URAC

Disease Management, Version 4.0, DM 3 - Provider Involvement in Disease Management Program Development


The Basics

This standard provides that, when your DM program first develops, then later updates, its program, it must involve practicing providers and content expertise with relevant expert

HIX Accreditation Timetables


 

Posted February 15, 2012

Health Plan, Version 7.1 P-NM 9-Written Agreement Inclusions


 

The Basics

While the previous standard described what must not be in your provider agreements, this standard prescribes what must be in your provider agreements.  It is a rather straightforward checklist:

  • the names of the parties to the agreement
  • minimum requirements for participating providers
  • the contractual obligations of both of the parties to the contract
  • events that may lead your organization to modify or terminate the provider's participation in the network
  • terms regulating your organization's access to consumer medical records in the possession of the participating provider
  • the healthcare services that the participating provider will provide under this agreement
  • claims submission requirements and prohibitions (e.g. billing of consumers)
  • provider payment methodology and fees
  • a description of the provider dispute resolution mechanism
  • contract term and termination procedures
  • terms describing requirements regarding confidentiality of patient health information
  • an antidiscrimination clause

Management Tips

Your provider contracting policy and procedure should explicitly require the elements of the standard for all new contracts.  In addition, you should conduct an audit of your present universe of contracts to get a sense of the extent of your organization's compliance with the standard.  Finally, for reasons we will explain in greater detail in a subsequent page, you should replicate nearly all of these requirements in your provider manual, whether or not that provider manual is incorporated by reference into your provider contracts.

URAC Accreditation Tips

About half of these elements are mandatory.  The rest are weighted between 2 and 4.

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

 

Health Plan, Version 7.1 P-CR 10-Consumer Safety Credentialing Investigation


The Basics

This extremely important standard requires that, if the credentialing process reveals information that indicates factors that may impact the quality of care or service provided to consumers, the organization conducts additional review and investigation of that provider.

Your organization's policy and procedure on this issue no doubt spells out the circumstances that should trigger further investigation.  Such circumstances are likely to include information about malpractice litigation, missing information, or inconsistent information.  What your policy probably provides for is closer examination of such files by a senior clinical staff person.  It's also very likely that your policy and procedure requires that such files be discussed in detail by the credentialing committee.

It will be particularly important that you follow the policy and procedure regarding how you document any such follow-up activities.  Documentation should be clear and detailed regarding what was done, who did it, and when the activity was conducted.

Management Tips

Your policy and procedure should be quite clear in providing guidance to credentialing staff members as to what should trigger further investigation.  Your policy also should provide clear guidance as to who should conduct investigations, and whether senior clinical personnel should be involved.  Finally, your policy should articulate explicitly how such a file should be presented to the credentialing committee.

URAC Accreditation Tips

This is a mandatory standard.

During the desktop review process, you should submit not only your credentialing plan, but some sort of description of the roles of various staff members, clinical or otherwise, in handling the identification and investigation of "problem files".  This documentation can come in the form of the credentialing plan, policies and procedures, or job descriptions.

During the on-site review, the standard will be verified through a review of credentialing files in which such investigations took place, as well as interviews with the senior clinical staff person and members of the credentialing staff.

Health Plan, Version 7.1 P-CR 3-Credentialing Committee


The Basics

CR 3 sets forth detailed guidelines for the structure and responsibilities of the Credentialing Committee.  Topics covered by this standard include: 

  • participating provider representation on the committee;
  • the requirement that the committee assess whether candidates for credentialing or recredentialing meet reasonable standards of care and the credentialing requirements of the organization;
  • making sure those standard-of-care assessments are based on appropriate input from clinical peers; and
  • a host of technical requirements, including meeting minutes, oversight of credentialing staff and organizations to which the company delegates credentialing, regularly assesses the credentialing plan and P&Ps, etc.

Management Tips

In recent reviews, URAC reviewers have been known to "ding" an application that doesn't provide enough detail about the participating providers on the committee.  URAC has said that it wants, specifically, "a description of the participating provider(s) member(s) and the requirements, terms, duration, selection procedures of their committee responsibilities."

Another recently noted stumbling block has been around subsection (d)(ii).  Even where your P&Ps note that the committee has the authority to delegation the handling of "clean claims" to the medical director, if your documentation does not actually indicate that it has (or has not) so delegated, you're likely to get the following comment back from the reviewer:

"Clarify whether or not the committee delegates approval of clean applications to the senior medical director."

URAC is likely to accept a variety of types of documentation to demonstrate this, either in the form of a P&P, committee charter, or committee minutes showing the act of delegation.

URAC Accreditation Tips

Two of the elements of the standard are mandatory; the rest are weighted either 3 or 4.. 

For purposes of the application at the AccreditNet submission stage, URAC recommends a detailed organization chart of the entire credentialing program, including the committee, as well as formal credentialing plan and P&Ps.  In addition, meeting minutes from the Credentialing Committee are essential to demonstrate that the plan and P&Ps are being approved and implemented.

 

 

The Basics

CR 3 sets forth detailed guidelines for the structure and responsibilities of the Credentialing Committee.  Topics covered by this standard include: 

  • participating provider representation on the committee;
  • the requirement that the committee assess whether candidates for credentialing or recredentialing meet reasonable standards of care and the credentialing requirements of the organization;
  • making sure those standard-of-care assessments are based on appropriate input from clinical peers; and
  • a host of technical requirements, including meeting minutes, oversight of credentialing staff and organizations to which the company delegates credentialing, regularly assesses the credentialing plan and P&Ps, etc.

Management Tips

In recent reviews, URAC reviewers have been known to "ding" an application that doesn't provide enough detail about the participating providers on the committee.  URAC has said that it wants, specifically, "a description of the participating provider(s) member(s) and the requirements, terms, duration, selection procedures of their committee responsibilities."

Another recently noted stumbling block has been around subsection (d)(ii).  Even where your P&Ps note that the committee has the authority to delegation the handling of "clean claims" to the medical director, if your documentation does not actually indicate that it has (or has not) so delegated, you're likely to get the following comment back from the reviewer:

"Clarify whether or not the committee delegates approval of clean applications to the senior medical director."

URAC is likely to accept a variety of types of documentation to demonstrate this, either in the form of a P&P, committee charter, or committee minutes showing the act of delegation.

URAC Accreditation Tips

Two of the elements of the standard are mandatory; the rest are weighted either 3 or 4.. 

For purposes of the application at the AccreditNet submission stage, URAC recommends a detailed organization chart of the entire credentialing program, including the committee, as well as formal credentialing plan and P&Ps.  In addition, meeting minutes from the Credentialing Committee are essential to demonstrate that the plan and P&Ps are being approved and implemented.

Don't Assume Your URAC Reviewer Knows What You Know


Every once in a while I need to remind our clients that our ultimate audience in a URAC review -- the reviewer herself -- does not know what we know about our client's P&Ps, operations, and personnel.  Because we're human, we often cannot see all the assumptions we make about what the reviewer must know.  Often, these assumptions are misplaced and lead to a miscommunication between applicant and reviewer.

In this 5-minute video, I talk a bit about these blind spots and the need to overcome them by making a counter-assumption -- the reviewer knows nothing about your company.

URAC -- Compliance with State and Federal Law


What happens when accreditation standards are different that state or federal laws?

It depends on whether the law is more rigorous than the URAC standard. If the law or regulation is tougher on the applicant than the standard, comply with the law. If the accreditation standard is tougher, comply with the standard.

If the law or regulation prohibits the applicant from following URAC's standard, you'll need to apply for a regulatory variance in your application. To do this, you must submit a copy of the law or regulation and any other information that would be helpful to communicate to the URAC reviewer that to comply with URAC would violate the law.

What will not fly is the preference of the applicant's lawyer. I was once told by an applicant that its general counsel had advised the company not to provide providers with the dispute resolution rights required by URAC's Health Network standards. When I spoke to the general counsel, he explained that state law didn't prohibit the giving of such rights, only that the giving of dispute resolution rights might give rise to litigation. This isnot grounds for a variance, only for a good chuckle.

How to Use the Citations Feature of URAC's AccreditNet Application


URAC Accreditation Tips

When you submit a document to URAC through AccrediNet, URAC's online document submission application, you will need to submit a citation for each document.  In fact, for standards that have several parts (which URAC calls "elements"), you may be submitting a submission for several, or even all, of the elements.

What is essential to know about these citations is their purpose, which is very important:  to direct the URAC reviewer's attention to the specific portion of the document which demonstrates compliance with that particular element.  

It is rare that an entire document supports an element.  Much more common is when a particular section (e.g., Page 3, Section I.V.3.a.) supports a particular element (e.g., Core 8(g)).  In such a case, you want to make it easy for the reviewer to find that particular support.  So, in this case, your citation for Core 8(g) should read: "Page 3, Section I.V.3.a.

You'll want to keep it simple.  Remember, the citation's sole purpose is to make the reviewer's job easy, so don't clutter it up with a lot of information that doesn't do that.  Here are some anti-clutter tips:

  • Don't include the name of the document.  The reviewer already knows the name of the document -- it's right above the citation.
  • Don't quote the language of the element.  The reviewer already knows that, too -- it's immediately to the left of the citations.
  • Don't refer to an entire section of the document (or worse yet, the entire document) when only one small portion of the document supports the element.
  • Don't combine several documents into one, except in the rarest of circumstances.  The default decision is to submit each document separately.  About the only time you'd want to combine documents would be if you were running up against URAC's 9-document/standard limit.  In that case, you might consider combining documents, but only if all documents are absolutely necessary to demonstrate compliance with the standards.

So, there are the don't's.  How about the do's?  

  • Do make sure that each element of a standard is cited by at least one document you are submitting.  Let me be clear.  This doesn't mean you have to have super-documents that meet all the elements of a standard.  Rather, it means that, when taken together, all of your documents must show support for all of the elements.  No support for an element means no points for that element.

Health Plan Version 7.1, P-CORE, Version 3.0 P-CORE 40 - Health Literacy


The Basics

This standard, a new, experimental standard, suggests that your organization should have policies and procedures that address health literacy.  In this context, the meaning of health literacy is, "The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate decisions regarding their health."  The three suggested elements are:

  • making sure the consumer materials are in plain language;
  • measuring the extent to which the organization's consumer documents use plain language; and
  • training staff members who interface with or write content for consumers.

Your organization may or may not have such a policy and procedure.  The standard is not required, yet, but likely will be in the future, so your organization may be developing a health literacy policy and procedure in anticipation of when this becomes a standard that is no longer optional.

Management Tips

The elements of this standard are known as Leading Indicators.  While they are worth no points in the accreditation calculation, URAC does want applicants to develop a policy and procedure for this issue, even if it is not yet implemented.  In light of the fact that this is likely to be a standard with point value as early as 2011 or 2012, we recommend that you develop the policy and procedure now, and begin implementing it over the next two or three years, if you do not currently have a health literacy program.

URAC Accreditation Tips

All three of the elements of the standard are leading Indicators.

For the desktop review, submit any policies and procedures addressing health literacy in consumer materials, as well as a policies and procedures that address staff training around this issue.  In addition, if you have any written materials already developed that incorporate health literacy in plain language, you should submit that, too.

During the on-site review, the reviewer will look for evidence of implementation, including a demonstration in communication materials have been reviewed and approved as complying with the health literacy in plain language policies of that organization.  In addition, the reviewer will interview program management and staff members to assess the extent to which you have implemented your policies and procedures regarding health literacy and plain language.

Health Plan Version 7.1, P-CORE, Version 3.0 P-CORE 37 - Consumer Rights and Responsibilities


The Basics

This standard requires that your organization implements a mechanism to inform consumers of rights and responsibilities relating to your services.  That mechanism should include specific guidelines for how and when the organization will advise consumers of those rights.  As a member of the staff, it will be incumbent upon you to know what your organization's policies and timelines contemplate regarding this notice.  

Management Tips

As you develop your policies and procedures around this, you have a good deal of flexibility.  URAC as a general preference, expressed in other standards, for multi-modal communications.  So, you may want to consider website, regular mail, or e-mail as modes of communication.

This standard will not apply the organization if you have no interface with any consumers.

URAC Accreditation Tips

This standard has a weight of 4.

For the desktop review phase, submit your policies and procedures describing your modes of distributing consumer rights and responsibilities.  In addition, you can submit sample newsletters or screenshots of Web pages.

During the on-site review, the reviewer will examine your documentation demonstrating that you've implemented these policies.  Furthermore, he/she will interview members of your staff who are involved in communicating with consumers.