4/20/2017 1 Rachelle L. Silva, BS, CPMSM, CPCS ArkAMSS Spring Conference APRIL 21, 2017 NCQA Standards Update and Effective Managed Care Tools/Best Practices Objectives Identify the NCQA standards to ensure compliance Discuss effective tools that will assist in making the credentialing process more efficient Incorporate best practices into the credentialing process to efficiently work with different managed care organizations NCQA CR1 The organization has a well-defined credentialing and recredentialing process for evaluating and selecting licensed independent practitioners to provide care to its members.
Transcript
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R a c h e l l e L . S i l v a , B S , C P M S M , C P C S
A r k A M S S S p r i n g C o n f e r e n c e
A P R I L 2 1 , 2 0 1 7
NCQA Standards Update and Effective Managed Care Tools/Best
Practices
Objectives
Identify the NCQA standards to ensure compliance
Discuss effective tools that will assist in making the credentialing process more efficient
Incorporate best practices into the credentialing process to efficiently work with different managed care organizations
NCQA CR1
The organization has a well-defined credentialing and recredentialing process for evaluating and selecting
licensed independent practitioners to provide care to its members.
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CR 1-Element A Practitioner Credentialing Guidelines
Factor 1: Practitioners within the scope of
credentialing Practitioners who are licensed, certified or registered by the state
to practice independently (without direction or supervision)
Practitioners who have an independent relationship with the organization
Practitioners who provide care to members under the organization’s medical benefits
Related information:
Practitioners who do not need to be credentialed
CR 1-A Continued
Factor 2: Verification sources The primary source (or its Web site)
A contracted agent of the primary source (or its Web site)
An NCQA-accepted source listed for the credential (or its Web site)
Cr 1-A Factor 2 Related Information
Appropriate Documentation Copies of credentialing information
Signed (or initialed) and dated checklist that includes, for each verification:
o The source used
o The date of verification
o The signature or initials of the person who verified the information
o The report date, if applicable
Automated Credentialing System – Unique electronic staff identifier
Refer to Appendix A
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CR 1-A Continued
Factor 3, 4: Decision-making criteria and process Practitioners credentialed before they provide care to members
Process for making credentialing decisions
Defined criteria required to reach a credentialing decision
o Criteria are designed to assess a practitioner’s ability to deliver care
Determine the scope of practitioners who may participate in the network
CR 1-A Factor 3, 4 Related Information
Provisional Credentialing
One-time use for practitioners applying for the first time
Required verifications:
o Current, valid license to practice
o Past 5 years malpractice claims/settlement history
o Current signed application with attestation
Follows the same decision making process
Not eligible if credentialed by a delegate for the organization
Maximum provisional status 60 calendar days
Verification time limits: HP – 180/365, CVO – 120/305, G/MA – 180/180
CR 1-A Continued
Factor 5: Managing credential files that meet
established criteria
Process used to identify files that meet criteria (e.g. clean files)
Process used to approve files that meet criteria
Related information:
Practitioner Termination
Practitioner Reinstatement
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CR 1-A Continued
Factor 6: Delegation If the organization delegates credentialing activities
What credentialing activities may be delegated
How the organization decides to delegate
CR 1-A Continued
Factor 7: Nondiscriminatory credentialing and
recredentialing
Does not base credentialing decisions on an applicant’s race, ethnic/national identify, gender, age, sexual orientation or patient type
Process for preventing discriminatory credentialing practices
Process for monitoring discriminatory credentialing practices
CR 1-A Continued
Factor 8: Discrepancies in credentialing information Process of notification when information obtained from other
sources varies substantially from that provided by the practitioner
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CR 1-A Continued
Factor 9: Notification of decisions Time frame for notification of applicants – 60 calendar days
What decisions require notification
Initial credentialing decisions (approval or denial)
Recredentialing denials
CR 1-A Continued
Factor 10: Participation of a medical director or
designated physician
Description of the overall responsibility in the credentialing process
Description of participation in the credentialing process
CR 1-A Continued
Factor 11: Ensuring confidentiality Paper credentials information
Electronic credentials information
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CR 1-A Continued
Factor 12: Practitioner directories and member
materials
Process to ensure information provided to network is consistent with information obtained during the credentialing process
CR 1-B Practitioner Rights
The organization notifies practitioners about their right to:
Factor 1: Review Information
Factor 2: Correct erroneous information from other sources
Factor 3: Application status
CR 2 Credentialing Committee
The organization designates a Credentialing Committee that uses a peer-review process to make
Other sources based on practitioner type Physicians – Appropriate state agencies, Federation of State Medical
Boards (FSMB)
Chiropractors – State Board of Chiropractic Examiners, Federation of Chiropractic Licensing Boards’ Chiropractic Information Network-Board Action Databank (CIN-BAD)
Oral Surgeons – State Board of Dental examiners or State Medical Board
Podiatrists – State Board of Podiatric Examiners, Federation of Podiatric Medical Boards
Non-physician health care professionals – State licensure or certification board, appropriate state agency
List of Excluded Individuals and Entities (maintained by OIG)
Medicare Exclusion Database (maintained by SAM)
Federal Employees Health Benefits Plan (FEHB) Program department record (published by the Office of Personnel Managed, OIG)
FSMB
CR 4 Recredentialing Cycle Length
The organization formally recredentials its practitioners at least every 36 months.
CR 4 Continued
Recredentialing Elements Applies to practitioners in the scope of credentialing defined in
CR 1
Requires an application and attestation
Applicable verifications as defined in CR 3
Each file contains the Credential Committee decision date
The 36 month cycle begins on the date of the previous Credential Committee decision
The 36 month cycle is to the month not to the day
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CR 4 Continued
Acceptable reasons to extend beyond 36 months Active military assignment
Maternity leave
Sabbatical
Practitioner must be recredentialed within 60 calendar days of a return to practice.
CR 4 Continued
Termination and reinstatement Termination for administrative reasons (e.g. failure to timely
submit a complete application)
o Can perform recredentialing to reinstate if done within 30 calendar days of termination
o Must perform initial credentialing if reinstated after 30 calendar days of termination
CR 5 Practitioner Office Site Quality
The organization has a process to ensure that the offices of all practitioners meet its office-site
standards.
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CR 5 – Element A Performance Standards and Thresholds
The organization sets site performance standards and thresholds for:
Physical accessibility o Handicapped accessible o Ease of entry
Physical appearance o Well-lit waiting room o Posted office hours
Adequacy of waiting and examining room space o Adequate seating o Appropriate size
Adequacy of medical/treatment record keeping o Secure/confidential filing system o Legible file markers o Records are easily located
CR 5 – Element B Site Visits and Ongoing Monitoring
Factor 1 – Monitor members complaints Establishes a reasonable complaint threshold for an office-site
visit that takes the severity of an issue into account
Has a process to monitor and investigate members complaints
CR 5 – Element B Continued
Factor 2 – Site Visits Uses a standardized survey form that incorporates the
organizations established performance standards and thresholds
Conducts a site visit for complaints if the complaint threshold is met
Performs site visit within 60 calendar days of the complaint threshold being met
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CR 5 – Element B Continued
Factor 3 – Instituting actions
Factor 4 – Effectiveness of actions
Factor 5 – Follow-up visit
Office site meets the complaint threshold for a different standard
Follow-up visit performed within 60 calendar days on the performance standards pertaining to that complaint
Implements an action plan for improvement
CR 5 – Element B Continued
Methods for identifying deficiencies Complaint monitoring
Practice-specific member surveys
Reports from Provider Relations staff visits
Staff audit
CR 6 Ongoing Monitoring
The organization develops and implements policies and procedures for ongoing monitoring of practitioner
sanctions, complaints and quality issues between recredentialing cycles and takes appropriate action
against practitioners when it identifies occurrences of poor quality.
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CR – 6 Continued
Factor 1 - Accepted verification sources for licensure and Medicare/Medicaid sanctions Same verification sources as identified in CR 4 – Element C
Factor 2 - Time frame for reviewing sanction information Within 30 calendar days of its release by the reporting entity if
the information is published on a set schedule
Queries for information at least every six months if documentation that the entity does not release in formation on a set schedule
Query every 12-18 months if the entity does not release sanction information reports
CR 6 Factor 2 Continued
Sanctions alert services Review information within 30 calendar days of a new alert
Shows evidence of subscription to the sanctions alert service
CR 6 Continued
Factor 3 - Investigating complaints Investigates practitioner specific complaints upon receipt
Evaluated practitioner’s history of complaints
Evaluates history of complaints for all practitioners at least every six months
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CR 6 Continued
Factor 4 – Adverse events
Monitor adverse events at least every six months
May limit adverse event monitoring to primary care practitioners and high-volume behavioral healthcare practitioners
Factor 5 – Implementing interventions
Interventions are identified in policies and procedures
Implemented for evidence of poor quality that could effect the health and safety of its members
CR 7 Notification to Authorities and Practitioner Appeal Rights
An organization that has taken action against a practitioner for quality reasons reports the action to
the appropriate authorities and offers the practitioner a formal appeal process.
CR 7 – Element A Actions Against Practitioners
Factor 1 – Range of actions available Policies and procedures specify that the organization will
o Review participating practitioners whose conduct could adversely affect members’ health or welfare
o Outline the actions that may be taken before termination
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CR 7 –Element B Reporting to authorities
Reporting to authorities Factor 2 – Element A Policies describe:
o What incidents are reportable
o How and when reporting will occur
o To whom incidents are reported
o The organization staff person responsible for reporting
Reporting authorities include NPDB, state agency or other regulatory body
CR 7 – Element C Practitioner Appeal Process
Factor 3- Element A – Policies describe the appeal process Written notification of the reasons for the professional review action
and a summary of the appeal rights process
Allowing practitioner to request a hearing and the specific time period for submitting the request
Allowing at least 30 days after notification for the practitioner to request a hearing
Allowing practitioner to be represented by an attorney or another person of their choice
Appointing a hearing officer or a panel of individuals to review the appeal
Written notification of the appeal decision with specific reasons for the decision
CR 7 – Element A Continued
Factor 4 – Making the appeal process known Process is detailed in policies and procedures
Practitioner is provided with the appeal rights and process at the time a professional review action is brought against a practitioner
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CR 8 Delegation of Credentialing Activities
If the organization delegates any NCQA-required credentialing activities, there is evidence of oversight
of the delegated activities.
CR 8 – Element A Delegation Agreement
Factor 1 – Mutual agreement Delegation activities are mutually agreed on before delegation
begins
A dated binding document is signed by the organization and the delegated entity
CR 8 – Element A Continued
Factor 2 – Assigning responsibilities Delegation agreement outlines the credentialing activities to be
performed by the delegate
Delegation agreement outlined the credentialing activities retained by the organization
o Organization can choose to make a general statement (e.g. the organization retains all other credentialing activities)
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CR 8 - Element A Continued
Factor 3 – Reporting Organization determines the method of reporting and the
content of the reports
o What information is reported by the delegate
o How and to whom the information is reported
Delegate reports at least semiannually
CR 8 – Element A Continued
Factor 4 – Performance monitoring
Policy review
Credential file audits
Factor 5 – Right to approve, suspend and terminate
Factor 6 – Consequences for failure to perform
CR 8 – Element B Provision for PHI
If the delegation agreement includes the use of protected health information (PHI) the agreement specifies:
Factor 1 – Allowed uses of PHI
Specifies PHI the delegate my use and disclose
Specifies whom PHI may be disclosed
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CR 8 – B - Continued
Factor 2, 3 – Delegate and Subdelegate safeguards Organization provides administrative, technical and physical
safeguards to ensure PHI:
o Confidentiality
o Integrity
o Availability
o Prevention of unauthorized or inappropriate access, use, or disclosure of PHI
CR 8 – Element B Continued
Factor 4 – Access to PHI Basic protections of physical facilities that store PHI
Protection of electronic systems from unauthorized access
Protection of electronic systems from internal and external tampering
CR 8 – Element B Continued
Factor 5 – Inappropriate us of PHI Agreement specifies procedures for delegates to identify and
report unauthorized:
o Access
o Use
o Disclosure
o Modification
o Destruction
Factor 6 – Disposal of PHI if delegation ends
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CR 8 – Element C Predelegation Evaluation
Organization evaluates the delegates ability to meet the NCQA standards:
Request for delegation determines:
o If delegate performs credentialing activities
o If delegate has credentialing policies and procedures
o If delegate will allow a review of the credential files
o If delegate is NCQA certified
CR 8 – Element C Continued
Policies and Procedures are reviewed for compliance with NCQA standards Credential files are audited for compliance with NCQA standards Effective date of the delegated credentialing agreement is determined after the organization has approved the delegate If effective date is greater than 12 months from the review a new review is conducted If new credentialing activities are added an audit is conducted to ensure NCQA compliance
CR 8 – Element D Review of Credentialing Process
Factor 1 – Review of the credentialing policies and
procedures
Factor 2 – Annual file audit
5% or 50 files whichever is less (at a minimum 10 initial credential files and 10 recredential files)
If less than 10 practitioners were credentialed/recredentialed all files are audited rather than a sample
NCQA 8/30 methodology
Factor 3 – Annual Evaluation
Factor 4 – Evaluation of reports
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CR 8 – Element E Opportunities for Improvement
Corrective action plan is required for: Policy and procedure deficiencies
Credential file deficiencies
Organization determines time frame to submit the corrective action plan
Failure to submit a corrective action plan is a breach
