CVO credentialing: The key to unlocking efficacy and lowering costs for payers

Welcome to the ever-evolving world of healthcare, where the stakes are high and the expectations even higher. 

As providers become more specialized and industry standards continue to evolve, it's critical to ensure that providers are qualified and meet these standards. That's where credentialing verification organizations (CVOs) come in. 

These organizations play a vital role in maintaining and verifying provider credentials, and can have a significant impact on both the efficacy of healthcare and the bottom line for health plans and payers.

In this blog post, we will explore the benefits of using a CVO, including how it can increase efficacy in healthcare and lower operating costs for health plans and payers.

What is a CVO and how it works

Let's talk about the power of CVOs - or credentialing verification organizations - in the healthcare industry. Simply put, a CVO is a third-party organization that ensures your provider qualifications are up to industry standards.

CVOs have the important task of verifying and maintaining the necessary credentials for healthcare professionals, including licensure, certification, education, training, and more. By doing so, CVOs help maintain the integrity of the provider-payer relationship while ensuring that quality care is delivered to health plans' members.

Not only does a CVO provide invaluable services to health plans and payers by streamlining the credential verification process, but it also frees up the time of those in charge to focus on their own expertise. 

This helps maximize efficiency and saves valuable resources that would otherwise be devoted to verifying provider credentials, helping to accelerate the transformation of payer organizations through leveraging digital technology and automation, helping to alleviate some of the most pressing issues health system chief information officers (CIOs) are facing which are tech talent shortages and an increased pressure to innovate as this Becker Hospital poll shows. 

With a CVO's advanced technology, resources, and industry experience, it's easier to stay up-to-date with compliance and regulations. By having accurate and up-to-date provider information, health plans and payers can process claims faster and with fewer delays, leading to better overall customer satisfaction.

In short, a CVO can provide countless benefits to the healthcare industry. It's no surprise that so many turn to CVO services to help lower costs and increase efficacy.

How CVO's can increase efficacy in healthcare

Credentialing verification organizations (CVOs) are a powerful tool for improving healthcare efficacy. By vetting and verifying that in-network providers meet stringent criteria, CVOs can create networks of only the most qualified doctors, leading to better care for patients.

These organizations undertake meticulous background checks that include detailed education, licensing, certification, and malpractice insurance reviews to confirm that providers meet regulatory standards set by both federal and state medical organizations. With the right set of credentials, a doctor can then join a network of other qualified professionals, ensuring patients receive the highest quality care available.

A CVO's stringent criteria leads to a high level of quality assurance, protecting patients and giving them the assurance that they are receiving the best possible care. The benefits extend to payers and health plans, who can maintain better relationships with patients and build trust by offering the best possible providers.

Through removing unqualified providers, CVOs can improve healthcare outcomes and help patients avoid frustrating experiences with subpar healthcare providers. With CVOs ensuring medical safety, everyone benefits from improved healthcare experiences.

How CVO's can lower operating costs for health plans and payers

Credentialing verification organizations (CVOs) provide an invaluable service for health plans and payers by offering a sophisticated approach to identifying and reducing fraud, waste, and abuse.

Leveraging modern tools

CVOs can utilize a comprehensive array of tools and tactics to check for things like licensing violations, improper claims, and other types of fraud. By examining data from multiple sources and using cutting-edge analytical techniques, CVOs can uncover hidden patterns and identify potential fraud that would otherwise go unnoticed.

Keeping a pulse on the fine print

This diligent approach to vetting can save health plans and payer organizations a significant amount of money by preventing fraudulent activities before they can occur. By ensuring that all claims are properly documented and authenticated, CVOs can help to prevent costly errors and unnecessary payouts. 

Preventing financial woes

As healthcare systems experience increasing financial and workforce pressures, the importance of efficient credentialing workflows is paramount. To avoid leaving money on the table, it's crucial to accelerate primary source verification, credentialing, payer enrollment, and licensure processes. In this case, it’s exactly what Family Care Center, a leader in comprehensive behavioral health services, leaned into when consulting with Medallion. 

Prior to our partnership, FCC worked under a fragmented provider credentialing process netting out to having only 30% of the providers at the time were credentialed, and 70% had not even submitted their applications. With Medallion’s help, we transformed their day-to-day focus resulting in 19 days faster to complete provider onboarding, 100 providers credentialed and earned a 100% score from Optum — significant gains in their process. 

The key to achieving these goals is to partner with a reputable CVO, which can streamline the verification and maintenance of provider qualifications. By leveraging the resources and expertise of a CVO, payer organizations can save time, reduce costs, and improve their reimbursement processes.

Additionally, by keeping close tabs on the charges being submitted by doctors and providers, CVOs can help to identify instances where costs are getting out of control. This can help health plans and payer organizations stay within their budgets while still delivering high-quality care to their members.

All in all, CVOs provide a vital service to the healthcare industry by improving the accuracy and efficiency of provider credentialing and verification. By helping to reduce fraud and manage costs, CVOs help health plans and payer organizations to deliver better care to their members while staying within their budgets.

Evaluating a CVO partnership for your payer organization

Credentialing verification organizations (CVOs) are the key to ensuring health plans and payers maintain industry standards for their providers. Partnering with a CVO saves time and money by preventing fraud and abuse in their networks. Patients have peace of mind knowing that only qualified professionals will be providing them care. Automating the credentialing process can help payers achieve greater efficiency throughout the process.

However, verifying provider credentials is a resource-intensive process that adds cost and time to the payer’s bottom line. During the initial credentialing process, common issues that can arise include incomplete paperwork, missing signatures, incorrect taxonomy codes, demographic discrepancies, outdated W9 or CAQH profile, and more.

This back-and-forth process between payers and healthcare systems creates a bottleneck that can result in substantial administrative costs and affect revenue generation for both parties stuck in the waiting game. 

But there are a key set of questions to consider when evaluating whether a CVO can help get you to where you want to be, faster. 

Medallion CVO evaluation

1. How many healthcare providers do we currently work with, and how many new providers do we anticipate adding to our network in the near future?
2. How much time and resources are we currently dedicating to the provider credentialing and verification process, and is this impacting our ability to bring new providers onboard in a timely manner?
3. How well do our current credentialing and verification processes meet compliance standards and regulatory requirements, and what risks does our organization face if we are not in compliance?
4. How much are we spending on internal resources to manage the credentialing and verification process, and how does this compare to the cost of outsourcing to a third-party organization?
5. What kind of experience and expertise do we have within our organization to manage the complexities of credentialing and verification, and can we leverage a third-party organization to help us achieve greater efficiency and effectiveness?
6. How well are we able to manage the ongoing monitoring of provider credentials and performance, and what tools or resources do we currently have in place to support this process?
7. How important is speed and accuracy in our provider credentialing and verification process, and are we able to meet the needs of our members and providers in a timely and effective manner?

By considering these questions, payer organizations can make an informed decision about whether to invest in a third-party credentialing verification organization like Medallion and how to best leverage their expertise to improve the efficacy and lower the costs of payer operations.

How Medallion helps payer organizations

Medallion is built to bring out the best of your workflows, saving you time and money by delivering you with a process that avoids the pitfalls of an inefficient credentialing workflow:

Medallion unites your operations

Only Medallion fixes broken credentialing committee workflows enabling you to manage your entire committee process on one platform that enables members to read files, review sanctions and log their votes.

Save time with accurate verifications every time

Leverage our automated primary source verifications to achieve a flawless credentialing and verifications process. With our pre-built integrations to hundreds of primary sources, you can automate primary source verifications and expedite provider credentialing.

See full visibility of provider data

Health plans and providers spend at least $2.1B annually to maintain their provider databases. Inaccurate directory data not only exposes plans to potential fines under the No Surprises Act, but also burdens providers with redundant attestations and complicates patients' care coordination efforts. Minimize inaccuracies and reduce costs by implementing a systematic and proactive provider data validation process to ensure up-to-date and reliable information with Medallion. Maintain your access to critical information throughout the credentialing verification process with provider data directly linked in their profile. 

Aggregating provider data for both direct credentialing & delegated agreements 

Payers can either directly credential providers or delegate credentialing of those providers to healthcare organizations. This means that aggregating data and information from both of these sources is difficult to manage and monitor. Instead, Medallion streamlines data aggregation and monitoring by adopting a unified credentialing management platform that accommodates both direct and delegated credentialing.

Direct communication with providers

Payers are naturally removed from direct communication with providers. Instead, they’re typically communicating with the provider group or healthcare organization. But this poses a challenge when it’s necessary to contact payers or when additional information is needed. It creates a barrier for payers that slows down the credentialing process. Leverage a platform that establishes direct communication with providers to expedite response times and build stronger relationships directly with the provider.

Eliminate problems caused by separate workflows

Centralize your operations, save time, keep costs low and ensure accuracy by streamlining all credentialing workflows to one user-friendly platform.