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 Network standards V.6.0 has a new interpretation for the initial and recredentialing of facilities.  The change affects the eight mandatory elements, N-CR 1(b)(i), (ii), (iii), (iv) (scope of the credentialing program) and N-CR 5(b), (d), (j), and (k) (initial and recredentialing application). The requirements include the review and collection of at least the following criteria:

• State licensure information
• Medicare Medicaid certification status (via OIG), accreditation status may also be collected
• A signed and dated initial and recredentialing application with attestation

The last requirement can also be achieved by the network’s online verification and print out.

This new requirement is causing many of our clients to scramble to collect applications and requested criteria in time for the URAC onsite visit.  It is more time consuming than expected.  We suggest that the credentialing department conduct a gap analysis of its facility credentialing files to determine what the files need and to send out applications for initial (if never credentialed) and recredentialing (every 3 years). The scope of “facilities” as defined by URAC includes:

• Acute in-patient facilities such as hospitals)
• Skilled nursing facilities
• Home health agencies
• Free standing surgical centers

However, URAC will hold you to the scope described in your policy or credentialing plan.

If this seems like a big task for your organization, remember that URAC generally has been receptive to action plans for a new implementation.  Your action plans should include the date the operation change was defined, the action to complete, and the dates for the actions.  For example, an action plan might state that during a review of URAC standards on September 1, 2010, the credentialing department discovered that a new process was required for facility credentialing.  Applications and cover letters were sent out to # of facilities on September 8, 2010 to request a signed application and criteria defined in the cover letter (attach example of application and letter).  It is our intent to process 50% of all facilities by December 1, 2010 and the remaining 50% by March 1, 2011.  Hopefully these dates occur before your URAC onsite audit to ensure that you achieve full compliance with the eight mandatory elements affected by the change in N-CR 1 and N-CR 5.

The Basics

This standard requires that the organization designated at least one senior clinical staff person to perform the functions described in Core 11.  This standard sets forth at the required qualifications of that person.  Those qualifications are:

• a current unrestricted clinical license,
• sufficient qualifications (e.g., experience, credentials, certifications) to conduct clinical oversight for the services provided by the organization,
• post-graduate patient care experience, and
• if the person is an M.D. or D.O., board certification.

This person typically is the medical or clinical director of your organization.  In a PBM, the general expectation is that he/she is an M.D.  or a D.O.

Management Tips

People in management positions should keep in mind that it is not sufficient that your senior clinician meet these minimum requirements.  Rather, it is also required that the job description for that person, or some other document describing the person's role, require all of these qualifications.

The person occupying this position can be part time or full time.

URAC Accreditation Tips

All of the elements of this standard except the requirement for board certification are mandatory.  The board certification requirement carries the weight of three.

Documentation for the initial submission should include the designated senior clinician's job description and resume.  In addition, you should submit either a program description or policies and procedures that described the senior clinician's role and accountabilities.

The on-site review will hinge on an interview of the designated senior clinician.  In addition, the reviewer will examine the clinician's personnel file to assure that licensure, board certification, and work history are all documented appropriately.

The URAC Board of Directors has given its blessing to the latest revision of URAC's Health Plan and Health Network standards.  While the standards won't make their way into Interpretive Guide form until late in Q1 or early Q2 2009, we do have a sense of some of the changes. 

Of particular interest to some of our clients will be the good news that the long, painful struggle over provider dispute resolution seems to have been resolved by this iteration (click here for a history of the issue).  As readers of this blog may recall, I submitted commentary and suggested changes to URAC's provider dispute resolution standards during the public commentary phase (click here for the full post and the suggested language).  Apparently, URAC has adopted this approach with a few modest improvements. 

The new standards, applicable to HMOs, PPOs, and/or PHOs, will be paired with the new Core 3.0 standards, about which we'll be writing in some detail over the next couple of months.  We gave you previews as to some of the key changes in Core 3.0 in our reporting from the URAC Summit back in October (click here for the first in that series of reports), but you'll have the full scoop later this winter.

Stay tuned.  There's lots of fresh news out of URAC, and we'll give you the details of the changes URAC has made i 2008 -- URAC's busiest year ever -- right here.  If you haven't already done so, please subscribe so you don't miss out on a thing.  Unsubscribe at any time, if you find yourself no longer needing to know the latest analysis out of URAC.

This new standard sets forth a series of requirements for disclosure to providers at least 45 days beforethe organization releases provider performance data to the public.  Those disclosures must include:

• the means utilized to gain input from providers on the development of the performance reporting program.
• the data, methodology, and measures used
• the intended use for the data
• the process for correcting erroneous data and for requesting reconsideration and appeal by the organization.

This standard offers a blend of transparency and due process, requiring the plan or network to notify affected providers of  a variety of elements of the program to use provider performance data.  Much is suggested by this standard, not the least of which is a process to assure that there is effective notification 45 days prior to use or publication.  I predict that this will be a sticking point for some organizations who fail to plan ahead and find market pressures to get a tiered network to market pushing up against this requirement to do so in a way that encourages provider input.

Again, URAC has not yet developed (or at least published) its review process information, but my guess is that the desktop reviewer will want to see a full policy and procedure describing this process, and that the onsite reviewer will ask for documentation of launch dates of tiered networks or published performance data, then look for documentation of full notice to providers 45 days prior. 

The v. 5.0 standard in both the Health Plan and Health Network standards required notification to providers of the determination on the application for credentialing no more than 60 calendar days after the determination.  The new, v. 5.1 version changes the time line to 10 business days. 

Note that this revision carries two important changes. The substantive change is to reduce the notification requirement deadline from 60 calendar days to 10 business days, slicing about 6 weeks off the process. While most of our clients will meet the new timeline, some applicants will have to tighten up their processes.

The second change is an increase in the weight from 3 to 4. Because this is a single-element standard, however, we believe that it will carry less relative weight in the new system than it does now.

In amending this standard, which describes an aspect of the provider dispute resolution process for clinical and quality disputes, URAC simply clarifies that its use is limited to participating providers. It does so by amending subsection (b) to read, “Includes the right to consideration by a second-level panel and the methods to request such consideration, and a mechanism for participating providers to present relevant information.” The new language is simply the word “participating”.

For a more complete discussion of URAC's provider dispute resolution standards, see my earlier blog.

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.

The Basics

This standard sets forth requirements for establishing goals and measuring performance for access and availability to providers.  However, our experience is that it is not written in a way so as to convey the full breadth of the requirement.  So, rather than repeat the standard here, I'll give you my version, which, I believe, more accurately captures what URAC seeks:

(a) With respect to access (i.e., geographic dispersion or travel time) of providers to provide care to consumers, the organization:
    (i) Establishes goals;
    (ii) Measures actual performance in comparison to those goals: and
    (iii) Makes improvements where necessary for the provider network.
(b) With respect to availability of providers to provide care to consumers (i.e., ability of consumers to receive care in a timely fashion), the organization:
    (i) Establishes goals;
    (ii) Measures actual performance in comparison to those goals: and
    (iii) Makes improvements where necessary for the provider network.

If you think about the standard this way, you are far less likely to make the most common NM 2 error, to submit documentation that relates only to geographic dispersion, and not the ability of consumers to receive care in a timely fashion.

Management Tips

So, what kind of documentation are we talking about here?

For “access”, since your goals will be expressed either geographically (e.g., “2 providers per specialty per county”) or drive-time (e.g., “no more than 30 minutes drive to a primary care provider in urban areas and no more than 45 minutes in rural areas”), documentation of measurement of your performance against those goals will be in the form of a GeoAccess or similar report.

On the other hand, for “availability”, since your goals will be expressed in terms of hours of availability (e.g., “office open at least 30 hours per week”) , wait times for appointments (e.g., “no more than a two week delay for a non-urgent appointment”),  or customer satisfaction regarding the ability to receive care in a timely manner (e.g., “85% customer approval of provider availability”),  documentation of measurement of your performance against those goals should include consumer surveys (like CAHPS), the results of so-called “Secret shopper” calls to your providers, and reports from your onsite visits to providers' offices.

As much as is humanly possible, however, in any event, you should strive to present performance measurement in the same units of measurement as you express your goals for both access and availability.

URAC Accreditation Tips

The standard has a weight of 4, and all of the elements are primary.

For the desktop review, submit a P&P and/or program document that outlines how you establish goals and measure performance regarding access and availability.  In addition, submit one or two sample reports (or portions of sample reports) for both access and availability.

The onsite review will involve both an interview of management personnel and an examination of your full access and availability reporting.

One of the two biggest controversies in URAC Health Plan and Health Network standards interpretation in the last 5 years just got more confusing: provider dispute resolution.

A little history helps. Back in 1998-2000, v. 2.0 listed every conceivable type of provider dispute and said that the URAC two-appeal, par provider on each appellate panel, dispute resolution system applied to all of them. Version 3.0 complicated matters by getting rid of the list of dispute types. When, as URAC’s main reviewer for the NM sections of the Health Plan and Health Network programs, I continued to apply the requirement to all provider disputes, URAC applicants complained that I was applying it too broadly.

At my recommendation, one such complaining applicant appealed to the URAC Accreditation Committee, arguing that the URAC-required dispute resolution system should apply only to clinical matters. The Accreditation Committee agreed with the applicant, and instructed me to draft language for the Interpretive Guide that explicitly limited its application to the kinds of disputes that are the subject of Quality Act reporting requirements. I did so, and my language ended up in the v. 3.2 Interpretive Guide.

The URAC Standards Committee then took my language and, with an apparently minor tweak, turned it into a standard in v. 4.0. However, the “minor” tweak was huge: by substituting its “or” for my “and”, the Committee extended the scope of the requirement back to a breadth reminiscent of v. 2.0 – any dispute that was related either to a termination/suspensions or quality/professional conduct. At first, I thought it was a typo, but an examination of minutes of that meeting revealed that it was a conscious choice by the committee.

Well, applicants started to complain as I (and the URAC Accreditation Committee) applied the v. 4.0 standard. A joint meeting of the Standards and Accreditation Committees in late 2004 did not resolve the issue. The committees and URAC staff asked me to draft language to make two appeals processes, with the current process limited to “quality-related” disputes and a new, less cumbersome process for administrative issues. That language was adopted, with very minor change, by the Standards Committee and sent “upstairs” to the URAC Board for ratification.

Instead of ratifying the Standards Committee solution, the Board sent it back to the Committee to rework. I was not privy to the Board meeting, and cannot say why. I trust there were good reasons for doing so. The Committee, at that point, decided to give up on fixing the v. 4.0 standards and, instead, to take up the issue in v. 5.0 discussions.

In July 2005, I stopped doing my 25-reviews-per-year for URAC as a reviewer and turned my attention to other healthcare consulting adventures. Somewhere in there, the committee took a completely different approach and created the new system, which bears none of my two-track draft language from the ill-fated 4.0 fix.

I won't bother you by copying here the way it reads now.  The truth is that it is filled with inconsistencies and impossible gaps, and reading it verbatim is more likely to cause headaches and confusion than clarity. 

I confess that for some time I did not understand this new approach. It retains the “or” language in the new NM 14, and thereby on its face creates no separate track for administrative disputes. Several folks I’ve talked to report that the word is that, despite the clear failure of the language to create a separate track for such disputes, that the intent of the standard (and the application by URAC reviewers of the standard) is that the full 2-tiered appellate system apply only to quality-related disputes.

Since the initial release of this version of the standards, URAC updated its AccreditNet Program Guide on the subject, and, as a result, here's what we now believe to be true about URAC's interpretation of these standards:

The intent of the v. 5.0 version of these standards, as we suspected, is to establish a two-track system of provider dispute resolution processes. One track, the clinical track (“Type B”), requires two levels of appeal, each of which has a clinical peer of the disputing physician. The other track (“Type A”) is for administrative disputes, such as claims payment, availability for appointments, and the like. Finally, the posting makes it clear that the URAC-required “due process” is not required where licensure revocation or conviction of claims fraud serve as the grounds for the provider’s termination.

This interpretive posting, we believe, should be given more weight than the literal reading of the standards themselves, which we believe will need to be revised again in order to reflect the intent of the drafters.

The real good news is that the next version of the standards, we understand, fix this problem altogether.  But that will be the subject of a different blog post.