. However, most health plans will choose to verify this information.

If a physician is board certified by a member board of the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA) in the specialty in which he or she will be treating members, then certification is considered to be the highest level of training to be verified. This is because ABMS and AOA specialty boards follow a standard practice of verifying education and training during their application process. Therefore, verification of ABMS or AOA board certification automatically includes verification of education and training. For non-ABMS and non-AOA specialty boards, organizations must first document in their policies if they accept certification from those boards and, if so, confirm how those boards conduct verification of training. They may vary in their verification practices, and as such, these boards may not always be considered the highest level of training. The health plan should obtain annual written confirmation as to whether education and training verification is performed.

Specialty boards vary in the term lengths of certification status based on when the physician became certified. Initially, certification was granted for the lifetime of the physician, but in the mid-1970s, time-limited certificates became the norm and ranged from six to 10 years, thus requiring recertification in order for a physician to remain board certified. The health plan must verify the expiration date or lifetime status of an applicant’s board certification to confirm his or her current status, and then it must document that information in the credentials file. Under URAC, if the board certification does not have an expiration date, then the health plan is only required to verify at initial credentialing.

There are multiple sources available to provide verification of board certification. For MDs and DOs certified through ABMS, organizations can go directly to the specialty board, and some, such as the American Board of Surgery, will provide this information free of charge. However, most plans will opt to use an ABMS display agent or contracted agent, as verification information is available for all ABMS specialties from one source. This list is maintained and updated by ABMS at www.abms.org/verify-certification/official-abms-display-agent-partners/. The AOA provides verification through its profile service, and it charges a separate fee for each profile requested. Other sources recognized by NCQA include the state licensing agencies, boards, and registries, with the caveat that the health plan must confirm annually that board certification status is primary source verified.

Source: Credentialing for Managed Care: Compliant Processes for Health Plans and Delegated Entities

Found in Categories: 
Credentialing, Provider Enrollment, Quality