As a URAC news release of a few weeks ago indicated, there is a new certification program available for international vendors of credentialing services.  Aparently, URAC has detected a need for some URAC-accredited companies to have certification of its international vendors who take on some of the labor-intensive aspects of the provider credentialing process. 

To gain certification, an international credentialing vendor will go through a mini-accreditation review.  At least at first, it seems that such applicants will not face an onsite review.  Rather, in addition to a special application for this certification program, applicants will need to comply with all of the Core standards as well eight of the standards from the credentialing section of the current Health Plan standards, P-CR 5-10, 12, and 14.  

Integral Healthcare Solutions is in the midst of a conducting research into the phenomenon of international credentialing vendors.  We will release the results of our research within a few weeks.  Our early results are pretty interesting, but we'll not jump to any conclusions until we're a bit farther along in our research.  Let us know at info@integralhs.com if you would like to get a copy of our report.  Or, just subscribe to this blog (yes, it's still free!), as we'll be publishing those results here. 

This standard, while easy to comply with, is not a slam dunk.  It provides:
The organization:

(a) Requires utilization management staff to identify themselves by name, title, and organization name; and

(b) Upon request, verbally informs patients; facility personnel; the attending physician and other ordering providers; and health professionals of specific utilization management requirements and procedures.

It carries a weight of only 3, and neither of its subsections is primary.  So, it is surely true to say that you can miss this all together and still have a great shot at accreditation.  However, since it is our theory as URAC consultants that we should leave no points on the table, is worth just a little extra staff training time to sweep up these readily available points.

The most common mistake that we have found relating to this standard happens when utilization management staff members identify themselves only by name and organization, omitting the job title.  This, obviously, is both easy to detect and easy to fix.

Less common, but perhaps slightly more difficult to address is the requirement of subsection (b).  A good way to diagnose problems with the standard is periodically to pose such requests to the members of your utilization management staff.  The question might sound like this: “imagine that I am a patient, and I want to know what the procedures are to get my procedure approved, and I want you to tell me in writing.  What are you going to send to me?” 

Obviously, this presumes that you have something easy to send to providers and patients that summarizes utilization management procedures and requirements.  If these procedures are embedded in a larger document that you do not want to send, I recommend that you have a ready supply of copies of that section of the document available for your staff members to send out to requesting providers and consumers.

The Basics

This standard places strict limitations on what non-clinicians (i.e., the administrative employees) in the UM program may do.  The short version is that they should never be put in a situation of evaluating or assessing clinical information.  For the most part, they shouldn't even touch clinical data.  Tasks should be limited to collecting non-clinical information and responding to service requests that have nothing to do with clinical evaluations.  The only occasion in which non-clinicians should touch clinical data is if they are collecting it in a structured format (e.g., tightly supervised scripts or automated mechanisms for collecting clinical data.

This standard is the first of a trio of standards designed to set clear restrictions on the use of non-clinical personnel in the review process.  As the Program Guide notes, it applies to all review processes, regardless of the degree of automation, that do not involve clinical judgment and that do not result in non-certification determinations.

Management Tips

Managers will need to make sure that your P&P on this topic explicitly outlines the responsibilities of non-clinical review staff, their reporting relationships, and scope of work.  You should also make sure your non-clinical staff members' job descriptions are clear in communicating that they are not involved in clinical evaluations.

URAC Accreditation Tips

The standard is weighted “4”, and subsections (a) and (d) are primary elements.

Documentation for desktop review includes your P&Ps on the topics and sample job descriptions of your non-clinical staff members.  It also is a good idea to submit sample scripts or algorithms for non-clinical review.

The on-site review will focus on interviews, demonstrations of any automated systems, and a review of sample scripts or algorithms.  More importantly, the URAC reviewer will be examining case files or evidence that the P&P regarding non-clinical staff involvement is strictly followed.

Do not be misled by the fact that the standard is weighted “4”.  It is inextricably linked to UM 9, which is weighted “5” and is therefore a mandatory standard.  Problems with compliance with UM 7 likely will trigger noncompliance with UM 9, destroying any chance your organization has of attaining full accreditation.

The Basics

UM 1 requires that the organization's clinical review criteria/scripts meet certain conditions.  Appropriate provider/experts need to have been involved with their development or approval, as well as their annual review.  They need to be based on sound science.  Finally they need the approval of a medical/clinical director.

Management Tips

A standard covers both internally-developed clinical criteria and commercial criteria.  However, the key distinction is in the review and approval process described in subsections (c) and (d).  For internally developed clinical criteria, the process is quite clear: the organization and actively-practicing physicians must review the criteria which, in turn, also must be approved by the medical director or clinical director.

For commercial criteria, the standard is a bit different in application, if not in general requirement.  Most commercial vendors of criteria update those criteria annually.  This annual updating process generally takes care of the requirements of subsection (c).   Of course, the criteria still need to be approved by the medical director.  However, if the organization does not receive annual updates from the commercial vendor, it is still incumbent upon the organization to put the criteria through the annual review required by subsection (c), including a review by actively practicing physicians.

URAC Accreditation Tips

The standard is weighted "4", and all subsections are primary elements.

The documentation required to be submitted for desktop review is straightforward: a policy and procedure describing the development and approval of criteria along with sample pre-review scripts or clinical criteria.

The real test, however, will be during the on-site review.  It is during that stage of the accreditation process that the reviewer will be asking to see specific documentation of the review process for the criteria.  She'll confirm not only the approvals by the senior clinician, but also documentation of expert involvement in development and review of the criteria/scripts.  She'll also look at case records to insure that they are being used properly.

What will be important for companies undergoing the reaccreditation process to remember is that the documentation of the clinical criteria review process must show annual review and approval.  It will not suffice for a three-year accredited company to show merely that it looked at the criteria recently.  Rather, documentation only to demonstrate the annual review required by this standard.

The Basics

This standard applies to all three types of UM reviews (prospective, concurrent, and retrospective), and governs the way the UM organization seeks, accepts, and uses information relevant to those reviews.  The organization:

• Must consider information from all reliable sources, so long as the sources will help with the decision
• Should collect no more information than is necessary to make the decision, including not routinely requiring all medical records for a patient
• May ask for, but may not routinely require, numerical codes for diagnoses or procedures
• Must share the information it receives in-house, so that multiple members of the organization are not submitting duplicative requests to providers and patients for information

The standard can best be understood as providing protection for the patient and providers from abusive and/or unnecessary requests for information upon which to base a certification determination.  In a nutshell, it requires that the organization use “all reasonable sources of information to collect only the information required,” and to share that information within the organization “so as to avoid repeated requests for information from enrollees or providers.”

Management Tips

This is one of those policies in which it is best to take the hint in the Program Guide: “UM organizations may take language from the URAC standards and weave it into their policies and procedures, evaluating it to make sure that it reflects their current way of doing business.”  Make sure, however, that your P&P is clear that your reviewers should request additional medical records if and only to the extent necessary.

Design your P&P to make sure that your organization doesn't make requests for the same information multiple times.  This can happen if information is not shared or if people work in what management consultants call "silos", or parts of the company that do not have regular communication with other parts of the organization.

In our experience as URAC consultants, the most common required change in organization’s policies and procedures on the subject is the elimination of a routine requirement numerically coded diagnoses or procedures.    The standard is quite clear in stating that such a routine requirement is simply not allowed.

URAC Accreditation Tips

The standard carries a weight of 4, and two of its six elements are primary.

The only documents you'll need to submit for desktop review are all the relevant P&Ps.  The onsite review will focus on the UM case file review.  In addition, the reviewer might ask to see documentation of reimbursement to providers for making copies, in order to make sure this is being done according to your P&P.

The Basics

This standard sets forth time frames for the conduct of concurrent review.  Concurrent review is UM conducted either in the midst of treatment (in-patient or out-patient) and/or while he/she is in the hospital.  The basic rule is that, if the UM organization intends to terminate or reduce a previously approved course of treatment or hospitalization that is underway, it should give the patient enough time to request a review of the decision and get a decision before the organization implements the decision.

That is straightforward enough.  However, the challenge comes in when the patient asks for an extension of that course of treatment or hospital stay.  In this regard, the standard itself is not written particularly well, as it leaves out certain scenarios.  A clarifying comment that URAC posted in March 2009 is a better source for understanding the time frames than the standard itself.  The time frames depend on two things -- whether the request is for urgent care, and whether it is received at least 24 hours before the certification expires.  Here's how it breaks down:

• If the request for extension is received more than 24 hours before expiration:
• If the case involves urgent care,  notification must be within 24 hours of receipt of request
• If the case involves non-urgent care, notification must be within 72 hours of receipt of request
• If the request for extension is received less than 24 hours before expiration, regardless of the urgency of the care, notification must be within 72 hours of receipt of the request

Management Tips

Again, the primary management role is to make sure the P&P is clearly written and the staff well-trained on the time frames.  

URAC Accreditation Tips

The standard is weighted 4, and all the elements are primary.

The required documentation is relatively straightforward: a policy and procedure describing your process, and a sample template of a written notice to the patient.  The on-site review, while straightforward, is substantially more rigorous: the reviewer will go through case files to make sure that you are meeting all of these timelines.

The Basics

CM 2 requires that the CM program employ enough case managers to provide services to consumers in the CM program.  In order to do this, according to this standard, the program must establish caseload guidelines that factor in considerations such as:

• Individual case severity and complexity;
• Organizational resources;
• Case manager role requirements, expertise, and training;
• Consumer satisfaction and outcomes/goals met;
• Client obligations; and
• Changes in member demographics.

On the one hand, the standard does not appear to be particularly onerous, as URAC is quite explicit in not specifying what an appropriate caseload is for a case management organization.  However, this is a bit deceptive, as the standard does have a certain degree of rigor embedded in it.

Management Tips

At the outset, the organization must define “caseload”, and be consistent in its application of that definition throughout its policies and procedures.  In our experience as consultants, many first-time applicants for accreditation do not meet this basic requirement at the outset of their accreditation process.

Second, the organization must develop caseload criteria which must reflect mindfulness about cases severity, complexity, and what role the case managers will play.  URAC reveals its deep respect for and association with the Case Management Society of America (“CMSA”) by referring applicants to that organization’s website (www.cmsa.org) for assistance in developing such criteria.

Third, the organization must have a mechanism for monitoring caseload with reference to these criteria.  Most organizations with which we have dealt as consultants use electronic case management tracking systems for this purpose.  Absent such software, simple spreadsheet analysis will suffice.  However, this tracking should be an ongoing activity of the case management supervisor, as the expectation of this standard is that the organization be prepared to adjust its staffing to accommodate any changes in caseload.

Fourth, the client/consumer complaint log should be sufficiently sophisticated to pick up any trends that might indicate that the caseload is getting too high.  Indicators in this category might include complaints about slow responsiveness from case managers, poor coordination, or even rude treatment by case managers.

URAC Accreditation Tips

All four elements of the standard are weighted 4.

The Program Guide suggests that an organization submit the following for purposes of the desktop review:

• Policy and procedure for determining case manager case load/staffing pattern.
• Consumer/client complaint log.
• Number of case managers/number of cases managed over the last year.

However, we recommend to our clients that they also submit any analyses or reports of caseload that they can submit.

The on-site review, the Program Guide tells us, will focus on:

• Interview with case management organization administrator(s) and supervisors.
• Interviews with randomly selected case managers.
• Review of consumer/client complaint log.
• Interview with appropriate quality management personnel.
• Caseload monitoring tool

What is interesting to note about this list of activities is the interview with appropriate quality management personnel.  This speaks to URAC’s commitment to interdepartmental coordination and integration of quality management throughout the program.  It also suggests that case manager caseload might be the subject of a Quality Improvement Project.

The Basics

CM 1 requires that the CM program documents, including the written program description and P&Ps, define "case management" consistent with URAC's definition of "case management."  In addition, the CM program must specify its goals and objectives.

Of course, what is key to understanding this standard is how URAC defines "case management":

A collaborative process of assessment, planning, facilitation and advocacy for options and services to meet a consumer’s health needs through communication and available resources to promote quality cost-effective outcomes.

Management Tips

Make sure that, if the case manager is involved in making benefits determinations, you clearly define his/her advocacy role.  

The emphasis on “advocacy” is in the Program Guide, and should be considered part of the “tea leaves” used to predict how a reviewer will apply this standard to your organization’s case management program.

The Case Management Program Description should include, at a bare minimum:

• The type and number of participants in the program;
• The structure of the organization of the program;
• The delivery model;
• The stakeholders;
• Whether services are provided telephonically and/or onsite; and
• The composition of the staff (including qualifications).

URAC Accreditation Tips

The standard's elements are weighted 3 and 2.

The applicant has some flexibility about what documentation to submit for desktop review. The Program Guide suggests that the reviewer will accept either a policy and procedure or some other document that constitutes a program description. In addition, organization charts and descriptions of case management staff members and their positions should be submitted.

However, we have noted that, at least among some URAC reviewers this year, a tendency to construe quite strictly in the last four sentences of this standard, “consistent with these Standards.” While the Program Guide makes it clear that the “definition of case management does not have to be the same as the definition in URAC’s Case Management Standards,” interpretations by reviewers in some recent reviews suggest that your definition better be pretty close to URAC’s.

Once you get past the desktop review, however, the on-site review should pose few problems, unless, that is, you have a member or members of your staff not on board with the collaborative approach required by the standards. This is pretty rare in our experience, but is certainly something to emphasize in staff training.

The Basics

This standard prohibits provider contracts from containing either a so-called "gag-clause" or a definition of UM that elevates cost and resource issues over clinical issues.

Management Tips

This standard is quite straightforward, and yet is often missed, at least on desktop review.  It is the classic example of the “it is not enough that you do it right, you must have a policy and procedure that requires that you do it right” philosophy discussed in another blog post on this site (http://integralhs.com/doing-right-not-enough-having-policy-do-it-right-required-too).

Very simply, submitting provider contracts that, in accord with the standard, do not include the two prohibited types of the language, is not enough.  You must also have a policy and procedure that prohibits the inclusion of such language in all provider contracts.  So, in your application, submit both a template agreement and the policy and procedure.

URAC Accreditation Tips

This is a mandatory standard, and all elements are primary.

For the desktop review, submit your applicable P&Ps (see Management Tips, above) and sample provider contracts.

The onsite review will involve an examination of between 15 and 30 provider contracts, as well as interviews of provider contracting management staff members.