URAC Accreditation Tips

IRO Core 1 requires that your organization clearly defines its structure, roles, and responsibilities.  This 2-weighted standard is rather straightforward and seldom the subject of a comment by URAC reviewers. Its purpose is to give the reviewer an understanding of the structure, ownership, and reporting mechanisms of the organization. The applicant should submit organizational charts at both the macro level (with senior organizational leadership described) and at the department level for the departments who are the subject of the accreditation under consideration. Additionally, organizational charts should show key committees, especially the Quality Management Committee and any other accreditation-relevant committees (e.g., credentialing committees for Health Plans and Health Networks). Any official company documents that describe the organization, particular the services that are the subject of the accreditation, will help, too.

If you submit these charts and program descriptions, you probably won't get any comments from the URAC reviewer. However, you may be asked for more information beyond this if there is something about the ownership structure that is unclear. For example, if you have a holding company or corporate affiliate, the name of which is all over your company documents but not reflected in the organizational charts, the reviewer may ask for some more detail.

The onsite review will simply be focused on making sure that what you said in the application is, in fact, the truth in practice. The interpretive guide says the following about the onsite review:

Recent (within past 6 months) reports demonstrating organizational oversight: reports will be analyzed along with any meeting minutes where they were presented and discussed

This review of reports and committee minutes, however, will be going on anyway in connection with other standards, so very little happens specifically and exclusively in connection with this standard.

The Basics

IRO Core 3 requires that your organization operate under policies and procedures ("P&Ps").  This is an incredibly important standard.  It requires several things of all employees.  First, you need to know where your organization's "master list of P&Ps" is.  If you don't know, find out.

Second, you need to be able to access -- quickly and easily -- the specific P&Ps that apply to your job.  Again, if you don't know, find out.

Third, you need to do your job in accord with those P&Ps.  Failing to do so is, itself, a way to miss this standard, even if what you are doing complies with the applicable URAC standard.  For example, if you are in the IT department performing an activity (e.g., destruction of old data) in a way that complies with the applicable URAC standard, you'll violate a mandatory element of this standard anyway if you are doing it in a way that is inconsistent with your organization's P&P on the subject.  So, if your P&P inaccurately describes the way things are done, get whoever is in charge of your P&Ps to change the P&P to fit reality.

Management Tips

IRO Core 3 sets forth a number of requirements for an organization's policies and procedures (P&P) processes.  Your organization must comply with its P&Ps, maintain a list, keep the P&Ps up-to-date through an annual review, and leave a paper-trail for each P&P of its effective, review, and revision dates, as well as who (or what committee) approves each P&P.

The standard applies "to the key services and internal programs established by the applicant. For purposes of accreditation, the policies and procedures that cover primary health care-related program services will be examined for compliance with these standards." So, while its scope is broad, many organizations will have a number of policies and procedures that are not affected by the requirements of the standard. As the Program Guide notes, "Policies and procedures covering general personnel, accounting, office management, and other such support services for the organization are not required as evidence for meeting these standards."

Third, mere maintenance of policies and procedures will not suffice. One of the most powerful two-word phrases in all of the URAC standards is subsection (b)'s "and complies." The effect of this phrase is to transform all your organization's policies and procedures into mandatory accreditation standards. In other words, even if you are complying with a particular URAC standard, if you are not in compliance with your own policy and procedure on the topic, you may run afoul of IRO Core 3(b). And that would be very bad.  The key to documenting this is to make sure that your applicable P&P includes the method by which the organization monitors its core business operations for compliance with written policies and procedures. 

Fourth, one of the more frequently missed elements of this standard is IRO Core 3(d)(i). While it may not be evident from the language of the standard, "review" and "revision" can be two entirely different events happening on entirely different dates. For example, if you review a policy without revising, your policy and procedure and/or your master list of P&Ps will need to indicate both dates, not simply the most recent day that somebody in authority looked at the policy. Therefore, either your P&P or your master list should have one place for the effective date, another place for the most recent revision, and another place for the most recent review.

URAC Accreditation Tips

Maintaining and complying with your P&Ps is mandatory. Mess up subsection (a), and you will do no better than a Conditional Accreditation.  The rest of the elements of the standard carry a weight of 2 or 3.

In a recent clarification, URAC has modified its stand on IRO Core 3(a). IRO Core 3(a) is triggered if:

• 3 occurrences of not complying with own P&P, or
• 2 occurrences of not complying with own P&P and in both instances, the applicant organization is then not meeting a Mandatory standard element (2 [M] not met).

For the desktop review, you should submit the master list of P&Ps, including the method by which the organization monitors its core business operations for compliance with written policies and procedures, and your policy and procedure on the maintenance of policies and procedures.

The on-site reviewer will assess whether your staff can easily access the policies and procedures that govern their work.  They could do this at any point during the day, during any interview.  The question might go like this: "If you have a question about how to do a particular aspect of your job, and your supervisor is not readily available, can you access the policy and procedure that might answer that question?  Could you show me, now, how you would do that?"

The Basics

This standard, another new one in version 4.0, establishes minimum requirements for the short- and long-term goals established in the CM participant's plan.  Each goal must:

• be measurable;
• be related to the CM assessment of consumer needs;
• have a timeline for the achievement of the goal; and
• be modified as the program participant's needs change.

Management Tips

Your plan template should provide case managers with guidance such that they establish both long- and short-term goals and that each goal contain all the components required by this standard.  It is important that you implement a clear policy assuring that these goals be evaluated periodically, not just so the case manager can measure the consumer's progress against the goals, but also to see if they need to be revised in the face of changes in the consumer's needs.

URAC Accreditation Tips

Each of the four elements of this standard is worth 3 points.

For the desktop review, submit your applicable P&Ps, including care plan forms.  In addition, show evidence that staff members have been trained on your P&Ps and forms regarding the development and maintenance of care plans.

The onsite reviewer will examine case files for evidence of implementation of this standard, and will interview case managers to make sure they're fully familiar with your organization's P&Ps regarding care plans.

The Basics

This standard, new to v. 4.0, requires that at either the initial assessment or later assessments, the case manager assesses and documents:

• current health status,
• clinical history, medication history,
• treatment plan,
• medication safety issues such as medication, adherence, and the need for reconciliation. 
• necessary resourcess to address the consumer's needs,
• needs related to care coordination (including care transitions),
• psychosocial status,
• any safety concerns.

URAC defines "medication reconciliation" as follows:

The process of creating the most accurate list possible of all medications a patient is taking - including drug name, dosage, frequency, and route - and comparing that list against the physician's admission, transfer and/or discharge orders, with the goal of providing correct medications to the patient at all transition points.

Each of these areas needs to be addressed in an assessment at some point in the process, or else you need to explain why you didn't assess an area.  That suggests that it's an excellent idea to address all of these areas as early in the process as possible.

Management Tips

The most common way to meet the requirements of this standard is to develop and require the use of a standardized clinical assessment tool, one that is used in interviews of the consumer and his/her family and providers.  In addition to such a tool, you'll need to make sure you have a P&P that describes the assessment process.

Naturally, not all these items may be appropriate for your organization's particular population, and the collection of some may even be prohibited by law. However, if the URAC reviewer, in conducting a case file review, finds that closed cases never address an area nor document why the area isn't addressed, she'll count the area as "not met."

URAC Accreditation Tips

Each of the eight elements of this standard is worth 3 points.

During the desktop review, the reviewer will expect to see your P&P describing, in detail, your assessment process as well as any tools used in that assessment.

During the onsite review, the reviewer will examine case files to find that a complete assessment has been conducted for each consumer.  In addition, the reviewer will talk with case managers about the assessment process.

The Basics

This standard requires that the CM program implement P&Ps that specify when the CM staff members (1) refer consumer questions and (2) initiate other communications (scheduled and non-scheduled) to ordering providers.

Management Tips

This new standard requires a rather simple, straightforward P&P that provides guidance to your staff about these two areas of communications with treating providers.  Naturally, the provider may not want to work with the CM program.  This does not obviate the need for you to have an applicable P&P addressing the topic.

URAC Accreditation Tips

The two elements of this standard are both worth 3 points.

For the desktop review, you need submit only the applicable P&P.

In addition to reviewing the P&P, the onsite reviewer will use the audit of individual case files to look for evidence of communication with providers consistent with the time frames described in the P&P.  In addition, the reviewer likely will ask the case manager(s) she interviews questions about provider communication, including:

• Do you ever communicate with the program participant's treating provider?
• How do you handle participants' clinical questions that should be addressed to their own physicians?
• What are the time constraints for referring questions to the treating provider?
• How do you document communications with treating providers?

The Basics

This standard requires that the results of the case file reviews be used in order to assess case managers' learning needs and to provide information for the required annual performance evaluation.  Whether you are a case manager or a supervisor of case managers, you'll need to know the particular connection in your company between the case file audits and case manager performance evaluation.

Management Tips

You P&Ps involving case manager performance evaluation must explicitly describe the connection between the file review process and the performance evaluation process.  Furthermore, the performance appraisal form used for case managers should demonstrate the use of the results of file audits.

URAC Accreditation Tips

This new standard weighs 3 points.

For the desktop review, submit:

• A P&P describing the relationship between file audits and case manager performance evaluation;
• The case file audit tool; and
• A template for case manager performance evaluation.

During the onsite review, the URAC reviewer will examine individual case manager personnel files for evidence in the annual performance evaluation of the use of the results of case file audits.

The Basics

This standard, new with version 4.0, requires that the CM program conduct an annual review of the CM program.  That review must examine the program's performance measures, structure, and P&Ps.  In addition, the annual program review should use the results of case file reviews to assess whether the program's performance measures are being met.  The report of the annual review should go to the organization's quality management committee. 

Management Tips

It's helpful to think about the individual case file reviews as an invaluable window into the performance of the whole program.  This can only be accomplished if you track and trend results from those reviews.  So, be sure to design your program-level performance measures so that they are integrated with the individual case file results.  So, while individual case file audits are useful tools for assessing the performance of individual case managers, they also need to be seen as markers of program performance.

Your approach to this integration needs to be spelled out in a program description, P&Ps, or other official program document.  In addition, the documentation of the implementation of that program performance needs to be clear to an outside observer.  Finally, that report should go to the quality management committee and recorded in the QMC meeting minutes. 

URAC Accreditation Tips

Both elements of this standard are worth 3 points.

For purposes of desktop review, submit the description of your approach to program performance analysis, probably in a program description or P&P.  Also, submit sample minutes of QMC meetings at which a report of such program performance analysis is presented and discussed.

It is at the onsite review that the URAC reviewer will want to see the full documentation of the annual program performance analysis.  In addition, she will interview the case managers (and supervisors) involved in the analysis, including such questions as:

• What measures of do you use to assess the case management program's performance?
• How do those measures relate to individual case management file reviews?
• Who conducts program performance analysis?
• When was the most recent program analysis presented to the quality management committee?
• Did the discussion at the QMC of that report lead to any suggestions for changes in order to improve program performance?

The Basics

This standard, new to this version, requires that all case managers be certified by a URAC-recognized program no less than 4 years after hire as a case manager.  URAC-approved certifications are listed here.

Management Tips

Only experience as a case manager counts when tabulating the 4 years.  It is important that you have a P&P that directly addresses this issue, even if you are a first-time applicant. 

URAC Accreditation Tips

This standard is a "Leading Indicator," meaning that, while it has no point value for this accreditation, it is useful to URAC if you attempt to document how you comply with the standard.  It also means there is no onsite verification.

For the desktop review, submit the applicable P&P. 

The Basics

This standard establishes requirements for the DM program’s telephonic communication system.  That system should:

• Allow the staff to receive and return calls;
• Have hours of operation that the program clearly communicates to program participants;
• Gives to those who call outside business hours appropriate instructions regarding emergency situations; and
• Have a means of documenting periodic evaluation of the system’s performance, including reporting mechanisms.

In addition, the system should operate under clear criteria that include instructions regarding

• Emergency situations
• Calls received outside the normal business hours

Not all DM programs are the same.  Your telephonic system should be appropriate for the kinds of services it provides to participants.

Management Tips

At a bare minimum your P&P and/or program description should describe a system that can receive and return calls about how the DM program operates.  It also should be very clear not only about the hours of operation, but how those hours will be communicated to consumers and what to do with consumer calls outside of those hours of operation.   You may forward such calls to a health call center or an after-hours nurse.
Make sure you have the capacity to conduct industry-standard analysis of telephonic access to services, such as

• Call wait times
• Call blockage
• Average speed of answer
• Abandonment rate.

URAC Accreditation Tips

Four of the five elements are weighted 4; the other is weighted 3.

The documents needed for the desktop review include not only the applicable P&P and/or program description, but also supporting exhibits such as scripts, call center reports, staff training agendas, or sample consumer materials that discuss the program’s hours of operation.

The onsite reviewer will listen to the recorded voice mail message.  He/she will ask for a demonstration of the call tracking system, and may ask the staff members such questions as:

• What happens when a program participant calls after your hours of operation?
• What are your hours of operation?
• What materials are used to communicate hours of operations to program participants?
• How does the program document and track the telephone system’s performance?
• Can you both receive and return telephone calls?

The Basics

This standard proposes that the DM program have subject matter experts (SMEs) review educational materials before the program uses them in the DM program.  In addition, it suggests that the medical director or his/her equivalent also review consumer health information.

Management Tips

Not only should your P&P or program description require the review and approval process discussed in this standard, but it also should outline how that review is to be documented, whether in the form of meeting minutes, attestations, or the completion of specified review forms.

URAC Accreditation Tips

The two elements of this new standard are each worth 1 point.

For the desktop review, submit the applicable P&P and/or program description, as well as any documentation of the review process (e.g., meeting minutes, memoranda, attestations).

The onsite reviewer will interview management personnel about the review process.  The reviewer also will look at recent documentation of the review process.