NCQA’s Credentialing Standards Ensure Safety and Integrity of Practitioner Networks

November 19, 2024 · Becky Kolinski

Patients rely on health care organizations to maintain networks of qualified practitioners so they can get timely, equitable and culturally responsive care. Credentialing is an essential function that protects the safety of patients and collects vital information for practitioner directories to help patients choose one who meets their needs.

Credentialing is detailed review and verification of a health care practitioner’s qualifications and experience—license, medical education, history of sanctions, prior malpractice cases and other information—before they join a network. NCQA requires recredentialing every three years.

NCQA recently updated its credentialing product suite of programs, providing a framework for health care organizations to implement industry best practices for practitioner credentialing, ongoing monitoring and recredentialing.

Which Organizations Perform Credentialing?

Health care delivery systems and health insurance plans must credential practitioners before they can join a network. Commercial CVOs may perform aspects of the credentialing process—such as license verification or review of sanctions—and pass that information to the health system or health plan.

An organization might use a third party to perform some of its credentialing functions. If an NCQA-Accredited health plan or health system delegates these functions, it must provide oversight by reviewing a sample of the delegate’s credentialing files—a time consuming, labor-intensive process. But if the delegate has earned NCQA’s Credentialing Accreditation or Certification, the organization may choose to forgo an audit.

How Did NCQA Update Its Credentialing Standards?

After performing extensive research, including a public comment period, NCQA combined its existing programs into a single program for Credentialing Accreditation and Certification. All requirements in the credentialing suite align with credentialing standards in NCQA’s Health Plan Accreditation program.

Organizations may pursue Accreditation, Certification or both. Credentialing Accreditation is for organizations with full oversight of the credentialing process, and a credentialing committee that has the authority to approve a practitioner for the network. Certification is for organizations that perform credentialing verification functions but do not have a credentialing committee. Certified organizations are often delegates of other health care organizations that maintain a network of practitioners.

Other changes to NCQA’s Credentialing standards:

• Interim Survey Option. The new Interim Survey option is ideal for organizations seeking first-time Accreditation. After NCQA reviews an organization’s policies and procedures, the organization has 18 months to prepare for its full survey.
• Shorter Verification Time Frame. Because most verifications for credentialing and recredentialing are performed electronically, NCQA shortened the time frame for completing these reviews. This allows organizations to access and work with more current data and get practitioners enrolled into networks faster.
• Collection of Practitioner Race/Ethnicity Data. Organizations are required to include an optional field for collecting a practitioner’s race, ethnicity and language information on the practitioner application. Having this information available in practitioner directories gives patients a better experience.

Benefits of Accreditation/Certification

There are many reasons to consider participating in NCQA’s Credentialing Accreditation or Certification programs.

• Engage With Health Plans. Health systems that earn NCQA Credentialing Accreditation may be more attractive contracting partners with health plans by making the credentialing process more efficient and effective and reducing the audit burden, since requirements across the programs are aligned.
• Increased Efficiency. Practitioners will be enrolled in networks faster, due to streamlined delegation agreements, and can begin seeing patients sooner, which will support organizational growth and business objectives.
• Patient Satisfaction. Patients will have access to qualified practitioners faster, and can make an informed choice about practitioners in the network.
• Enhanced Reputation. Organizations that go through NCQA’s rigorous Accreditation/Certification process show their commitment to quality and build a reputation as a trusted partner for delegation arrangements.

Your Next Steps

• Learn more about NCQA’s Credentialing Accreditation and Certification.
• Purchase a copy of the standards in the NCQA Store.
• Watch our recent webinar, Credentialing 101.
• Enroll in our Credentialing Accreditation and Certification Updates.