Establishing and Understanding a CVO Cheryl Cisneros RN
Establishing and Understanding a CVO Cheryl Cisneros, RN, BSN, CPCS, CPMSM Client Success Manager and Consultant
q Define what is a Credentials Verification Organization (CVO), types of CVOs and history q What it takes to develop a CVO q Services provided by a CVO q Benefits of CVO NCQA Certification
A CVO is an organization which gathers data and verifies the credentials of health care practitioners. Typically it includes physicians, dentists, advanced practice nurses, physicians assistants, psychologists, and other practitioners who are members of a health care organization or health plan. • Provides credentialing services • Provides supportive services • Overcomes obstacles • Opportune efficiencies • Improves onboarding timeframes
CVOs have evolved over time with a consistent focus to create streamlined workflow processes. Over 30+ years ago medical societies centralized credentialing As managed care organizations (health plans) increased, so did CVOs Today CVOs support organizations to provide services which meet increased demands. How? Developing Internal CVOs Enterprise Credentialing
Credentialing and Payor Enrollment: What is the difference? Credentialing is the process of obtaining, reviewing and verifying the documentation provided by a licensed professional for granting hospital membership and/or privileges or for payor enrollment. Payor Enrollment is the process to request participation in a Commercial health insurance network, Medicare and/or Medicaid. It also includes when you add, change, term a practitioner or group office practice location. Confirmation is completed to insure timely and optimal reimbursement of submitted claims for services provided by practitioners to enrollees and patients.
Types of CVOs Health Care Organization CVO Independent CVO Regulatory Body Requirements Organization Requirements Not for Profit Payer Delegation Requirements Certified / Accredited Regulatory Body Requirements Customer Requirements For Profit Certified / Accredited Contracted
Shared vision of the future state which includes a plan with goals, target dates and accountabilities. Endorsement and Ongoing Collaborative Support: q Health System Leadership q Medical Staff Office Leaders q Health Plan, PHO, IPA q CVO Leaders q Staff
Developing a CVO What do you need to consider?
§ What is the cost to credential a practitioner? § Baseline Metrics ü Time to Credential ü Volume Data ü Practitioner Satisfaction § Develop Budget ü Staff – work with human resources ü Office Space ü Software ü Equipment
§ Request for Application § Applications (organization, state mandated, addendum) § Attestation / Release of Information § Privileges § Bylaws, Rules and Regulations, Credentialing Plan § Application & Reappointment Packets § Practitioner Enrollment Packet § Payer Applications § Policy and Procedures, etc.
§ Application Request § Send Application & Privileges § Application & Privilege Review § Verification § Approval Process § Handoffs § Communication § Update Database(s)
§ Initial Application § Recredentialing § Locum Tenens § Request for Additional Privileges § Case Logs § NPDB CQ Enrollment § Criminal Background Check
q Education and Training ü Medical School ü Residency/ Internship ü Graduate Education ü Fellowship q Licensure q DEA , Controlled Substance q Work History q Malpractice and Sanction History q Board Certification
q Professional Licensure q Office of Inspector General (OIG) q Medicare / Medicaid Sanction List q Medicare Opt Out q Social Security Master Death File
q Professional License q DEA q Controlled Substance (as required by state) q Insurance q Board Certification
Audit(s) ü Initial and Locum - Verifications and Database ü Reappointment - Verifications and Database Maintenance q Offices q University(s) q Graduate Educational Programs q Hospitals q Board Certification q Etc.
q Reports ü Expirables ü Payer rosters ü Ad. Hoc – i. e. Business Development, Marketing q Metrics ü Application Verification TAT ü Onboarding TAT ü Total Applications Completed q Health Information – i. e. Flu, Immunization Compliance
q Recognized by Commercial Health Plans q Health Plan Credentialing Delegation Agreements q Reduce burden of organization’s need to submit payer credentialing applications for employed practitioners q Improved onboarding timeframes Decreased onboarding timeframe impacts your Organization’s Bottom Line!
Cheryl Cisneros, RN, BSN, CPMSM, CPCS Client Success Manager and Consultant Morrisey, A Health. Stream Company Cheryl. Cisneros@Health. Stream. com
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