For many of the URAC accreditation programs, an essential component of the onsite review is one or more file reviews.  For example, for Health Plan and Health Network, the reviewer will examine provider contracts to assess compliance with the applicable Network Management standards. Similarly, the medical management modules (UM, WCUM, CM, DM, DrUM, etc.) involve reviews of consumer case files to assess compliance with standards in each of those modules.

There are a few things to know about the file reviews:

• Files are selected in the morning of the review from a case log. Right after the opening remarks, the reviewer(s) will select files for review. They will do so from a log of the case files. Therefore, you'll need to be able to present a list to the reviewer(s) of all the cases in a particular category in the form of a case log. 
• Case logs should be separated by category. If there are several types of files to be reviewed during the onsite review, make sure you have a separate log for each type. So, if your organization seeks HUM accreditation, be sure your expedited reviews are separated from your standard reviews, and that your first-level reviews are in a separate log from your appeals. 
• Files will be selected from the full period for which you are being assessed. If your organization is seeking reaccreditation, you'll need to be able to provide logs all the way back to your date of accreditation. If you are a first-time applicant, files can be pulled all the way back to the day you hit "submit" on your document submission to AccreditNet.
• Files must be produced within 90 minutes (and we recommend quicker). Once the URAC reviewer hands you a list of files to be pulled, she will expect the files to be back to her within 90 minutes. We have found that, if you can get them there in 60 minutes, the reviewer will be even happier (which is a state of mind in which you want your reviewer). This is true even if you keep your records off-site. If you keep records off-site, you still need to be able to produce them for the reviewer within 90 minutes. We won't begin to list the ways you might end up doing it, but you should address this issue early in the process, as the logistical challenges may be substantial. The only exception to this rule is Health Plan/Network provider contracts. If you keep them off-site, you may ask the reviewer to preselect contracts for review before she shows up at your offices, giving you a few days' lead time to pull them. Do not expect this kind of leaway for UM, CM, DM, or other medical management patient case files. URAC's rule on this is very firm.

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. 

This CMS standard provides:

All MAOs that offer CCPs must ensure continuity and coordination of care through procedures for timely communication of clinical information among contracted network providers, with the member, and with his/her designees (if applicable).

The URAC standard implementing this is MAP-CCP2.

The Basics

This standard requires that your organization have policies and teachers to assure timely communication of clinical information among the members of your provider network, and between those providers and consumers and their families.  Those policies and procedures need to include:

• mechanisms to ensure that the organization on the network path sufficient information for quality continuous patient care and quality review;
• mechanisms for appropriate and confidential exchange of information throughout the network; and
• procedures to assure consumers have timely access to records and other information regarding their health and enrollment in health plan.

URAC Accreditation Tips

Documents be included with your desktop review submissions should include policies and procedures, the provider manual, sample provider newsletters addressing coordination of care, and the results of audits of medical records.  Member newsletters and education materials might be useful submissions, as well.

The on-site interview of the medical Director, utilization management and case management staff will include questions such as:

• What are the organization policies and procedures for care coordination?
• How are providers informed about the network care coordination services?
• Are member's medical records' audited?
• What items are on the tool ( follow-up care, education in self-care, health promotion activities, & referrals for care needs?)
• What education materials does the plan provide members to assist with coordinating their care?
• What requirements does the plan set for communication between the PCP and specialist?
• Are summaries sent to the PCP?
• A member is discharged from the hospital what is the expectation of the facility to inform the member of follow-up care needs?
• How often are enrollee member records audited?
• What policies and procedures are disseminated to providers regarding documentation guidelines?

The Basics

Not unlike URAC's requirements in the UM standards for concurrent review nurses, this standard requires that case managers working in the field:

• Carry clear identification (usually a name tag with a photo and the name of the organization); and
• Cooperate with the facility's procedures for visiting.

Management Tips

The intent of this standard, of course, is to make sure relationships between the CM program and the visited facilities are smooth and clear.  Agreements trump assumptions (and even this standard), so if you have a working relationship with a particular facility that is clear and, preferably, documented, that will govern case manager behavior.

URAC Accreditation Tips

The elements of this standard weighted 2 and 4.

Again, the key is documentation.  Have a solid P&P for onsite visits, and make sure you comply with that P&P.  If your visits are governed by agreements with facilities or facility P&Ps, make sure you have a record of those agreements and/or P&Ps.  

The program guide suggests that the reviewer may accompany a case manager on such a visit.  I'd be pretty surprised if that happened in the time-crunch world of a CM review, but it's a good idea to be prepared for that possibility.  More likely is the telephonic interview, in which the URAC reviewer will randomly select a field case manager to talk to about how she arranges her visits.

The Basics

Under this standard, you need to be familiar with your organization's P&P that describes the criteria you should use to decide whether and when to discharge a consumer from the program.  You should not only know your organization's P&P on the topic, but somewhere along the way should have received training on that P&P.  Finally, make sure you always document both the date of the discharge/termination and the rationale for that action.  

Management Tips

This standard requires the CM Program to do the following things:

• Write a P&P that describes -- clearly -- what criteria it uses to decide when and whether to discharge a consumer from the program, or terminate CM services to that consumer.
• Train the CM program's staff members on these criteria.
• Upon discharge or termination, record both the date of the discharge/termination and the rationale for that action.  The CM program should make sure that the documented rationale is consistent with the criteria outlined in the P&P.

As the program guide makes clear, URAC has expectations about this standard that are not embodied in the standard itself.  To meet those expectations:

• Make sure that the consumer is advised of the criteria early in his/her relationship with the case manager.  In other words, it should come as no surprise to the consumer that, when he/she meets her care goal, or returns to work, or in some other ways triggers the discharge criteria, that his/her relationship with the CM program will be ended.
• Notify all the providers of the discharge/termination.  The consumer's transition out of the CM program should be clinically smooth and safe.

As is always the case with URAC, it is not enough that you do these things, but also that you describe and require them in your P&P.

What if your clients set the criteria for discharge?  This is not uncommon, and it usually happens in the contract itself.  In this case, make sure your P&P allows for the possibility that the criteria in the P&P may be overridden by the policy established in the contract by the client.

URAC Accreditation Tips

The three elements of this standard are weighted 4, 2, and 2.

The desktop review will focus on the adequacy of the P&P.  Further, if your clients do set the criteria, list the clients that do so and summarize the discharge criteria for each in a table that you submit to URAC.

The onsite review will focus, as usual, on interviews.  However, more importantly, the reviewer, as a part of her examination of case files, will check to make sure that the discharge criteria have been followed with your consumers.