If ongoing achievement of excellent credentialing practices in your credentials verification organization (CVO) is the equivalent of a successful lunar landing, then you’ll want to plant a flag to mark the feat. (Not to mention that the flag will serve as a reminder of the need to maintain such performance.) So, will you fly the NCQA or URAC flag?

They’re both excellent choices for practices, plans, or departments responsible for accurately and efficiently verifying practitioner credentials. There’s a third option too, using a certified third-party CVO if you can’t or choose not to conduct the credentialing in house.

Becoming certified or affiliating with a certified CVO and maintaining the designation is a financial and resource-heavy investment for many health plans and CVOs, and for some it’s cost prohibitive. Of course the vast majority of people in the industry on both the provider and consumer sides understand the value of being accredited—and many would argue that it’s a critical benchmark in today’s value-based environment.

The decision comes down to the appropriateness for the clients that your org or department serves and whether achievement of certification matters to them, and the culture of your organization.

To certify or not

Calculate the costs of certification versus the potential loss of business without it. Then determine if you have resources to create and/or adhere to your own framework for following regs and pursuing quality improvement. In other words, you can likely do that on your own using your own resources and benchmarks. But at what point does the cost-benefit equation point to certification over DIY?

For internal CVOs, certification shows alignment with state regs and a mantra to strive toward best practices, engendering confidence in your department. For external or commercial CVOs, lack of accreditation can mean a loss of potential business. CVO certification provides among other things:

  • A signal to patients or clients that your organization or department values consumer protection and customer service
  • A framework to strive for industry best practices
  • A potential advantage over competitors and overall recognition in the industry
  • The opportunity to reduce or eliminate delegation pre-assessment and oversight audits by clients
  • An opening to achieve delegation status with payers

More about the certifying bodies

NCQA: While The Joint Commission has a lock on the market in terms of the number of accredited U.S. hospitals, the National Committee for Quality Assurance (NCQA) corners the majority of the market on certifying CVOs. Compared with URAC, NCQA requires certified CVOs to manage to more specific and lengthier qualifications. NCQA reportedly certifies about 200 CVOs.

URAC: Meeting URAC accreditation standards may be less costly than NCQA, though certification through URAC is of equal value. Compared with NCQA, URAC certification is often described as being more flexible than NCQA . URAC reportedly certifies a handful of CVOs

Resources

There’s an excellent NAMSS presentation on becoming certified here, written by Amy Niehaus, MBA, CPMSM, CPCS.

Download IntelliSoft’s NCQA standards quick reference guide here.