The business of verifying doctors' credentials is coming into its own.
The National Committee for Quality Assurance officially recognized that sector late last month by issuing badges of certification to 18 credentials verification organizations.
But the sector has been building for several years to meet intensifying needs for thoroughness in checking claims made by doctors as well as claims made against them.
Before managed care, the process of verifying physician credentials and searching for any sanctions was mainly a job for the hospital at which a doctor sought staff privileges.
That plodding, doc-by-doc investigation can't cut it anymore under pressure from healthcare contractors and accreditation agencies such as the NCQA for current, accurate records on hundreds of physicians in group practices and HMO provider panels.
A cottage industry of verification businesses has moved in to fill a gap by building databases on physicians and other healthcare professionals, providing for ongoing updates and promising quick turnaround on inquiries through the use of information technology.
For example, Credential Information and Verification Services, a Rockville, Md.-based company founded in 1991, has 8 million records on healthcare delivery professionals, said Mike Buckler, director of sales and marketing.
About 70% of the records are on physicians, osteopaths, dentists, podiatrists and chiropractors, while the rest cover newer areas in which credentials are becoming an issue such as physical therapy, occupational therapy, acupuncture and mental-health professions, Buckler said.
He estimated the current size of the credentials verification business at $100 million to $150 million, which would include both the operations of contract management businesses and the internal operations of large commercial health plans that increasingly perform verification tasks themselves.
The NCQA, a Washington-based agency that specializes in evaluating the fitness of managed-care organizations, has zeroed in on the credentials and practice histories of physicians as a major component of its accreditation scrutiny. Physician qualifications and evaluation account for 25% of an HMO's total score, second only to quality management and improvement as an accreditation priority.
Demands on health plans include not only seeing to it that all physicians are suitably credentialed but also overseeing the process used to verify credentials and keep them up to date.
Until the NCQA announced it would evaluate and certify credentials verification organizations, HMOs that delegated the credentialing task still had to demonstrate their ongoing oversight of the outside agency. That led to duplication of effort as one HMO after another descended on the same verification agencies to perform the same routines, the NCQA said.
The NCQA split up the business of verification into 10 separate elements for certification purposes (See chart).
HMOs and other clients won't have to show evidence of oversight for elements that earn the one-year certification, the NCQA said. Verification businesses may offer more services than those for which they're certified, but their clients will have to continue to oversee noncertified services.
Only one company among the first 18 evaluated by the NCQA-Atlanta-based Equifax Medical Credentials Verification Services-was certified for all 10 services. Ironically, Equifax earned that status just as it was deciding to put the division up for sale. But that was part of a larger decision to get out of the healthcare information business entirely (See related story, p. 32).
Credential Information and Verification Services received certification for nine of 10 service elements, as did three other companies: Med Advantage, Orlando, Fla.; Sweetwater Health Enterprises, Dallas; and Oklahoma Centralized Verification Organization, a unit of Tulsa (Okla.) Medical Society.
Businesses certified for eight services include Columbia HCA Credentials Processing Center, a Fort Lauderdale, Fla.-based division of Columbia/HCA Healthcare Corp. Others with eight certified services are Gadrian Corp., Englewood, Colo.; Healthcare Credentials Management Services, San Diego, a unit of Deerfield, Ill.-based MMI Cos.; InterQual, Marlborough, Mass.; and Medilert-IRIS, Scottsdale, Ariz.