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.

As I described elsewhere, URAC has a new category of standard in its new scoring system: Leading Indicator, which it defines as a "non-weighted, optional element highlighting effective practices not yet widely adopted in health care."  HCP 8 is just such a standard:

Data for physicians and other providers is collected and aggregated. [L]

I am not really sure what URAC is trying to accomplish with this standard that it has not already addressed in the other standards.  Hopefully, a member of the Standards Committee will read this and comment, clearing it up for all of us.

The HCP proposed standard that is of least interest to URAC, at least if you look at the weight it would be assigned, is HCP 7, which reads:

Organizations have a written plan to aggregate data from various sources using an appropriate methodology for the purposes of health care performance reporting on physicians and other providers. [1]

Even the interpretive information that URAC provides is sparse:

Collecting and aggregating data, including data collected across various payers, helps to achieve a more representative and valid sample.

There is little reason to think that an organization would need to do more than to submit such a written plan at the AccreditNet phase of the process.  It seems unlikely that this would be the subject of any activity during the onsite review. 

Of all the new standards proposed for the revised Health Plan/Health Network v. 5.1 standards, this is the most significant, if only for its length and therefore for the relative weight in the new scoring system.  It reads:

If the organization creates programs for physician or other provider performance measurement, reporting and tiering (including rating, ranking or measurement designations): [--]
(a) Accurate, reliable, and valid measures must be used, and [--]
(i) Endorsed by the National Quality Forum where available; and [3]
(ii) If not available, then the Ambulatory Quality Alliance, the AMA-convened PCPI, or national accreditor-endorsed measures are used; and [3]
(iii) If none of the above are available, then measures based upon nationally recognized practice guidelines are used. [3]
(b) Measures used must be: [--]
(i) Clearly delineated; and [3]
(ii) Appropriately risk adjusted to account for characteristics of the physician’s or other provider’s patient population such as case mix, severity of patient’s condition, comorbidities, and outlier populations. [4]
(c) Categories of measurement cannot exclusively include cost efficiency, but must also include quality of performance. [M]
(i) Both types of measures are calculated and reported separately; and [M]
(ii) If combined, the individual component scores and their proportion of the combined score must be disclosed separately. [M]
(d) When comparing or ranking physicians and other providers: [--]
(i) The relative weight of each measure and each type of measure must be publicly available; [4]
(ii) Cost efficiency measures must compare physicians and other providers by specialty area or peer group and geography. [4]
(e) Data: [--]
(i) Must describe statistical basis for number of patients (data) used; and [3]
(ii) Must use current data consistent with the proper timeframe to attain adequate sample sizes. [3]

As you can see, it has 3 mandatory subsections and 30 other "scoring points", making this about as consequential a standard as you'll find anywhere in the revised standards.  

This standard does five basic things:

1. Establishes a minimum threshold for the source of the measures to be used the performance measurement system;
2. Requires risk adjustment;
3. Insists on the inclusion of quality measures and thereby prohibits cost-efficiency-only performance measurement;
4. Creates standards of fairness in the use of performance measures to compare providers; and
5. Establishes minimum requirements -- albeit vague ones -- for the statistical validity of the measures being used, with particular attention on sampling methodology.

One can assume that the documentation for this standard will need to be extensive.  Most of it, I'm imagining, will be submitted during the AccreditNet phase of the application process -- extensive P&Ps, program descriptions, and documentation supporting the choices made about measurement selection and sampling methodology.  The onsite review, I'm guessing, will hold few surprises, assuming the initial documentation submission is sufficient to get past the desktop review.

The proposed new standard, HCP 5, establishes minimum requirements for the due process that must be allowed to providers who choose to appeal an organization's performance measurement.  It reads:

If the physician or other provider makes an appeal within 30 days of receiving notice from the organization, then no change will be made to the information or ranking and it will remain unpublished until such time as the dispute is resolved. [4]

By requiring the health plan or health network to resolve a timely-filed provider appeal before it can implement a performance measurement publication or use in tiering, this standard places a premium on handling appeals promptly.  Think of it this way -- if you publish or use in network tiering a new or newly revised performance measurement system when there is an outstanding appeal that was timely filed, you have violated this standard.

This suggests what will be useful information for reviewers.  Certainly, at the AccreditNet phase you'll need to submit a P&P that mirrors the standard.  The onsite review likely will look like a two-fold request -- one for the a list of the dates of any launch or revision to your performance measurement system and the other for a list of provider appeals.  The reviewer will then cross check the two lists, looking for publication before appeal resolution.

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 Basics

This standard requires that your criteria for selecting providers to participate in your network address quality of care and service requirements.  In addition, you should have criteria that allow you to exclude otherwise eligible providers from your network should business reasons apply.

The quality requirements are relatively straightforward.  For quality of care, most URAC applicants submit their credentialing requirements, such as valid, unrestricted license in the applicable state, current DEA certificate (if applicable), appropriate education and training for specialty, board certification in specialty, proof of liability insurance or self insurance, good standing with Medicaid and Medicare, etc.  For quality of service, we usually see requirements regarding responsiveness of the provider’s office staff, cleanliness of the provider’s office, hours of operation, and the like.  

The "business reasons" element is a bit trickier for some.  As URAC's interpretive comments note:

NM 3(c) is intended to allow the organization flexibility in not accepting providers that otherwise meet the criteria for quality and service.  For example, if the organization already has enough qualified primary care providers, it might not accept another qualified primary care provider based on business needs.

Make sure your documentation gives you the flexibility to say "no" if your network is full in that specialty or some other business reason has you want to restrict a network (except, of course, if you operate in a state with an "Any Willing Provider" law).  

URAC Accreditation Tips

This is a mandatory (weight=5) standard.  The quality of care and service elements are primary, and the "business reasons" element is secondary.

Your initial documentary submission should include the documents that establish these minimum requirements for inclusion in the provider network, whether they be P&Ps, a credentialing plan, or some other official organizational document.  

The onsite review will involve management interviews to assure an understanding of the organization's policies on all three elements.

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.