The Mihalik Blog

Changes to NCQA 2009 Standards

I thought I’d update you on changes to NCQA standards for Health Plan Accreditationthat go into effect July 1, 2009. Remember that NCQA issues updates throughout the year so it’s likely that there will be additional changes before July 1, 2009 when these standards go into effect.  

 

The value of standards in determining accreditation outcomes continues to decline.  In 2009, standards account for 57 points, down from 61.3 points in 2008.  Points derived from HEDISresults will make up the remaining 43 points. 

 

For 2009, NCQA requires that the clinical practice guidelines used for QI 9A, Adoption and Distribution of Guidelines, be approved and in place for more than 24 months.  This means health plans will be forced to implement the guideline update process referenced in Factor 3, which is required every two years.  This change means that guidelines presented for a survey under the 2009 standards must be in place as you are reading this sentence.

 

MEM 1F requires that health plans have an alternative to web-based health risk appraisals (HRA).  Printed versions of the HRA must include the same content as the web version, including follow-up resources.

 

While NCQA maintains that use of a vendor for MEM 1, Health Risk Appraisals, and MEM 2, Interactive Consumer Health Tools, is not surveyed as if it were delegation, this is not the case for MEM 4A and 4B, where use of a PBM or other organization to provide pharmacy benefit information by web or telephone constitutes delegation. 

 

In one of the more significant changes, NCQA has determined that the quality improvement process for pharmacy benefit information, MEM 4C, must address all eight factors in Elements MEM 4A and 4B.  Prior to this change, the extent of the quality improvement process was unspecified. 

 

Using a process to allow members to request ID cards and PCP changes by email does not meet the requirement to complete the transactions in one attempt by web as required by MEM 5A.

 

Making MEM 6A, Innovations in Member Service, just a bit easier, allowing members to keep track of their personal health information on a tracking sheet accessible through the health plan's web site and providing a link from the health plan’s web site to a free online personal health record and encouraging members to access it each constitute providing online personal health records.

 

Although MEM 7A specifies email access to the health information line staff, NCQA has clarified in the explanation that a web-based messaging system, rather than traditional e-mail, meets the intent of the standard.

NCQA Accredits L.A. Care Health Plan!

L.A. Care Health Plan has been awarded an Accreditation status of "Excellent" from the National Committee for Quality Assurance.  Excellent is the highest ranking possible for a health plan.

The Mihalik Group is proud to have worked side-by-side with L.A. Care’s staff for several years throughout this arduous process to maximize the company’s performance.

L.A. Care Health Plan (Local Initiative Health Authority of Los Angeles County) is a public entity and community-accountable health plan serving over 800,000 residents of Los Angeles County through a variety of programs including Medi-Cal, Healthy Families, L.A. Care’s Healthy Kids, and L.A. Care’s Medicare Advantage Special Needs Plan.

64,000 Questions

Let’s face it, the ugly truth about preparing for survey is that presentation of material makes a difference.

 

Nobody knows your material better than you.  Your job, in preparing for survey, is to demonstrate your compliance with standards in an easy-to-understand manner. 

 

The first indication that you may have failed at this most important task is that you get a lot of questions from the survey team.  Honestly, the fewer questions the better.  Under current survey protocols, surveyors are not going to “down-score” you without asking for clarification.  So, the fewer questions you get the better (for everyone). 

 

If you’ve managed to garner just a few questions from the survey team, you’re clearly on the right track—both in terms of actually being in compliance and in terms of demonstrating that compliance.  Even so, ask yourself if you made it easy for the survey team. 

 

For most standards, it helps to write a brief narrative describing HOW your organization meets the standard.  If you’re going to go to the trouble of writing such a narrative—and I strongly suggest you do—don’t just say the equivalent of “We do x, y, and z” parroting back the language of the standard.  Describe HOW you ACCOMPLISH “x, y, and z.”  Think of this narrative as the executive summary.  It should summarize the information to be gleaned from reviewing the evidence you’ve supplied. 

 

And while we’re on the topic of evidence…don’t just dump every document you can think of on the surveyors.  Plan your approach.  You might have gotten just a few questions because you gave the surveyors the documentary equivalent of the kitchen sink, the bathroom sink, and the laundry sink which they dutifully slogged through to find the precious bits.  But think.  Was all that really necessary?  If all that’s needed is a policy and procedure to describe your process for doing something that’s all you should supply.

 

Finally, highlight and annotate.  If you can’t pinpoint the exact sections of each document that provide evidence of compliance chances are the surveyors can’t either.  Highlight the “must read” portions of each document.  Put a little text box next to the selection noting the relevant standard. 

 

Just because you’ve always done it a particular way doesn’t mean it will get you through the next survey.  Expectations change.  Interpretations change.  As Will Rogers once said, “Even if you’re on the right track you’ll get run over if you just sit there.”  Surveyor variability is another potential issue.  The surveyor who said you did it correctly last time may have been wrong.  If the next surveyor correctly determines that you are not in compliance, having gotten credit last time won’t be likely to change the outcome. 

 

If you’re struggling with deciding what evidence to provide, which sections to highlight, or how much evidence is enough you need to give serious consideration to bringing in a knowledgeable consultant.  A good consultant brings a perspective gleaned from experience with scores and scores of surveys—a perspective that few other individuals have regardless of how long they’ve been in their jobs.  A consultant can pinpoint changes, explain the evolution of a standard, provide insights to what is coming “down the road,” and suggest ways to improve compliance as well as ways to improve evidence of compliance. 

 

An indication that you’ve done a great job is…nothing…no questions from the surveyors, that is.