ncqa accreditation quality of care Dec 15, 2022

When you hear about physician abrasion in healthcare, you may not think about how it could impact your NCQA Accreditation, but it can. Though there are various reasons for physician abrasion, the most common ones relate to payers’ prior authorization processes, high rates of denied claims and requests for clinical information, and interoperability between providers and payers, brought about by mergers and acquisitions (M&A), entries into new markets, changes in provider networks, value-based payments, demands for new technology, and new rules in government oversight. Because physician abrasion impacts the quality of care and service to members, it is incumbent on organizations to continually monitor and evaluate their utilization management procedures, health outcomes, and member satisfaction.

Physician Abrasion and Health Systems:

There is no shortage of examples of physician abrasion resulting from current changes in the healthcare industry, particularly post-pandemic. So, what has changed? While much healthcare was on-hold during the pandemic, members/patients are now seeking services and procedures including those considered elective, taxing availability of providers. The need for coordination and continuity of care between medical and behavioral healthcare services is even more pronounced now with increasing rates of behavioral health visits, impacting access to care. The need for new models of whole-person care, such as those seen in some patient-centered medical homes, is driving organizations to merge or acquire others that may offer social services, nutrition, or advocacy, but at the same time, drive changes in provider contracts, networks, payment, technology, and utilization management procedures.

Priority Health (based in Michigan):

I had the opportunity to speak with Crain Communications about the upcoming move of Priority Health in Southeast Michigan, competing with Blue Cross Blue Shield of Michigan (BCBS MI) for greater market share around the metro Detroit area. Priority Health will gain about 29,000 members in January 2023 because of Priority’s new partnership with Corewell Health East’s Beaumont Accountable Care Organization (ACO) and its more than 2000 physicians. While this change gives members new access to more in-state providers, it also results in changes on the provider side with new value-based contracts and data exchange.

I commented that Priority may run into roadblocks with providers already aligned with BCBS MI:

“The Blues have invested in a win-win initiative in coaching provider offices to provide quality care, which results in higher quality scores for the Blues and typically lower costs as these providers are in value-based payments…The providers don’t know Priority as well, and it’s always going to be ‘How much are you going to pay me?’ and ‘How quickly are you going to pay me?’, along with ‘How much hassle is it going to be to work with you?"  To read the full article, "Priority Health using Corewell  merger as stepping stone in SE Michigan" that was published November 21, 2022- click here.

UnityPoint Health (based in Iowa):

Just as impactful as mergers and acquisitions are to physician abrasion, so is a significant rise in denied claims experienced by health systems like UnityPoint Health. Over a recent 15-month period they saw a significant rise in requests-for-information denials from their commercial and managed care payers as compared to Iowa’s Medicare system whereby requests remained flat. They noted that while the denials do not necessarily result in a loss of payment, they require additional work to process and turn off the timely payment contract provisions. To read the read the full article from November 21, 2022 - click here.

Physician Abrasion and State Regulations:

While physician abrasion continues, some states have acted this year to reform their prior authorization laws. Michigan, Pennsylvania, and Texas, for example, enacted new provisions to protect providers, such as shortened timeframes to review a prior authorization request, using evidence-based criteria, publishing more detailed lists of requirements, and specialty peer review.

At the same time, a requirement by Pennsylvania for insurers to provide by June 1, 2023, a standardized electronic (internet/web portal) prior authorization process to exchange clinical information could also lead to more physician abrasion as they comply with various systems.

Physician Abrasion and Payers:

 A survey conducted in 2022 by America’s Health Insurance Plans (AHIP) identified that some electronic health records (EHR) are not enabled for prior authorization, and that the cost and burden of upgrading EHRs for electronic prior authorization as top barriers. Other barriers noted are the lack of interoperability between EHR vendors, the cost for payers to enable their systems for electronic exchange, and the lack of electronic prior authorization systems currently on the market. Click here to read more.

Because the utilization management (UM) process is highly impactful to healthcare quality, NCQA requires a thorough annual evaluation of the health plan’s UM program, where only a “met” score is available, no partial score. (See NCQA’s standards on Utilization Management).

Organizations that promptly identify its issues and causes of physician abrasion can more readily develop solutions to help prevent negative impact to its NCQA Accreditation status. 

Here is an example of one approach to quality improvement for utilization management.



High rate of denials

o   Unclear medical policy

o   Policy on new technology not current

o   Change in criteria not communicated timely

o   Benefit coding is outdated

o   Strict tiered requirements

o   Place or level of service not covered

o   Frequency limits exceeded

o   High reversal rates of denials

Provider complaints

o   Extended time to review prior authorizations

o   New value-based payment arrangements

o   High number of medical record requests

o   Role of health plan in managing care

o   Employer groups switching allegiance in health systems

Member Impacts on CAHPS and HEDIS:

Issues that cause physician abrasion may also affect members and could lead to lower scores on member satisfaction and health outcomes and increase costs to the health plan.

  • Untimely decisions on prior authorizations can delay patient care and lead to poor health outcomes
  • Changes in providers can lead to a lack of provider availability and access to care, causing missed preventive services
  • New corporate names and policies could lead to confusion or lack of trust
  • Dissatisfied PCPs or specialists could lead to member dissatisfaction or attrition from the health plan

Our focus has been on physician abrasion and the impact of quality through the lens of utilization management procedures. There are steps you can take to be proactive and help avert physician abrasion.

  • Scrutinize your utilization management policies and procedures
  • Track, monitor, and evaluate in detail all claim denials
  • Examine complaints from both members and providers as they relate to prior authorization procedures
  • Engage network providers to better understand their viewpoints

Call to Action:

  • Ensure you follow NCQA Utilization Management standards on UM program evaluation
  • Contact MHR for Training on Utilization Management

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