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 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.

The Basics

This relatively new standard proposes that the DM program address not only the content of educational materials provided to participants (DM 22), but also the means of delivering those materials.  Thus, a program that complies with this standard will target educational materials based on the participant’s current stage of care.  In addition, a program that complies with this standard is proactive in providing health information, and supports informed participant decision making and self-care skill building and motivation, as well as comfort and acceptance by the consumer.  Educational materials should address consumer health literacy (see Core 40).  The information should be easy to use, accurate, and involve the use of community resources and other health care organizations.

Management Tips

This standard provides guidance useful to taking a basic DM program into a more advanced stage of its development.  Some of the components are already required by core standards (health literacy and accuracy), but some – such as the requirement that the educational materials target information needs based on the participant’s current level of care – are more cutting-edge for some programs.  One of the particular challenges of this standard will be documenting the implementation of those P&Ps that do address all these elements.  The use of community resources by the DM program is an important objective of this standard.

URAC Accreditation Tips

The eight elements of this standard are each weighted 1. 

You likely will be able to submit the same documents (P&Ps and sample educational materials) that you submitted for the previous standard.  In addition, if you have any reports of consumer focus groups, submit them for this standard.

The onsite reviewer will interview staff and management for their assessment of where the program is headed in terms of advancing consumer education.  An emphasis on growing use of community resources may be evident. 

The Basics

This important standard describes the ongoing education the DM program must provide to consumers.  That education must include:

• Topics related to self-management regarding the clinical condition and the participant’s use of clinical and educational resources;
• Materials reflecting the target participants’ learning needs; and
• Reflect evidence-based best practices.

The system used in the DM program must provide for documenting which educational materials go to the individual participant.

Management Tips

The P&P or portion of the program description dealing with consumer education should provide guidance as to which educational materials should be sent to which consumers.  In addition, it should specifically address the issue of assuring that those materials match the needs – linguistic, educational, and otherwise – of the persons to whom they are to be sent.  Those materials should be designed to help the participant achieve his/her condition-specific goals.  We recommend that the program periodically evaluate the effectiveness of educational materials in the course of broader evaluation of the DM program’s effectiveness.

URAC Accreditation Tips

All four elements of the standard are mandatory.

Submit to URAC the applicable P&Ps described above, as well as samples of both educational materials for each clinical condition and research that supports the educational materials provided to program participants.

The onsite reviewer will need to be able to see all of the educational materials that you provide to program participants, as well as evidence that those materials have been reviewed by either the program director or clinical experts.  In addition, the DM staff interviews may address such questions as:

• How do you determine what educational materials, if any, to send to a participant?
• In what way do those materials relate to the clinical and non-clinical goals of program participants?
• How do you evaluate the educational needs of the participant?

The Basics

This standard outlines the requirements for the clinical decision support tools used in the DM program.  “Clinical decision support tools” are defined as “protocols, guidelines, or algorithms that assist in the clinical decision-making process.” 

The most important element of this standard requires that your program enlist the aid of providers with appropriate expertise in the process of reviewing, no less frequently than annually, the decision support tools, updating them when appropriate. 

In addition, the tools should be up-to-date with clinical knowledge and practice and incorporate any available evidence-based practices.

Management Tips

Don’t merely rely on the tool itself as documentation; make sure you have a P&P that describes the clinical decision support tools in use for each condition within the DM program.  That P&P should describe clearly the review and approval process, including the process of selecting providers to conduct the review to assure that they have the appropriate qualifications to review the tool(s)

URAC Accreditation Tips

One of the three elements is mandatory; the other two are worth 3 points each.
Not only must you submit the applicable P&P and a copy of the decision support tool(s) themselves, but you should also provide URAC with sample minutes of meetings at which expert providers reviewed and perhaps revised decision support tools. 

The onsite reviewer will examine the tools themselves, and ask for a demonstration of their use.  In addition, the reviewer will interview both the IT and DM staff members on the tools, including questions such as:

• What clinical decision support tools do you use for [a particular condition within the program]?
• How often is that tool reviewed and/or revised?
• Who is involved in the review process?
• How do you access the tool?
• How does the tool help you provide the appropriate disease management services to the participant?

The Basics

The standard requires that the DM program’s interventions for each condition are based on evidence.  If there is no scientific evidence to support the chosen interventions,  the interventions must be assigned to program participants based on the available data, such as the information received during the assessment/stratification process.  In addition, the standard requires that interventions are tracked for each program participant.

Interventions include such activities as:

• Education on how to take medicines and use medical equipment;
• Help with modifying behavior, such as lifestyle changes;
• Clinical monitoring;
• Provision of educational material about self-care.

Management Tips

The applicable P&P should clearly describe:

• The relationship between assessment and interventions;
• The evidentiary and theoretical basis for the selected interventions;
• The process for documenting interventions.

The ability to track interventions will be critical.  The tracking mechanism must record the participant’s assessment information, stratification level, and interventions over time.  Because interventions will vary by clinical condition, the tracking mechanism needs to be able to reflect those differences.

It may be a good idea to conduct periodic monitoring of case files to make sure that interventions are appropriate, based on the data collected in the assessment process and the resultant stratification.

URAC Accreditation Tip

The three elements of this standard are worth 3 points each.

At the desktop review phase, submit not only the applicable P&P for assigning interventions but also relevant exhibits, like referral forms, sample educational materials, or other evidence of implementation of consumer interventions.

The onsite review will involve staff interviews, including a demonstration of the intervention-tracking system(s), and an examination of consumer files for evidence of compliance with the standard.  Interview questions may include:

• What types of interventions do you suggest for consumers with [one of the conditions covered by the DM program]?
• Do the interventions vary by stratification level?
• How does the information you collect in the assessment process relate to the interventions you suggest for the participant?
• To your knowledge, on what evidence are the interventions based?
• How do you document what interventions you suggest to a participant in the program?
• How do you document a participant’s interventions?

The Basics

This standard outlines the basic requirements regarding the DM program’s contact with consumers.  There should be a document that specifies:

• The period of time after identification of the consumer as eligible for the program within which the program should initiate contact;
• How and how often the program contacts consumers;
• The method of documenting consumer contacts;
• The means by which the program reports the effectiveness of consumer engagement to the program’s clients; and
• How the program communicates its consent policies to consumers.

Your best preparation will be to locate and review that document.

Management Tips

While URAC gives your program a lot of flexibility around consumer contacts, it does prescribe a maximum of 3 months from consumer identification as the limit for initial contact.  Documentation of a good faith attempt to contact within that period of time will suffice; actual contact is not required.  The documentation should describe what method(s) should be used to contact the eligible consumer.

URAC Accreditation Tips

The five elements of the standard range from 2 to 4 in weight.

The documentation to be submitted to URAC via AccreditNet should include the P&Ps and any supporting documents like timelines, consent forms, or flowcharts.  In addition, you should submit sample client reports indicating consumer contacts, attempted and successful.  Screen shots of the tracking system, too, are acceptable submissions. 

The onsite reviewer will interview members of the staff about consumer contact processes.  Questions may include:

• How soon after a person is identified as being eligible for the DM program must you contact them?
• How do you contact them?
• How frequently should you be contacting a participant in the program? 
• Does your prescribed frequency of contact vary, depending on the clinical condition of the consumer or the level of his/her stratification?
• What is the mechanism for documenting the fact that you attempted to contact the consumer?
• How do you document the consumer’s consent to be in the program?

In addition, the reviewer will want to see client-specific reports with consumer contact information.  Finally, the reviewer’s examination of consumer case files will include an assessment of whether he/she has been contacted within the proper time after being identified as being eligible for the program.

The Basics

If your DM program offers predictive risk modeling (and not all programs do), this standard specifies the information the program must be able to provide:

• Risk calculation models used;
• The evidence upon which the modeling is based;
• How the model was validated;
• How (and how often) the models are reviewed and updated; and
• What methodology the program uses to stratify and categorize the observed population..

Management Tips

We recommend that you create a distinct document for your predictive risk modeling process.  It should be a historical document, addressing the development of the model.  It should be descriptive, specifying such things as data sources, parameters, and variables.  Finally, it should be a prescriptive document, defining such things as required frequency of validation and method of validation.

URAC Accreditation Tips

The five elements of this standard each weigh 2. 

If your program does not offer predictive risk modeling, submit an attestation to that affect as your sole documentation.  If the program offers such modeling, submit a document that describes the variables, anticipated outcomes, processes for updating the model, and a validation protocol.  The protocol should include the source(s) and time frame of the data, processes for data integrity, and model validation processes.

For the onsite review, prepare a presentation of the model for the reviewer, including client reports.  The reviewer will interview the data analysts involved in producing the risk analyses.  The interview might include some of the following questions:

• When was this model developed?
• Who was involved in its development?
• What is the underlying evidence for the model?
• What are the model’s key variables?
• What are the data sources?
• Was the model tested before implementation?
• Please tell me about the implementation process for the model.
• How often do you validate the model?
• Do you hire a third-party to conduct or help with the validation process?
• Have you made any changes over time in the model?

The Basics

This standard requires that the DM program have a mechanism for stratifying eligible patients.  URAC defines “stratification” as a “process for sorting a population of eligible consumers into groups relating to the need for disease management interventions.”  In other words, through your assessment process, you must divide eligible consumers into various groups.  Your process must:

• Specify the criteria by which consumers are placed in each group, including an identification of levels at which the consumer will receive an individual assessment;
• Define the data sources for stratification and assessment;
• Stratify the participants at the beginning of their participation in the program;
• Contain time restrictions for completing the stratification and assessment;
• Identify and document comorbidities so they can be considered when assigning interventions;
• Include periodic restratification/re-assessment (no less frequently than annually); and
• Be based on scientific evidence, if possible.

Management Tips

Your P&Ps or program description must describe each level in your stratification system, along with a description of the relationship between each level and the program’s various interventions.  Differences between the various levels could relate to different interventions, different frequencies of contact, or different assessments. 

Your documentation should also be clear about the sources of data used in the program to place individuals in various levels.  It also should explain the reasoning underlying the stratification.

Finally, make sure that participants in our program are periodically reassessed with a possibility of that assessment placing them in a different level in the stratification system.

URAC Accreditation Tips

All seven elements of this standard are weighted 4.

For the desktop review, submit P&Ps, a flow chart of the stratification process, and perhaps screen shots of the online tools used in the assessment and stratification process.

The onsite review will involve both a demonstration of the assessment/stratification process and interviews with the staff.   Questions may include:

• What tools do you use to assess a program participant?
• How do those tools help you to identify to what level a participant should be assigned?
• What are some of the differences in your program’s interventions from one level to the next? 

The onsite reviewer, during the examination of individual case files, will look for evidence that the assessment addresses co-morbidities, results in assignment to a particular level, and assigns interventions consistent with the program’s stratification P&Ps.