In 2019, NCQA transitioned the Disease Management (DM) standards to Population Health Program (PHP) standards, following the industry trend. Only 30 organizations currently have PHP accreditation, and MHR has consulted with five of the organizations and has surveyed three other accredited organizations. Only one of the firms consulted with previously had DM accreditation and the other four are new to accreditation. All but one of the firms are standalone organizations specializing in a single disease entity. The other firm is a very large physician organization responsible for 500,000 members that brought two high-cost diseases through accreditation. MHR trains staff on the standards and expectations, transferring knowledge to help them be successful on an ongoing basis. Since all the organizations use a case management approach to the highest segment of the population, case management accreditation is a great fit for PHP-accredited organizations, which is reflected in almost half of the PHP organizations also having CM accreditation.

Case management (CM) accreditation is frequently sought by physician organizations, case management or PHP specialty organizations, TPAs, ACOs, and hospitals who have members attributed to them by payers. Health plan accreditation’s case management standard is limited to complex case management instead of wider scope in the CM accreditation standards, which encompass traditional, transitional, and complex case management. Two of the current MHR consultants are case management certified and conduct case management surveys for NCQA along with Long Term Services and Supports CM surveys. Even though the complex case management health plan standards do not contain must-pass requirements, they are considerable points for the complex case management file reviews. Health plans delegating services to CM organizations reduce their risk by delegating to an NCQA-accredited entity as any files chosen from an accredited organization for their survey will receive automatic credit for the files. So, it provides the health plans with less risk in delegating. It also provides some level of comfort that the delegated organization has an accreditation entity reviewing processes and files. It should also decrease the level of oversight by the health plan, decreasing administrative costs to the accredited organization and the health plan.

Utilization Management (UM) accreditation is frequently sought by similar organizations mentioned under case management, along with pharmacy benefit management companies. Unlike CM, UM contains what is called must-pass requirements. Files from delegated organizations are included in the health plan’s universe of files that can be selected for their survey.  Included in must-pass requirements are new System Controls for denials and appeals and file reviews for medical, behavioral, and pharmacy denials. Delegating these standards to a non-accredited organization who has a high volume of denials and appeals could cause health plans to be placed on a corrective action plan (CAP) and three or more can cause a denial of accreditation. Therefore, the risk is high for plans to delegate UM to other organizations.

Organizations new to accreditation “don’t know what they don’t know.” Therefore, the consultants, who have a high skill set in UM and prepare health plans for accreditation, keep current on the new requirements and NCQA’s interpretation and nuances of the requirements. Additionally, because most of them are also surveyors, they have inside knowledge of NCQA’s expectations for application of the standards and help the organization’s staff to understand the interpretation. UM is the most rules-based standards outside of credentialing, and the number of pages of the standards is twice as long for UM as it is for credentialing.

MHR has four consultants who have been surveying organizations for several years for Multicultural Health Care (MHC) Distinction, which has now been named Health Equity and is a three-year accreditation (HEA).

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Credentialing is one of the most standard sets that health plans delegate to other organizations. This can be seen on the NCQA report card site where almost 160 organizations who have credentialing accreditation are listed, the highest number of organizations accredited outside of health plan accreditation. Physician organizations, hospitals, health networks and systems, ACOs, specialty organizations (vision, dental, chiropractic, alternative health), and national or regional health plans are typical entities that hold credentialing accreditation.

More recently the credentialing and re-credentialing file reviews became must-pass requirements, and Systems Controls for credentialing also became a must-pass requirement. Therefore, plans are at greater risk because the delegate files are included in the universe of files subject to file review during the health plan’s accreditation. It is also a risk for the organizations pursuing credentialing accreditation, as these file reviews are a must-pass for them also. The level of oversight can be decreased for accredited entities and provides less risk to the health plan that delegates credentialing to them. The reason for using a consulting firm, especially one that has so many NCQA surveyors, is to decrease risk and increase the certainty of being accredited the first time through without a corrective action plan.

There are over 100 NCQA-certified CVOs in the US listed on the NCQA Report Card. CVO organizations can be standalone organizations or may be similar to the entities that have Credentialing Accreditation. One of the main differences between Credentialing Accreditation is that they must have a committee, whereas the CVO does not. Both need to have some type of quality program and evaluate important metrics. New to the 2022 CVO standards that go into effect July 1, 2022, is the must-pass requirement for Systems Controls that were implemented for other products previously. Every organization that MHR works with is struggling with meeting these new requirements. Because it’s a must-pass requirement, it is always prudent to have a consultant review these documents to assure they are compliant with this evolving standard.

Surveyors review 75 credentialing files for CVOs and conduct a (virtual) site review to evaluate the systems for protecting confidential information. Having CVO certification provides automatic credit for the 11 potential primary source verification components available. Since CVOs do not have a credentialing committee, the timeliness of verification still must be measured for each component from the time of the first verification until the committee’s decision or approval of clean files by the physician responsible for credentialing.

There are 41 MBHO standards, and seven of those are not separately found in the health plan (HP) standards, which contain 48 standards. Therefore, there is a significant crossover. But several of the elements are different between these two major standard sets, along with differences in applying the standards to behavioral health care. MHR consultants both survey the MBHOs and consult and partner with them to prepare for their accreditation and assist in systems improvement. Most of the consultants have experience in the behavioral health managed care setting or have behavioral health care experience and understand the nuances and differences. Knowledge and experience are critical when hiring a consulting firm. There are just over 30 NCQA-accredited MBHOs in the US, and six of those belong to two legal entities.

The NCQA WHP standards encompass 13 areas: Client Engagement, Data Exchange, Privacy, Engaging the Population, Health Appraisal, Identification and Targeting, Self-Management Tools, Health Coaching, Rights and Responsibilities, Measuring Effectiveness (Accreditation or Certification), Incentive Management, and Reporting WHP Performance. For WHP accreditation (10), with performance reporting, all but the Measuring Effectiveness for Certification standard must be met. However, NCQA allows individual Certifications for Health Appraisal, Self-Management Tools, and Health Coaching. If these are chosen, then Privacy and Confidentiality, and Measuring Effectiveness also must be met. For individual certifications, organizations range from having one certified product to three. The most population are Health Appraisal (21) and Self-Management Tools (15). This makes sense, as these two provide automatic credit for relevant standards for NCQA-accredited health plans and MBHOs. Ten organizations are currently accredited for the total standards, and four additional are accredited for the higher bar of also producing Performance Reporting. MHR consultants both survey this product and prepare organizations to meet these requirements.

The NCQA HIP product is the least used certification. HIP encompasses Pharmacy Benefit Information (3), Health Information Line (5), Support for Healthy Living (2), and Physician and Hospital Directory (5). Any can be pursued separately, or organizations could strive for certification in all of these. As can be seen, by the numbers in parentheses, the most pursue Health Information Line or Physician and Hospital Directory. At least half of the organizations certified for HIP also have another certification or accreditation that is complementary to the HIP standards. All the consultants have extensive experience in preparing organizations for the Pharmacy Benefit Information and Physician and Hospital Directory, as these are part of the health plan standards. The Health Information Line and Support for Healthy Living used to be part of the health plan standards, so the consultants are very familiar with both surveying them and preparing organizations for certification. Half of the organizations have at least two accreditations or certifications.

Health Plan Accreditation is the original NCQA accreditation product from which all others have derived and grown to support this accreditation. NCQA’s Report Card site lists over 1,100 health plans that have NCQA accreditation. NCQA offers a glide path to accreditation by allowing Interim accreditation first for a subset of the entire standards without more rigorous look-back periods for meeting the standards. Interim accreditation helps organizations meet state regulations that require accreditation, typically for the Medicaid line of business, and can only be done once. If Plans do not pass Interim Surveys, they can re-apply in a year, but only a First Survey is then allowed. Interim allows health plans new to NCQA accreditation to slowly ramp up to the next step, which is the First accreditation. For First accreditations, which occur 18 months after the Interim Survey, all the standards except for remeasurement must be met, with a shorter look-back period of six months. First is a major step, as Plans must have documentation for all standards and implement outcomes measurement and analysis that goes beyond HEDIS measures. However, HEDIS is not required to be submitted until the year after the Interim or First Survey accreditation status is effective.

First Surveys can be the second step in Accreditation or could be the initial foray into Accreditation; NCQA allows either. Many health plans find that Interim does help staff used to NCQA requirements and to become more purposeful and formalized prior to meeting First Survey requirements. Even then, MHR has found through consulting and conducting NCQA surveys that plans have a major struggle in reaching First Survey requirements.

NCQA Renewal Surveys occur three years after the prior survey. For this survey, the requirements are more rigorous. Documented processes must in be in place for the entire 24-month look-back period, many materials must be in place throughout the look-back period, and annual reports must have two annual requirements that are separated by 12 – 14 months. This means that to meet the intent of the standard, processes must be systematized and be occurring at regular intervals. Those organizations that lose staff, have not systematized processes, and have fallen behind have many challenges in meeting requirements. Because of the newer must-pass requirements for Systems Controls for Denials, Appeals, and Credentialing files with a specified look-back period, corrective action plans (CAPs) have become very frequently seen in many organizations. The MHR consultants work with clients proactively to prevent CAPs and prioritize these standards, but when clients do not respond quickly enough to meet look-back period requirements, CAPs can occur.

The consultants perform gap evaluations, gap mitigation assistance in ongoing document reviews, file reviews for complex case management, denials (medical, behavioral, and pharmacy), appeals, credentialing, and re-credentialing. MHR consultants have worked with many organizations new to accreditation and know that many do not have sufficient documentation when the consulting period begins but must develop the documentation as they go. Although MHR’s philosophy is to have clients develop their own documentation and then have MHR review those documents, at times clients do not have the skills nor the experience to develop them on their own. Some clients will purchase the MHR templates to write analysis documents themselves, but occasionally to frequently ask the consultants to model the necessary documentation once so that they can replicate it for future documentation needs. Also, frequently there are new staff in organizations. MHR has proprietary trainings for every standard set that can be purchased that are conducted live and virtually.

MHR has worked with several organizations to assist them in developing a compliant model of care (MOC) for scrutiny by NCQA on behalf of CMS. NCQA trains the surveyors selected for MOC review with guidance from CMS on any changes for the calendar year. MOCs are typically submitted to NCQA in February for the following calendar year, so organizations must plan quite a bit ahead of time to develop and submit the MOC. There are four major sections and several sub-sections that must be completed, and the scoring is based on meeting a specific number of points for each area. The greatest area of struggle by clients is the lack of detail and specifics and focusing only on processes and not outcomes. Three of the MHR consultants conduct MOC surveys, and one of the three on behalf of NCQA is an executive reviewer for the evaluation of other surveyors’ work. MHR clients score 99 – 100% on their submitted MOCs. Of course, our consultants do not review any MHR clients’ work as that would be a conflict of interest.

Four different Accreditation programs are supported by one of NCQA’S newer programs. Population Health Management Prevalidation can provide support for Population Health, Case Management, Managed Behavioral Health Organizations, and Health Plan Accreditation. There are currently 16 organizations that hold this certification, and MHR has worked with two of them. Only internal NCQA staff review this product, so MHR only has experience with assisting organizations to successfully meet the standards.

MHR has spent hundreds of hours developing various templates and tools to support different accreditations. Some of these are free to clients, but most are available for purchasing the license for use by the organization that purchased them. Because analysis is the more challenging of reports required for accreditation due to quantitative and qualitative analysis, the templates provide detailed guidance for completing the analyses, prompting the writer for the required information. The other major challenge for managing accreditation is delegation. MHR has a suite of tools to provide guidance to organizations and methods of tracking oversight and compliance.