Tip: Consider CVO certification status (and other performance gauges)

NCQA certification or URAC accreditation can be instrumental in evaluating whether a CVO meets minimum industry standards and will be able to provide the services that a health plan or system needs. Certification or accreditation is essentially an accreditor’s stamp of approval on the CVO’s abilities to perform certain functions according to its standards. Organizations should verify a CVO’s certification or accreditation status, which is readily available on the accreditors’ websites. Note: Due to differences in standards, NCQA and URAC currently do not recognize each other’s CVO certification (or accreditation) when it comes to delegation oversight.

Certification/accreditation carries benefits for CVOs, as well as for the entities seeking their services. For CVOs, certification or accreditation can generate new business and reduce or eliminate the delegation preassessment and oversight audits performed by their many clients. For health plans, contracting with a certified or accredited CVO means that any credentialing element being considered for delegation and for which the CVO has been NCQA certified or URAC accredited does not have to be reviewed during the preassessment or annual reviews of the delegated entity. This results in reduced oversight responsibilities, fewer required resources, and less overall turnaround time to perform delegation oversight activities. For health systems, an internal CVO with certification or accreditation may enhance their ability to attain delegated credentialing with health plans and thereby improve their provider enrollment process.

However, just as health plans do not have to be accredited by NCQA or URAC, CVOs are not required to be certified or accredited. Organizations that choose to delegate credentialing activities to a noncertified/nonaccredited CVO may consider additional approaches to evaluating its capabilities, in addition to assessing the CVO’s compliance with the plan’s internal policies, procedures, and applicable accreditation standards. The following are some additional evaluation methods, which can also be used as quality checks for certified/accredited CVOs:

• Use a questionnaire to evaluate the CVO’s structure, and include questions regarding its licensure, liability insurance, management and staff qualifications (e.g., certification by National Association Medical Staff Services), and years of experience in credentialing.
• Request CVO-specific metrics for the past year, including average turnaround times (regular and expedited files), error rates, and client accreditation results related to credentialing.
• Send the potential CVO a few practitioner applications to process that have already been processed internally by the health plan. Doing so enables the health plan to compare the results to determine whether the CVO is checking all of the same sources as the health plan and has arrived at the same findings.
• Obtain references from current CVO clients. 
• Consider The Joint Commission’s 10 guiding principles for CVOs. Although they are geared toward Joint Commission–accredited hospitals, these principles—which appear under the definition of a CVO in the glossary of the accreditor’s standards—apply to any organization considering the use of a CVO.

Source: Credentialing for Managed Care