The Mihalik Blog

Auto-Credit Woes

Using an NCQA accredited or certified vendor can lock in scores of 100% for many elements.  This is great news for organizations looking to improve their accreditation outcomes. 

In order for the auto-credit to apply, however, the delegation agreement must clearly describe which elements are delegated and the vendor’s accreditation or certification must cover the specific elements.   

For the former requirement, I suggest that the delegation agreement describe which elements are delegated using language that is as close to the wording of the NCQA standards as possible.  In addition, the accreditation manuals contain appendices that contain information on delegation.  These appendices include language that should be included in the delegation agreements for the auto-credit to apply.

For the second requirement, it is important to look at the specific standards and elements under which the organization was accredited or certified to know if you will be able to get auto-credit.  Disease management is one of the areas where the Managed Care Organization (MCO) and Health Plan Accreditation (HPA) standards have diverged from the Disease Management Accreditation/Certification standards.  Unless a disease management vendor was surveyed under standards that match those in the 2007 MCO or 2008 HPA standards, you won’t get auto-credit for all of the disease management elements.

If you delegate elements to an organization that are not covered under that organization’s NCQA accreditation or certification, remember that you are not relieved of oversight for those elements.  For example, you will now need to conduct a pre-delegation audit and an annual evaluation for the elements not covered under the organization’s NCQA accreditation or certification. 

Demonstrating Web Functionality During a Survey

A number of standards in the Member Connections and Members’ Rights and Responsibilities categories of NCQA’s Health Plan Accreditation program require web-based functionality.  Demonstrating this functionality is a requirement of the survey process.

Unless access to your site is explicitly prohibited, most of the elements that require web-based functionality must be tested by the surveyors.  This means that you need to give the surveyors IDs and passwords, if required, to access and use the site.  Don’t forget to embed a hyperlink to the website in the ISS as well.

Not all of your web-based functions may be password protected.  Often, physician and hospital directories are available on a health plan’s public site.  Other functions, like changing a PCP or requesting a new ID card, are typically on a secure site accessible by ID and password only. 

If you cannot give surveyors access to your site to test the web-based functionality you should be prepared to demonstrate why access is not possible.  If surveyors cannot test the site itself, you should provide screen shots of the whole process accompanied by a step-by-step explanation of how the process works and what the screen shots demonstrate. 

Integrating Member Information

It’s been way too long since my last post.  A combination of writer’s block and lots of deadlines conspired to prevent blog entries.  I apologize to those of you who’ve been periodically looking here for new information. 

I write the entries myself—unless the entry notes that it’s been written by someone else—and sometimes I just can’t keep up with my editorial calendar. 

Anyhow, enough of that.

Integrating member information is an element in the Disease Management Standard for NCQA’s Health Plan Accreditation program.  Questions have arisen about just what NCQA expects for such integration, given that the areas involved are ones that are frequently delegated. 

Just to recap, QI 8I, Integrating Member Information, requires that the health plan integrate information between a health information line, a disease management program, a case management program, and a utilization management program to facilitate access to member health information for continuity of care. 

Even when one or more of these functions are delegated, NCQA expects the integration of member information to occur.  This integration can be quite a challenge without delegation!

What you need to think about is whether the current systems and processes will allow staff performing each of these different functions to have access to member information when needed.  Consider for example:

·        If a member in the asthma disease management program called the health information line to get advice on what to do for a bee sting that seemed to be getting worse, would the staff at the health information line know that the member had asthma and was in the asthma disease management program?

·        If a member in a complex case management program were hospitalized, would the complex case management staff know of the hospitalization?  How long would it take for them to find out?

I could go on, but you get the idea.  Come up with a series of scenarios for how members could utilize the services provided by each of the four components mentioned above, and see if your current systems and processes would allow staff to have access information about the member’s involvement with the other program(s). 

Despite the fact that NCQA does not typically look at documentation prepared by delegates, except for the file review standards, this may be an element where delegate-prepared reports will be needed to demonstrate that the integration is, in fact, happening.