Delegated Credentialing & CVO Operations Flashcards

Under what circumstance must a delegating organization terminate a delegation agreement with a CVO?

Answer: When the CVO fails to correct deficiencies identified in an audit within the agreed corrective action timeframe

Delegation should be revoked when a CVO fails to remediate audit deficiencies within agreed timeframes, indicating an inability to meet the required performance standards.

How is the required file review sample size typically determined during a CVO oversight audit?

Answer: According to the sample size defined by applicable accreditation standards or the delegation agreement

The required audit sample size is typically specified by accreditation standards such as NCQA or defined within the delegation agreement to ensure statistically valid oversight.

Which of the following is typically NOT within the scope of a CVO's delegated credentialing activities?

Answer: Making final adverse credentialing decisions that affect provider panel status without delegating entity review

While CVOs can perform many credentialing verification functions, final adverse decisions affecting provider panel status typically require review and approval by the delegating entity's credentialing committee.

During its NCQA accreditation renewal, what must a health plan demonstrate regarding any credentialing CVOs it uses?

Answer: That proper delegation agreements are in place and required oversight audits have been conducted

For NCQA accreditation, health plans must demonstrate they have valid delegation agreements with CVOs and have conducted required oversight audits to verify CVO compliance with standards.

Before engaging a new CVO for credentialing delegation, what should a hospital system evaluate?

Answer: The CVO's accreditation status, operational processes, technology, and compliance track record

Before delegating credentialing, the hospital should assess the CVO's accreditation, operational processes, technology capabilities, and compliance history to ensure they can perform functions to required standards.

What is the purpose of a pre-delegation audit when establishing a new CVO relationship?

Answer: To assess whether the CVO is capable of performing delegated functions before the formal delegation begins

A pre-delegation audit assesses the prospective CVO's capabilities, processes, and compliance posture before formal delegation begins, reducing risk for the delegating entity.

In which situation would a health plan most likely choose to use a CVO for credentialing rather than performing it in-house?

Answer: When the health plan wants to reduce credentialing costs, increase efficiency, or leverage specialized credentialing expertise

Organizations typically delegate to CVOs to achieve cost savings, operational efficiency, faster turnaround times, and access to specialized credentialing expertise and technology infrastructure.