Verifying the credentials of medical professionals is essential not only for patient safety but also for a health care organization’s ability to bill and be reimbursed for services. Credentialing confirms that any provider caring for patients has completed the required education, training, licensure and certifications to practice safely and independently.
Along with provider enrollment, credentialing is essential before a single order can be placed or a service provided. A provider — and, by extension, the organization — cannot bill or receive payment for services performed by an uncredentialed clinician.
That’s where credentialing verification organizations (CVOs) come in.
What is a CVO?
A CVO is a third-party entity that verifies a healthcare provider’s qualifications using primary-source verification. The credentials verified include licensure, education, medical training, work experience, malpractice insurance and other qualifications for practice. The CVO obtains documentation directly from authoritative sources such as:
- State licensing boards
- Medical schools and training programs
- Certification bodies
- Exclusion and sanctions databases
- Professional references
- Malpractice insurance carriers
CVOs do not accept self-reported data for these requirements. They also screen providers for current and historical exclusions, sanctions, debarments and other disciplinary actions to help safeguard patients and protect organizations from practitioners who may be out of compliance with safety standards.
Upon certification verification, a provider can then enroll with payers so their organization can bill for services. Recredentialing is required every three years to help ensure continued compliance with current standards.
A Critical Time-Consuming Process, Simplified
Proper credentialing can be a time-consuming process, often taking several months. Primary sources must be checked, identities must be confirmed, and ongoing monitoring is required to alert organizations of any changes in provider status. For organizations without the resources or specialized staff to manage this workload, partnering with an experienced CVO is essential.
If providers are not properly credentialed, payers can deny coverage and organizational workflow is disrupted — resulting in backlogs, unfilled clinical positions and lost revenue.
How Advantum Can Help
As the size and depth of Advantum Health’s RCM client base continues to grow — now serving more than 25,000 providers and over 4,000 organizations — we collaborate with an organization that specializes in CVO to simplify the process for our clients. Because we deeply understand the credentialing lifecycle and our clients’ operational needs, we streamline documentation collection and ensure accuracy at every step, supported by advanced technology and expert staff.
While many Advantum clients choose a full-service approach — for billing, other related revenue cycle management (RCM) services, enrollment and credentialing through our Provider Enrollment Services (PES) team — clients may also work with the CVO of their choice. We collaborate seamlessly with outside CVOs to ensure processes remain efficient and reimbursement timelines are protected.
Typically, credentialing is an additional service layered onto provider enrollment. Advantum helps clients gather and update all necessary documents required for the provider’s CAQH (Council for Affordable Quality Healthcare) information. CAHQ’s secure platform is used by healthcare organizations to centralize professional and practice information for payer enrollment and the CVO process. They can then securely share that information with the organizations they authorize. When working with an outside CVO, Advantum can manage all coordination to reduce client workload and streamline execution.
Things to Consider Before Hiring a CVO
Experience
Does the CVO have substantial experience credentialing different types of healthcare professionals across various care settings? Improper or insufficient credentialing can compromise an organization’s accreditation, payer participation — including Medicare — and expose it to litigation. The CVO’s qualifications and experience are essential to ensure safe, competent clinical providers, quality of patient care, and reduce organizational risk.
Accreditation
Has the CVO undergone accreditation by the National Committee for Quality Assurance (NCQA) or the Utilization Review Accreditation Commission (URAC)? These accreditations signal to payers, providers, and patients that the organization upholds rigorous standards and is committed to strengthening health care quality and safety.
NCQA and URAC CVO certification is not a one-time accreditation; CVOs must commit to re-evaluation every three years to maintain their good standing. (See PDF of comprehensive guide to accreditation and certification from NCQA.)
Not All CVOs Are Alike
Every healthcare organization is different, and none have identical needs. When interviewing a CVO, make sure they utilize a credentialing program that meets all your criteria.
Advantum Health has coordinated enrollment and credentialing for hundreds of organizations and thousands of providers for more than 25 years, and is deeply familiar with the ever-evolving requirements that drive safe care delivery, compliant billing and optimal reimbursement.
Learn more
Want to better understand how Advantum Health’s Provider Enrollment Services and credentialing can help you manage this critical aspect of your operations efficiently and effectively? Schedule a consult today.