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Medallion + NCQA: A better way to reduce risk

Improper credentialing of healthcare providers are among the top 10 leading causes of malpractice claims against healthcare organizations. So, what can be done to prevent this?

In healthcare, ensuring patient safety is always a top priority. And according to a recent report by the National Practitioner Data Bank, improper credentialing and privileging of healthcare providers are among the top 10 leading causes of malpractice claims against healthcare organizations.

That's where the National Committee for Quality Assurance (NCQA) comes in. It evaluates the credentialing and re-credentialing of healthcare providers to ensure that they meet industry standards. 

With standardized quality measures and increased compliance regulations, obtaining NCQA accreditation has become a crucial aspect of the healthcare industry.

But how can healthcare organizations achieve this accreditation? 

The answer lies in establishing policies and procedures that integrate departments and use automation and technology to ensure compliance. 

By doing so, they not only reduce risk exposure and safeguard patients but also cut down on administrative strain.

In this post, we'll explore the importance of NCQA accreditation, what an NCQA audit entails, and how a healthcare organization like yours can prepare for a successful audit with the help of Medallion.

What is provider credentialing?

Provider credentialing is a complex and essential process in the healthcare industry. 

It involves multiple stages, including verifying a provider's education, training, and licensure to ensure they meet the necessary qualifications for their job. 

The credentialing challenges can be significant, with potential consequences for patients and healthcare organizations. It's crucial to maintain quality and safety in healthcare, but that requires diligence and attention to detail.

In the next section, we'll take a closer look at these challenges and what you can do to address them so your organization can ensure the best possible patient outcomes.

What are the challenges of credentialing in healthcare?

Credentialing is a vital process for healthcare organizations, but it's also a complex one with many challenges. One of the most significant obstacles is the risk of revenue loss due to inadequate credentialing. Organizations could miss out on payments without a robust credentialing program and those organizations could face fines or corrective action plans.

So, what are the most common mistakes made during the credentialing process that lead to potential revenue loss? These include: 

  • Timing and planning errors
  • Inaccurate data entry
  • Incomplete provider applications
  • Compliance oversights
  • Enrollment problems
  • Manual processes

According to a 2020 Joint Commission report, inadequate credentialing practices can contribute to patient harm and increase liability for healthcare organizations. Effective credentialing processes are essential to ensure patient safety and mitigate risk.

To reduce the risk of non-compliance and safeguard patients, healthcare organizations must establish comprehensive credentialing policies and procedures that address these challenges head-on.

NCQA and audit-readiness

When it comes to standing out in the healthcare industry, few things are more impressive than achieving NCQA accreditation. The National Committee for Quality Assurance sets a high bar for healthcare organizations, evaluating everything from provider credentials to ongoing monitoring and reporting.

To become accredited, organizations must undergo a rigorous audit process that assesses these crucial components, including credentialing policies and procedures, completed credentialing packets, and ongoing monitoring reports.

Achieving NCQA accreditation isn't just a feather in your cap; it's also a way to show your commitment to patient safety and quality care. And it's essential to be audit-ready in every way.

In the next section, we'll explore what it means to be audit-ready and how Medallion can help your organization achieve and maintain NCQA accreditation.

What to expect during an NCQA audit?

In preparation for an NCQA audit, healthcare organizations must know what to expect during the process. 

The audit process is divided into several parts:

  • A self-assessment
  • An on-site visit
  • A review of credentialing packets
  • Ongoing monitoring reports

Site visits

During the remote or on-site visit, NCQA surveyors will review your documentation, policies, and procedures and interview your staff. Once the surveyors have completed their review, they will prepare a report of their findings. If they find that your organization meets the NCQA standards, you will receive accreditation or certification. However, if any issues need to be addressed, you will need to submit a plan of correction to show how you intend to fix them.

Credentialing packet reviews + monitoring

The audit process also involves the review of credentialing packets and ongoing monitoring reports. These credentialing packets include credentials verification forms and provider applications while ongoing monitoring reports like medicare/Medicaid sanctions reports are checked to ensure that organizations comply with the regulations.

By being prepared and having accurate and up-to-date documentation, healthcare organizations can avoid non-compliance and safeguard patient safety. 

Achieving NCQA accreditation can give your organization an edge in the competitive healthcare market, so it's crucial to understand what to expect during the audit process.

Streamlining with technology

The traditional paper-based credentialing process can create a bottleneck for healthcare organizations as the industry continues to evolve and expand. Luckily, technology has come a long way, and automated credentialing solutions can significantly improve the credentialing process's accuracy, efficiency, and compliance.

For example, Family Care Center has successfully streamlined its credentialing process with Medallion's automated credentialing solution. Medallion's platform simplifies the provider enrollment and credentialing process by automating tasks like data entry, verification, and record keeping.

By leveraging the power of automation, healthcare organizations like Family Care Center can reduce the time and administrative burden of the credentialing process while ensuring compliance with regulatory requirements.

Automated credentialing solutions like Medallion can increase accuracy, efficiency, and compliance, making the process faster and easier for all involved. Let’s take a closer look at this in the next section. 

A word on Medallion's credentialing verification organization services

Regarding credentialing, partnering with an NCQA-accredited credentialing verification organization (CVO) like Medallion can significantly benefit your healthcare organization. 

By delegating credentialing responsibilities to us, your organization can free up internal resources and benefit from the industry expertise and streamlined processes that CVOs offer.

Working with Medallion can also help your internal teams improve efficiency and reduce administrative burdens. Our experienced team can help you better navigate the complex credentialing process, stay up-to-date with changing regulations, and provide ongoing support to maintain compliance.

Medallion also has robust processes to protect sensitive data, which can help address any concerns around security and compliance.

How to prepare for an NCQA audit 

Preparing for an NCQA audit may sound like a daunting task, but there are practical steps your organization can take to increase your chances of success.

  • Review the requirements. Firstly, it's crucial to familiarize yourself with the NCQA standards to know what to expect during the audit. 
  • Self-assess. Organizations can conduct a self-assessment to identify areas for improvement and align their policies and procedures with the NCQA standards.
  • Turn to modern software. Leveraging modern technology like Medallion can also be a valuable resource, providing checklists, gap analyses, and action plans to address any identified gaps.
  • Do internal training and monitoring. Organizations must keep their credentialing packers up-to-date and ensure their providers meet the NCQA standards for credentialing and privilege. Conducting internal training and reviewing ongoing monitoring reports are also essential.

By following these steps, your healthcare organization can improve your quality and safety performance, meet regulatory requirements and ultimately reach a successful NCQA audit.

Investing to boost patient safety and quality

As we've seen, the credentialing process is essential for maintaining the quality and safety of patient care. But with the high stakes of compliance, it can be a challenge for many healthcare organizations to navigate the complex process.

That's where tools like Medallion come in. By automating and streamlining the credentialing process, healthcare organizations can reduce administrative burden and improve compliance with NCQA standards.

Achieving NCQA accreditation is a significant accomplishment for any healthcare organization. It's a mark of quality and excellence that can differentiate you from the competition and give patients and stakeholders peace of mind.

At the end of the day, healthcare organizations must be proactive in ensuring their credentialing and privileging policies are up-to-date, efficient, and effective. With Medallion's support, you can streamline your credentialing process, reduce risk exposure and provide the best possible care for your patients.