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.