URAC

Health Plan, Version 7.1 P-NM 2-Provider Network Access and Availability


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.
(c) The organization reports the measurements described above to the quality management Committee.

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 three elements of this standard are weighted either 3 or 4..

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.

Health Plan, Version 7.1 P-NM 1-Scope of Services


 

The Basics

With this standard, you are required to answer the question, what services do we provide, and where do we provide them?

This standard is important to URAC reviewers, because it helps them understand the nature of your network.  Are you a general healthcare services network or specialty network?  Do you provide health care services in a small region, statewide, or nationally?  The rest of the review will be guided by the documentation and answers to interview questions that you provide in connection with this standard.

Your organization likely answers both of these questions in official documents, such as marketing documents, regulatory filings, and the geo-access maps that help you manage your provider network.  Make sure you are familiar with how your organization officially answers these questions.

Management Tips

Remember, you do not get credit for doing things that you do not document.  So, the fact that you operate in a certain area and provide certain health care services is insufficient for purposes of this accreditation process.  Rather, you need to be able to document, with official company documents, what services you provide and where you provide them.  You are allowed a good deal of flexibility in how you do this.  Your documentation might be in marketing materials, regulatory materials, internal policies and procedures or plans, or reports.

URAC Accreditation Tips

Each of the two elements of this standard is weighted 4.

Your desktop review documentation is likely to be some combination of plans (business, marketing, strategic), service area maps, geo-access analyses, and regulatory filings.

The on-site reviewer will verify your compliance with the standard through an examination of your organizational documents and interviews with network management and provider relations management personnel.

 

P-MHP 3 - MH/SUD Parity Addressed in Contractor Written Agreements


The Basics

This standard accomplishes two objectives. First, it pulls into the scope of URAC's provider contracting requirements any agreements with mental health and substance use disorder (MH/SUD) providers. Second, it adds a requirement that such contracts include a requirement that your MH/SUD providers comply with mental health parity laws and regulations.

Management Tips

To comply with this standard, make sure that you have revised all your provider contract templates to address the specific requirement that your MH/SUD providers comply with parity laws and regulations. We also recommend that you modify your provider contracting P&P to include MH/SUD providers and the new contractual requirement.

URAC Accreditation Tips

This standard is worth a total of 8 points.

For the desktop review, submit a template provider agreement for MH/SUD providers.

The onsite review will include interviews with the Compliance Officer and the Senior Clinical Staff Person. In addition, the reviewer will, during his/her review of your provider contracts, will examine a sample of your MH/SUD provider agreements for compliance with this standard.

P-MHP 2 - UM Protocols Applied to MH/SUD Benefits


The Basics

This standard requires that the organization submit a detailed analysis that its utilization management protocols, as applied to mental health and/or substance use disorders, are not more restrictive than for medical/surgical benefits. The analysis you submit should be reasonably detailed. In thos situations where you are relying upon evidence to justify a difference between the MH/SUD protocols and the med-surg protocols, be sure to submit that evidence; don't merely reference its existence.

Management Tips

Because UM protocols are nonquantitative treatment limitations, there are no hard and fast rules here. URAC says it won't second-guess your analysis; just make sure it is well-reasoned and sufficiently detailed to pass the "sniff test."

URAC Accreditation Tips

This standard is worth 4 points.

For the desktop review, provide the detailed analysis or an executive summary of that analysis.

The mock onsite review will include an interview with the Compliance Officer and the Senior Clinical Staff Person.

P-MHP 1 - Analysis of Compliance with Mental Health Parity Law


The Basics

This standard requires that the organization submit documentation that either is a formal attestation that the organization is exempt or, if the organization is not exempt, a detailed analysis that demonstrates its compliance with applicable mental health parity laws. Such analysis should demonstrate that its mental health and/or substance abuse disorder services do not have more restrictive treatment limitations (quantitative or nonquantitative) or financial requirements.

Management Tips

The detailed analysis you submit for this standard must provide a reasoned demonstration that your health plan's benefit structure complies with the Mental Health Parity and Addiction Equity Act (MHPAEA). Don't forget to include an analysis of pharmacy benefits within this documentation. Also, if you are going to justify a difference between mental health/substance abuse benefits, be sure to include the medical or scientific evidence underlying that distinction. URAC will not accept a bare statement that such evidence exists.

URAC Accreditation Tips

URAC's scoring is a bit confusing for this standard. The way it looks is that it is worth either 4 points if you submit the attestation or 12 points if you submit the analysis. I know of no other standard in URAC's world that works this way. We'll keep an eye on this to see if this is an error or merely a new way to score a standard.

For the desktop review, submit either the signed attestation or the detailed product analysis report. If that report is too long, submit an executive summary.

The onsite review will involve an interview with the Compliance Officer and the Senior Clinical Staff Person. 

Health Network, Version 7.0 N-NM 17-Participating Provider Suspension Mechanism for Consumer Safety


The Basics

The standard is for the special situation of a provider whose conduct is so egregious as to give rise to a well-founded concern by your medical director that the provider is posing a threat to the well-being of your consumers.  This is a very important consumer safety standard.  Not only must you are medical director be freed from the requirement of taking such a dispute through the normal, often slow, dispute resolution process, it places an affirmative requirement on him or her to handle such a situation in an expeditious manner.

The proper procedure, once the medical director concludes that the provider poses such a danger, is to suspend immediately the provider.  Then, after the suspension, your organization should conduct an expedited investigation to make sure that the medical Director's concerns were well-founded.  Finally, the dispute resolution mechanism described in the previous standards must be made available to the suspended provider.

Management Tips

The requirements of this standard must be embodied in your credentialing plan or a policy and procedure that explicitly contemplates this circumstance.  In addition, your medical director must be absolutely clear that he or she not only has this authority, but also an affirmative obligation to exercise this authority.

URAC Accreditation Tips

All three elements of this standard are mandatory.

For the desktop review phase, you may submit the same documentation that you submit for the previous dispute resolution standards.  

During the on-site review, this issue will come up in the reviewer's interview with the medical director.  He or she must be prepared to answer this question, as it is almost a certainty to come up.  This kind of emergency suspension procedure is fairly uncommon, so it would not be surprising if you had no documented examples.  However, if you do, we recommend that you be prepared to produce one or more examples of such an emergency suspension for the reviewer's examination.

Health Network, Version 7.0 N-NM 11-Other Participating Provider Agreement Documentation


The Basics

This standard contemplates that not all of your existing contracts with participating providers contain all of the requirements of the previous several standards.  Rather than forcing your organization to go back and amend all of the extant, noncompliant participating provider agreements, URAC allows you to "fix" to these agreements by using your provider manual or other similar document that describes the relationship between your organization and the providers in your network.  So long as your provider manual contains all of the required provisions of the previous several standards, or, in the alternative, you provide instructions to your providers on how to obtain the documents that incorporated these required elements into your relationship with disputing providers, you need not go back and amend old, noncompliant agreements.  However, note that, on an ongoing basis, your new contracts do need to comply with the previous several standards.

Management Tips

The simplest way to take advantage of this standard is to make sure that your provider manual contains all of the requirements included in the previous several standards.

URAC Accreditation Tips

The two elements of this standard are weighted 4.

See N-NM 7 for a description of the desktop and on-site review requirements.

Health Network, Version 7.0 N-NM 10-Written Agreement Subcontracting


The Basics

This standard was written to deal with the situation that might otherwise be considered delegation, as in the case where your organization contracts with a provider group that, in turn, contracts with an individual provider.  Rather than subject that relationship to all of the requirements of delegation oversight, the standard simply says that your basic agreement with the provider organization must contain a clause that stipulates that, if the organization should enter into a subcontract with another provider for participation in your provider networks, the relationship between the provider organization and that provider be subject to the terms of the contract between your organization and the provider organization.

Management Tips

This standard is likely to require special attention, as it is relatively new.  Your contracts likely do not have this clause unless they were written within the last three years.  So, make sure your current contracting policy and procedure contains this requirement.  In addition, make sure that it is included in your provider manual (and you'll see why this is important on the next page).  Finally, make sure that your current contract templates contain this clause.

URAC Accreditation Tips

This standard is mandatory.

See N-NM 7 for a description of the desktop and on-site review requirements.

Health Network, Version 7.0 N-NM 8-Participating Provider Written Agreement Exclusions


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 URAC's “it is not enough that you do it right, you must have a policy and procedure that requires that you do it right” philosophy.

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

Both elements of this standard are mandatory.

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.