Q&A: What’s the difference between Joint Commission and NCQA standards regarding the use of CVOs?
Hospitals use credentialing verification organizations (CVO) for many reasons (distributing and receiving applications, conducting primary source verification, collecting references, querying the NPDB as an agent of the hospital, and verifying clinical experience). Every hospital that uses a CVO should note that the hospital still bears the ultimate responsibility for the entire credentialing process and its outcome. Thus, a hospital should monitor a CVO's activities to ensure that it follows all policies and procedures.
The Joint Commission states that hospitals that use information from a CVO should be confident that the data they receive is complete, accurate, and timely. The Joint Commission also outlines principles to initially and periodically evaluate a CVO with regard to the following aspects:
• What data are available from the CVO
• How the CVO collects data, how the information is developed, and what verification processes are used
• Information on the CVO's database functions including limitations on the information available (e.g., practitioners who are not in the database); turnaround time for reporting; and a summary of quality control processes including transmission accuracy, data integrity, data security, and technical specifications
• The method by which the information will be transmitted from CVO to the hospital
• Specification of what information is obtained from the primary source versus a secondary source
• Whether time-sensitive data are collected and verified (e.g., licensure) and whether information on expiration dates is provided, as well as the date on which the information was last updated
• A certification that the information transmitted to the hospital reflects the information the CVO obtained
• Whether the information obtained is complete or if there is additional information available (and, if so, where to obtain it)
• The mechanisms available through the quality control system to resolve issues regarding transmission errors, inconsistencies, or other data concerns
• The Joint Commission also states that hospitals should have a formal arrangement with the CVO for communication regarding changes in credentialing information
NCQA requirements differ slightly, stating that:
There must be a mutually agreed-upon document describing each organization’s responsibilities, the delegated activities, at least semiannual reporting to the organization, the process for evaluation of the CVO’s performance, and remedies if the CVO does not fulfill its obligations
If the CVO has access to protected health information (PHI)—on members or practitioners—the CVO will adhere to defined regulations related to the PHI (see NCQA standards for further details)
The managed care organization (MCO), managed behavioral healthcare organization (MBHO), physician organization (PO) or preferred provider organization (PPO) must retain the right to approve/terminate/suspend practitioners, providers, and sites based on quality issues
The MCO/MBHO/PO/PPO evaluates the delegated agency’s capability to perform the delegated activities prior to delegation and annually thereafter*
The MCO/MBHO/PO/PPO audits, at least annually, credentialing files against NCQA standards* (Note: Credentials file audits include 5% or 50 practitioner files (whichever is less). At a minimum, 10 credentialing files and 10 recredentialing files must be reviewed. T
The organization may use the NCQA “8/30 methodology” found at www.ncqa.org/updates)
The MCO/MBHO/PO/PPO evaluates, at least annually, the CVO’s performance of the delegated activities and reporting.*
The MCO/MBHO/PO/PPO has identified and followed up on opportunities for improvement as applicable at least once in the past two years.*
*Note: Oversight is not required if the CVO is NCQA certified or the entity is NCQA accredited for the credentialing/ recredentialing function.
Searching for CVO? If your healthcare organization is considering outsourcing its credentialing activities to a CVO, start your search with CPDR. If you subscribe to CPDR, you have access to a list of CVOs online. Not yet a CPDR subscriber? CVU invites you to sign up for a free 30-day trial. To sign up, click here.
Sources: CPDR online and Verify & Comply, Fourth Edition, HCPro Inc.
