The 5 Most Common Reasons for Accreditation Loss & How to Avoid Them Updated 2023

Join our experienced senior consultants as they discuss the top 5 reasons why accreditation can be lost. They'll also answer your questions about how to avoid these pitfalls. Our experts include: Dr. Thomas Goddard, the CEO of IHS Lesley Malus Reed, the President Susan DeMarino, the Compliance Officer Sana Wrigley, the COO.

See more educational accreditation-related videos here.

Transcript

[00:00:08.940] - Sanalynn Wrigley

Hello and welcome to our webinar on accreditation loss. My name is Sanalynn Wrigley and I am the Chief Operating Officer of Integral Healthcare Solutions that we're having this webinar and so grateful that all of you have taken the time in your day to come join us. So without further ado, I will go ahead and introduce our panel today. Just start us off. We have Thomas Goddard.

[00:00:34.380] - Thomas Goddard

Hi.

[00:00:35.900] - Sanalynn Wrigley

Tom is our CEO and runs the whole show. Tom, tell us a little bit about yourself.

[00:00:42.380] - Thomas Goddard

I got involved with URAC 20 years ago. I joined URAC as the Chief Operating Officer and General counsel and in addition to those responsibilities, also served as a reviewer on Health Plan and Health Network at first and then website and then others along over the years. And I founded this company, Integral Healthcare Solutions, in 2002 and we've been working with URAC and other accreditation organizations ever since then, mainly working with organizations seeking accreditation from URAC by training. I'm a lawyer and an industrial organizational psychologist and I live in sunny Tucson.

[00:01:31.180] - Sanalynn Wrigley

Thank you, Tom. Next up, we have Lesley Malus Reed, company president for IHS. Lesley, introduce yourself.

[00:01:38.270] - Lesley Malus Reed

Hi. Good afternoon, everybody. I started in the Canadian healthcare system and I joined URAC in 1997 and helped develop a lot of the Credentialing network health plan standards. And I've been helping applicants get ready for accreditation here at IHS since 2003. That's when I joined Tom to do that after we'd been on the road for many years as reviewers together.

[00:02:03.160] - Sanalynn Wrigley

Awesome. Thank you. And last, but certainly not least, Sue DeMarino, former Vice President of URAC and our Chief clinical officer.

[00:02:13.420] - Sue DeMarino

Hi everyone. As Sana has indicated, I was at URAC for 17 years, started in 1999 as their primary case management reviewer and through the years had many positions. I left there approximately three years ago and joined Tom and Lesley and the gang at IHS. And my background is I'm a registered nurse, I have a master's in healthcare administration, and I'm really excited to be here today.

[00:02:46.420] - Sanalynn Wrigley

Thank you. Sue. So why a webinar on accreditation loss? Tom?

[00:02:53.000] - Thomas Goddard

Well, what we've noticed is because all of us have been involved with this URAC process for 20 years on both sides, as reviewers and as consultants to applicants. And what we've noticed in the last handful of years is a sharp increase in the number of organizations, accredited organizations that are denied accreditation, either denied in the reaccreditation process or have lost accreditation in the middle of their three year span. And there are some key reasons that we're going to talk about in a bit about why that is happening. But when we were young reviewers 20 years ago, we would almost never see a denial or any sort of revocation. But now we're seeing a lot more and we're being contacted a lot more by organizations who were accredited under one version and submitted largely the same documents and came back and got a denial or got a midterm review by your act that caused them to lose their accreditation. And so this is kind of new and we thought it was worth talking about today.

[00:04:10.720] - Sanalynn Wrigley

Thank you. So we've gathered up five of the major reasons that we've been seeing lately for accreditation laws, and we're going to go through them one at a time. So the first reason is failure of data integrity. Tom Lesley Sue, who wants to start?

[00:04:30.180] - Thomas Goddard

Well, Sue and I worked on a client that, without getting into the details of the client, URAC was under the impression that a record could be changed that should not be changed. And it was a medical management kind of organization. And so that's one kind of data integrity problem that we've seen. In this case, you're supposed to have only clinicians writing up their decision and their reasons for their decision. Having the possibility that non clinicians might be able to go back in and edit or non physicians might be able to go back in and edit those comments was one version of that. Data integrity failures can come in a lot of different forms, and that's one we've seen.

[00:05:31.020] - Sanalynn Wrigley

Anything to add, Lesley Sue?

[00:05:35.980] - Sue DeMarino

No, I don't have anything else to add. Possibly just making sure that you have the protocols in place to ensure that data integrity is being monitored. Looking at who has access to which records, who can make changes to them, is one of the key components that will keep you on the right side of the compliance isSue.

[00:06:03.860] - Lesley Malus Reed

And I think the obvious thing also is if you're going to update and change your systems, you still want to take it through an audit and a test to make sure it can meet all of the standards. And if you're unsure about that, you could always send in an inquiry to your act to ask them whether it's still meeting It or contact your consultant to work it out with them as well. It's always a good idea to do a little file review of yourselves every now and then just to make sure you are checking all of those requirements to make sure that you're still in compliance.

[00:06:39.600] - Thomas Goddard

It's important to know that URAC thinks about data integrity, not necessarily the way a lot of It professionals I've talked to over the years think about that phrase it's very specifically, accuracy and traceability. And traceability can often be an isSue. If you can't tell who has touched in your database and when they touched it, that can be a problem.

[00:07:07.080] - Sanalynn Wrigley

Thank you, Tom. Our next major reason we are seeing for accreditation loss is that somebody inadvertently changed a process such that it was out of compliance with a mandatory standard. Tom smiling and nodding. Lesley looks like she wants to start us off. Go for.

[00:07:28.400] - Lesley Malus Reed

So there's so many reasons why this happens. Sometimes you might be going for a dual accreditation, sometimes you might have turnover and you are improving your policies and procedures, and it just takes you off the rails for what the standard was. There's a third reason, too, a standard that you have been going for through three different accreditations. Core 3.0 you might have gone through. You're getting ready to do it for the third time now. And although the standard hasn't changed, the interpretation of the standard may have been tweaked. So you want to make sure that you are constantly ensuring in your annual review, which is required in your core three standard, your annual review of your policy procedures, that you're still not only complying on paper, but you're implementing it as well. With staff turnover, sometimes that goes off the rails with trying to go for another accreditation or another module. It also can take you completely off the rails. You will change everything and then scramble again when it's time to go for the next accreditation to get back in line.

[00:08:45.000] - Sue DeMarino

And I will tell you from my experience, sometimes you see new leadership that will come in. It goes to Lesley's idea about staff turnover. Well, it goes a little further as well because if you have leadership that doesn't understand the standards and they see that from a budgetary perspective that it's not making sense sometimes you'll see some tweaking of the resources that are available to stay into compliance. Or they may request changes just because it's not the way they're used to doing things as a leader. So making sure that you have that open communication with your leaders, having subject matter experts who can go to those leaders and say, yes, I understand. However, are you aware that we are accredited and that one of our mandatory standards is having a quality committee? Typically I see quality initiatives lost first when there are budgetary constraints and there are so many standards related to quality. You want to not give up your quality program if you need to make cuts to your.

[00:10:00.170] - Sanalynn Wrigley

Programs, almost any sort of stochastic change or dramatic event in your organization's history can throw you out off track. I mean, let's imagine that you had one line of business that wasn't within the scope of the accreditation three years ago, and now you've in fact, it was perhaps a nascent line of business and you weren't sure you needed to be accredited. And then in the interim, you've decided it's going to be accredited. If you just pull that in to the scope of the accreditation, you may have policies and procedures that were developed for a line of business that was not within the scope of the accreditation three years ago. And now you've decided it is, and somebody forgot to say, wait a minute. We got to make sure those policies are compliant with your act accreditation, even though they didn't need to be three years ago. So any dramatic change in the organizational structure or personnel can cause this to happen.

[00:11:03.940] - Thomas Goddard

Awesome. Thank you so much. Are we ready for reason number three? All right. The third reason that we see accreditation loss happening more often these days is that staff failed to consistently implement the compliant processes, and that failure went undetected.

[00:11:23.420] - Lesley Malus Reed

Audit, audit, audit. Having a process to ensure that you are staying in compliance with the standard core three says that you must have policies and that you must comply with them, and that's a mandatory element. So you want to make sure that you stay on the right side of compliance as it relates to following your policies and procedures.

[00:11:56.380] - Sue DeMarino

And I empathize with those who are running the accreditation program and trying to keep everybody in line because everybody's on board the year that you're going for it. But when you have to maintain it for the next two years, it is really hard to get buy in from those who are participating with it. And all I can say is that it's a very expensive process, and it's important that from the top down that everybody buys in to stay on goal for reviewing those procedures, getting the reports and metrics in, and making sure that you're moving the train along so that you're not scrambling three years later.

[00:12:37.240] - Sanalynn Wrigley

This happens a lot in the quality management area, but elsewhere as well, where there are certain things that the quality management committee simply has to even. So, first, make sure it meets quarterly, and second, make sure that you make sure that the QMC continues to do what it's supposed to do every single quarter and every year. A very often missed requirement is perhaps one of the performance metrics that you're supposed to be tracking. You just stop tracking for a while. You're supposed to track for most of the URAC accreditation programs, satisfaction complaints and access, and one of those might fall off the table, or your QMC might forget to do an annual evaluation of the effectiveness of the quality program. And as Sue said, audit audit audit either internally or have somebody come in and externally audit to keep you on track.

[00:13:39.100] - Thomas Goddard

Thank you so much. Moving right along to the fourth common reason we are seeing for accreditation loss committee failures. Either a committee didn't meet with the required frequency or it didn't do what it was supposed to do at those meetings.

[00:13:54.980] - Sue DeMarino

So I think this really runs on the last thing that we were talking about. And we're hoping that the quality improvement projects that everybody's working on and metrics that we're collecting are meaningful and that we're not just doing it to meet a URAC standard, that we're doing it to find how we can improve satisfaction and how we can improve our business. And so it'll be really important to make sure that your committees are meeting not just quality, but your compliance Committee, that your Compliance committee is hand in hand with your quality Committee to make sure that you can demonstrate, as Sue said earlier, audit, audit your compliance with your own regulations. So hopefully, in this continual quest for satisfaction, it's leading you through quality and through compliance and your other requirements that you have to do to meet as a committee.

[00:14:50.420] - Sanalynn Wrigley

Yeah, I think I probably answered two questions at once with the last one. They do kind of happen together sometimes. And it's not just quality. It could be credentialing. Credentialing has its own for example, one client we know of looked away from the they kind of changed their policy and procedure approval process across the board. And in doing that, they took away the regular reporting or running by of Credentialing policies to the Credentialing Committee. Easy to happen because the core three requirement of you got to have all your policies and procedures reviewed and approved each year doesn't say how or when. So it would be easy to see how you could someone rewriting that policy, say, well, it doesn't say we have to take it to the Credentialing Committee, let's take it to the Quality Committee or to this committee over there. But there's a subset of the policies and procedures for a health plan or a health network that must go to the Credentialing Committee. And so that's actually both the third and the fourth isSue there. Somebody changed a process and thought a little bit about how it would impact your act compliance, and it complied with core three, but not with the Credentialing standard that requires the Credentialing Committee to be involved.

[00:16:38.340] - Lesley Malus Reed

And for all of you folks who are accredited for specialty pharmacy, the Clinical Oversight Committee standards are really important. That talks about evaluating your patient management program on an annual basis. So you want to pay attention to the Clinical Oversight Committee for those specialty pharmacies to make sure that they're meeting as your policy dictates.

[00:17:08.540] - Thomas Goddard

Thank you. Sue, it occurs to me that the other committee that struggles with this might be compliance, in that I think we've seen a number of clients who maybe somebody new comes in for compliance and they keep up with tracking compliance with the laws they know about, but not necessarily monitoring for new laws and regulations.

[00:17:26.800] - Sanalynn Wrigley

Right.

[00:17:27.540] - Thomas Goddard

That's something I've heard you three talk about a number of times.

[00:17:30.710] - Lesley Malus Reed

Well, and the other piece of compliance is ensuring that things like your licensure is up to date. I can speak to two real life experiences where as a reviewer, I went out to check a state license and I found that their license had been not denied but suspended, and it had been six months and they didn't know it. So making sure that there are those kind of mechanisms, sometimes you use organizations to help you stay on track of what if you're an organization that has licenses in multiple states, so you're a national company and you're required to have 30 different licenses. Some organizations will use an organization to help them stay on track. And we have seen organizations that have run afoul of their accreditation compliance because for whatever reason, the organization missed a state. And therefore, when know URAC becomes aware that you're not licensed in one of the states that you say that you are, that's another key component to compliance that you need to stay on top of.

[00:18:54.480] - Sanalynn Wrigley

And back to your point, Sue, about auditing. Auditing your delegated contractors, whether they're within the scope of the URAC accreditation or not. Audit your delegated contractors.

[00:19:11.060] - Thomas Goddard

All right. And final reason that we are seeing lately for accreditation loss is a failure to report significant organizational changes to URAC in a timely manner. And others don't know about this requirement. Let's tell them.

[00:19:28.840] - Sanalynn Wrigley

Well, it's outside of the standards. It's in your contract with URAC. It's in what's called the AA, the accreditation agreement. And right in there it says anytime and it defines what a significant organizational change is. And you would be surprised at how broad that definition is. More things than you know, I suspect, are included within the scope of that provision that requires that you report it. A more obvious one is an acquisition or a merger, but significant change of certain senior executives in your organization. What else.

[00:20:11.720] - Sue DeMarino

Sue and change of address.

[00:20:14.920] - Lesley Malus Reed

Moving from one state to another may result in a potential organizational change on site where they come on site to make sure that you're following the same policies and procedures. Things like a new medical director, if you decide to delegate a function, either to if you send it offshore, there's requirements for you to submit that change prior to that delegation occurring. If it's being done offshore, any other change is typically 30 days. If a state or federal organization comes in and does some type of investigation and you've not made notification, that could result in you losing your accreditation. The other big one indirectly related to your agreement is failure to report measures. You can lose your accreditation if you don't report your measures. If there's measures tied to your accreditation program.

[00:21:33.920] - Sue DeMarino

Ashley Sue, can you talk about that for a little bit? It's such a good point, and people always are asking us, when do we need to start reporting our measures?

[00:21:45.220] - Lesley Malus Reed

Sure. So typically, what happens if an organization is getting accredited and there are measures associated with their program? Giving an example of a timeline will make it clearer to you. So anytime in 2018, if you become accredited, january 1 of 2019, you have to start collecting the data you reported in 2020 and then every year thereafter. I believe it's October 1, the last time I checked URAC website for their FAQs related to measures. Every October 1, URAC will release some specifics to the measures for you to be aware of for the next calendar year. And there are different reporting requirements. For instance, if you are a pharma applicant, you have to have your data gathering process validated by an outside entity. So there's those budgetary requirements that you have to think of as you're preparing to do measures, and then there's a.

[00:23:02.810] - Sue DeMarino

Lot of people who are on from different modules. Do all modules require reporting? I don't want to start a panic.

[00:23:09.430] - Sue DeMarino

For those who... No, it's very defined. I think, as far as I can remember off the top of my head, case management has measures, health Plan has measures, the pharma standards, specialty Mail, DTM, PBM all have measures associated with them, and Marketplace has measures associated with.

[00:23:44.000] - Thomas Goddard

Thank you. Any other thoughts on that?

[00:23:47.920] - Sanalynn Wrigley

I don't think so.

[00:23:49.270] - Thomas Goddard

All right. Well, with that, we'll move on to questions with three votes. How often does URAC conduct mock monitoring on site reviews, and how do they work?

[00:23:58.850] - Sue DeMarino

So I'm going to start this one off soon, and I'll send it to you. But they hold a lottery, and if you win the lottery, you get to have an on site monitoring. And so a certain percentage every year, and you might get the monitoring on site six months after you got your accreditation or six months before. Sue, I'll let you fill in those details.

[00:24:21.120] - Lesley Malus Reed

Sure. Okay. So every year, URAC budgets to do a certain number of mock monitoring of monitoring on site. Nothing mock about it, and you get noticed three to five days. They may have changed that policy since I've left URAC, but that typically was the notice that you would get. Typically, the dates don't change. You can't change the dates for a monitoring onsite. I hear that they've been doing more of them virtually than actually on site, and they will look at things like document review. There's no interviews that go on, so it's mostly file review that they're validating. There's a large majority of them that are mandatory standards, and as Lesley indicated, they just select a certain percentage, and you get the notice, and then they show up. And how they work is it's usually one reviewer that comes either does it virtually or comes on site and they will then take those results. And if you need an action plan, they'll ask you for an action plan. If they find egregious issues, they may take your application back to the accreditation committee for a decision, a discussion and decision. That doesn't happen very often. Usually it's more action plans to come into compliance.

[00:25:50.220] - Sue DeMarino

So for those of you who are ACHC, it's not the same day. They don't ring the doorbell and say, we're here for your review. They do give you a little bit of notice. Two business days. Is that what it is, Sue?

[00:26:03.520] - Lesley Malus Reed

I think so.

[00:26:05.580] - Sue DeMarino

But what's great about it, especially I love when it actually happens a year or six months before the next accreditation, because it gives you a really good heads up for what to fix before they come back on site.

[00:26:17.250] - Sanalynn Wrigley

And it also kind of wakes the organization up. Oh my God, accreditation. I do believe it's true to say that Sue and I were on the very first monitoring on site review that URAC ever conducted.

[00:26:33.060] - Lesley Malus Reed

That's true.

[00:26:34.090] - Sanalynn Wrigley

Before the program had been established, URAC decided, well, we need to take a look at that organization. And we called the same morning from National Airport to let them know we were on the way. I wanted to repel down the side of the building and break through the window.

[00:26:52.140] - Lesley Malus Reed

Typically, in my experience, the monitoring on sites were done in the middle year of your accreditation cycle. But Lesley's right, it can be six months after you get your accreditation. Typically it's not done six months at the end of your accreditation in the last six months because you're already preparing for your re accreditation visit. So it's typically in that middle year that they do.

[00:27:16.500] - Sanalynn Wrigley

And there's one other thing I want to say about a monitoring onsite review is to be distinguished from a four cause review. They're the same in a sense. They both can happen anytime in the three year period. But the forecause is in response to a complaint. Either a consumer or a provider will phone in a complaint and the process goes through much the same, very similar process. They'll let you know they're coming on site. They come on site or they don't let you know.

[00:27:54.410] - Lesley Malus Reed

They do not let you know if it's a for cause on site. They'll call you the morning of at 08:00 and say, hey, we'll be there at nine, okay? Now unless something's changed in the last few years, but that's been my experience.

[00:28:10.980] - Sanalynn Wrigley

And then in either case, if there are issues that concern them, they could come back, they could kind of dig around some more, they can ask for documentation. It's a pretty dramatic process to go through. One of the other differences between the two is the appeal process is a little bit different for the two. Those are technical details that hopefully you won't have to worry about it.

[00:28:41.020] - Thomas Goddard

Here's hoping. All right, our next question also with three votes. Votes discuss the best way to prove primary source verification. Screenshot of page of documentation of date.

[00:28:53.460] - Sue DeMarino

Site and checker Kay Lesley for a licensure for so in your application. There are two areas where you can submit primary source verification of licensure. It may have to do with showing that you have licensure for your senior clinical person or for their board certification and doing a screenshot. As long as it shows the date and has within it, the expiration of the license or board certification will work. In an actual Credentialing file, same thing they're looking for. You might be showing them an electronic version or a print off of the report that you received. It needs to have the date that it was verified and the expiration date of the actual licensure or board certification. There's one standard I might as well touch upon, which is Cr nine B and that has to do with a Credentialing standard in both network and in health plan. Now, it requires that you're going to primary source verify board certification or the highest level of education. If it is a type of provider that only has an education, no board certification, then you would only need to verify that the one time. For initial Credentialing, you don't need to re verify it for recredentialing, but for your onsite reviews you need to be able to archive it and show that it was once done.

[00:30:38.550] - Sue DeMarino

So you need to be able to always attach it into your Credentialing file. Never shred it, give it away, don't archive it forever. Make sure that if you are archiving it, you're reattaching it to always show that you initially did that education. Anything to just and you may have.

[00:30:57.500] - Lesley Malus Reed

Said it and I may have missed it. Making sure that whatever printout you have, make sure that it shows the site that you went out to visit. So for instance, if it was the state of Pennsylvania, you could see that it was a PA nursing license that.

[00:31:11.370] - Sue DeMarino

Was verified through the Katrina happens and there is no state website and you're doing it by telephone. Just make sure that you have who verified it for you, the information, the credentials itself. So you'd want to know the expiration date, whether the license was in good standing and who you are that verified it on what date.

[00:31:33.240] - Thomas Goddard

All right, well, I think we probably have time for one last question and we have a couple left here with votes. So right at the top of my list is, is there a good approach to combining multiple accreditation programs?

[00:31:49.180] - Sanalynn Wrigley

Let me frame this so that we answer both. Actually, there are two questions implied here. I can hear three questions implied here. Let's start with what if you have multiple accreditation programs with the same accreditation organization, not uncommon at all. You've got a health plan that also has a disease management program or a health call center. So built into URAC is the overlapping. If you're going through at the same time, the same core will be used so you'll be able to coordinate that. And so then it becomes one great big accreditation program effort. Now, a subset of that is, what if you're on two different schedules? This happened to regular client of ours many, many moons ago, where they had in one year their health plan was up, and then the next year their disease management was up and it was making them crazy because they were always in a state of reaccreditation, which can be bad for the stresses. So they went to URAC and said, we want to get these all on the same schedule. And URAC was accommodating for that. And Sue, I think you were in leadership back when the health plan I was thinking of did this about 15 years ago.

[00:33:15.430] - Sanalynn Wrigley

So that's another realm. But then you've got the situation where particularly in the pharmacy world, a number of payers, PBMs and otherwise are requiring their pharmacies to have multiple accreditations from multiple accreditation organizations. They might say URAC plus somebody else, or URAC plus ACHC. And in that situation, the obvious answer is to make sure that you comply with the more rigorous of the standards that are on the same subject. You might find that a particular ACHC standard is not quite as high a bar as the URAC standard. And then you need to kind of make sure that you're going with this one and not this one. And this will happen particularly as you broaden your compliance tracking mechanism, as we talked about earlier, as you start to say, well, everything is compliance contracts and laws and accreditation programs. And what you'll start to find is some of our clients have found is that if you put everything in goldfinch or a similar software, if there were such a thing, you can actually see the relationship between these standards and accommodate your policies accordingly. What did I leave out?

[00:34:36.640] - Sue DeMarino

I think it also ties back to what we talked about at the beginning of this discussion is by choosing that higher stringent standard, it'll help you make sure you're always meeting the mandatory standards. We were talking about how we got off track earlier when you changed up your policies and procedures. So as you choose the higher stringent standard, you need to make sure you're still auditing that policy and procedure to ensure it has all of the details from all of the accreditation organizations you want. So if, for example, NCQA requires a fellowship as your highest primary source verification as opposed to your residency? Well, if not everybody has fellowship, we still have to make sure we're keeping all the details as we go down for all the different types of accreditation that we are going to include in our policy procedure to ensure that it's going to be compliant for all of the organizations that we apply for.

[00:35:33.680] - Thomas Goddard

Excellent. Well, that does bring us to time. So thank you very much. If you have any further questions, you're welcome to reach out, send us an email. If you have a topic you'd like to see us do a webinar on, go ahead and shoot us an email, let us know. Thank you very much and we hope you have an excellent rest of your day.

[00:35:52.630] - Sanalynn Wrigley

Take care, everybody. Thank you. Bye.