Healthcare Credentialing News & Insights

Credentialing Standards October 2016

How to Choose Between NCQA and URAC Accreditation for Credentialing

Credentialing Standards October 2016

How to Choose Between NCQA and URAC Accreditation for Credentialing

Provider credentialing is a necessary business function for health plans and is required in order to ensure quality of care for members. When implementing — or reevaluating —  a credentialing process, there are a few important factors to consider such as cost, employee time and even whether to adhere to NCQA or URAC standards. A lot of  organizations complete the work in-house; others choose to reap significant cost and time savings by working with a certified credentials verification organization (CVO).

 

How Should We Satisfy the Credentialing Requirement?

The credentialing requirement is just one component that health plans need to satisfy in order to achieve accreditation from an organization like URAC or NCQA. In order to meet the credentialing requirement, a health plan must demonstrate that it verifies primary source data for all of its providers, reviews any sanctions that have been imposed on its providers, and that it recredentials providers, at minimum, every three years. This credentialing review process includes a 6-month working period after which the accrediting organization will audit the credentials completed during that time. If the off-site document review is successful, they will then conduct a final onsite audit and credentialing file review. If your credentialing process adheres to core standards and demonstrates compliance, the health plan will meet its credentialing requirement for accreditation. The auditing process usually takes about 6 to 9 months. However, the comprehensive and rigorous preparation for the entire end-to-end auditing process may take longer.  And in order to maintain an accredited status, it must be repeated every 3 years.

Before entering into the accreditation review process, you will want to make sure your organization has a thorough understanding of the credentialing requirements and has a compliant standardized and documented process in place.

⇒ Read more about NCQA credentialing standards and URAC credentialing standards.

 

Why Health Plans Choose a Certified CVO

Another way to meet the credentialing requirement is by choosing a CVO that has been certified as meeting NCQA or URAC standards. Health plans choose to work with certified CVO such as CredSimple for three main reasons:

  1. Get the credentialing certification credit, without the hassle. The health plan accreditation process requires a great deal of company resources, including substantial employee time. Plus, you’ll need to repeat this process every 3 years to remain accredited.
  2. A certified CVO has already passed a rigorous review process and has demonstrated compliance. By using a certified CVO, you automatically have an accredited credentialing process in place.
  3. Using a CVO cuts costs and decreases the number of in-house employees dedicated solely to the credentialing process.

 

Why Health Plans Choose CredSimple

Our clients chose CredSimple because our platform is built to maximize the value of your credentialing function to the entire organization. We designed our system to boost credentialing speed and compliance while simultaneously ensuring data quality —  together increasing the value of the credentialing process.

The typical credentialing process includes an in-house team, manual processes and legacy software. While other CVOs continue to use manual processes or legacy software, CredSimple’s smart technology automates the credentialing process at every step — from our online application to verifying data to committee review. For companies with large provider networks, our primary source verification technology alone can increase credentialing capabilities by 90% and sets a new industry standard for efficient primary source verification. Rather than having to search, print (or screen capture) and file the primary source elements, our technology instantly matches primary sources and produces a file that is compliant to industry standards. This technology is why are are able to credential providers in 5 days.

 

Should I Choose URAC or NCQA for Provider Credentialing?

Whether you decide to credential in-house or to work with a CVO, you’ll want to decide whether to adhere to the URAC standards or NCQA standards. The requirements are similar though NCQA has a larger reach, with more than 40,000 accredited organizations and certified CVOs compared to URAC’s 800+.

When it comes to CVOs, both NCQA and URAC standards require rigorous on-site and off-site audits to ensure a CVO has a proper process for conducting primary source verifications and medical credentialing of independently licensed providers. A health plan that chooses a certified CVO can rest easy knowing that their credentialing process is being handled compliantly.

If your health plan is already accredited by NCQA, there is a significant benefit to choosing an NCQA-certified CVO. Your health plan will automatically meet all NCQA accreditation requirements, translating into a simplified auditing process. NCQA audits both CVOs and health plans and holds both to the same standards. On the other hand, if you’re currently NCQA accredited, using a URAC-certified CVO will not automatically meet NCQA’s requirements (although the requirements for the two overlap).

 

We’re Here to Help

If you have any questions at all about what makes sense for your organization or what to consider when choosing the right CVO for your organization, we’re happy to help. You can contact us here or you’re welcome to give us a call at (866) 688-8881 from Monday – Friday between 9:00 a.m. – 6:00 p.m. Eastern.

 

To learn more about CredSimple: