NCQA Accreditation Pitfalls Part 4: Member File reviews

 NCQA Accreditation Pitfalls Part 4: Member File reviews

There is always a member file review for both Health Plan and Disease management. I can’t emphasize enough to have technical people involved when creating the specifications for the file pull. If you have questions or concerns get them addressed by NCQA well in advance of doing the file pull. Go over the pull with your assigned NCQA rep to make sure the contents are exactly what NCQA is looking for. Do not give NCQA the minimum number of members. The point of the review is to prove that you are following for established policies and procedures.  This should relatively easy to do with the documentation you have already provided. This can be a nightmare if you are inconsistent in policies and procedures.

NCQA Accreditation Pitfalls Part 3: Staffing the Compliance team.

Part 3 NCQA Accreditation Pitfalls: Staffing the Compliance team.

                I’m going to pretty blunt on this topic, just grabbing any old clinical person and putting them in charge of NCQA accreditation for either your Health Plan or DM organizational is a recipe for disaster.  That might have worked 4 years ago where the standards where much easier but not anymore.  NCQA requirements have become increasing technically, with considerable emphasis on legal concerns.  The clinical part of the accreditation is really 1/3 of it with another 1/3 being IT and legal and the rest being Quality initiatives (with heavy emphasis on performance measurements).  Unless your Clinical lead has a technology background you’ll have issues.  The ideal team really is having a clinical member and IT member (preferably a technical analyst) and a compliance/legal member.  My background is IT/Compliance and I have a clinical person on staff. We actually complement each other pretty well and cover most areas. I am never surprised on how little the health plans understand about NCQA requirements. We usually find ourselves answering Health Plan questions on their own NCQA Accreditation. Internally we spend a lot of time answering product/sales questions. Our work does branch into performance and HEDIS measures also.A lot of questions arise with CMS and HHS questions. In some ways you end up being the sage of all things accreditation related.  It's an interesting segment to work in. Most organizations have legal staff to handle "compliance" but that tends to be contracts and legal. Clinical staff handles programs and IT staff handles infrastructure but who puts it all together in a complete package and make sure the varied organizations complete their regulatory and accreditation goals? Just tooting my own horn here, it's the compliance team.  You really need to ask the questions of who, what and why.  

Part 2 NCQA Accreditation Pitfalls Organizational Push back

Part 2 NCQA Accreditation Pitfalls Organizational Push back:

                Now in the quest to acquire the documentation that is required for accreditation you will invariably run into many groups internally that ask why do you need this and we don’t have time or desire to do this.   The best solution to this problem is you have a very high level sponsor for this undertaking.  You will need to pull out the “big guns” to get some of what you need done.  There will be times in order to get policies and procedures in place for 12 months at least you will need someone at the top level of your organization saying that this is not optional but mandatory and go do it.  You will fail in getting the accreditation done in the time frame you were looking to do without this support.  NCQA accreditation affects operations, legal, clinical and IT areas.  These groups typically don’t always work well together nor have solid cross-departmental working relationships.  You’ll need someone to lay down the law and usually a lowly manager or director isn’t going to have the pull.  Ideally the Chief Medical Officer or the COO is the ideal sponsor. They usually have enough clout cross organizationally to get movement.  Another situation that can arise is that you get asked to create the documentation for a particular group. This is a really bad idea for a couple of reasons. First is that you are writing documentation just to get accreditation. That’s not the purpose it’s to create an environment for better health care. It’s a situation to avoid at all costs.  The other issue that arises is now you are the owner of the documentation.  Should the NCQA team really own the SOP for training health coaches on Privacy issues???  This can be a real pitfall. This is where you need to pull out the big guns and get that particular group on board with doing what is needed. Another aspect to this situation is education. I cannot stress enough for the need for the accreditation organization to make its purpose, goals and needs understood by the company at large.  Many times companies do not spend the time and effort to understand what NCQA accreditation entails and what it means for a company organizationally. For some it’s something that is done every 3 years at the last minute and pass by the skin of their teeth or on probation. Many plans look at it as an extra burden that can be cast aside when times are rough. Very few realize that the accreditation put policies, procedures and process that are needed to survive in the very complex world of US Health Care.  Anyone operating in the compliance field understands the value of these and the protection they provide when state, federal or internal auditors arrive to do audit.   Ranging from sales to IT everyone has a vested interest in understand what accreditation entails and encompasses.

Part 1 NCQA Accreditation Pitfalls

 After working in the compliance segment for a while I've decided to put together thoughts, ideas and musings on a bunch topics. I'd like to muse about NCQA Accreditation's, HEDIS and DM Performance Measurements.

Part 1 NCQA Accreditation Pitfalls- Time to complete and Look back periods:

 When many organizations decide to go for NCQA accreditation the first time a lot of bad assumption are made as it is assumed this can easily be done in a “few months”.  This usually happens when a senior leader in the organization makes the assumption that assigning someone to the task will just get it done (without reading the required documentation).  Usually this means some nurse or manager in the compliance/clinical regulatory area gets stuck with the task. Once they begin reading the requirements reality dawns on them that this is at least a 12 month long undertaking (minimum look back period).  Now the manager has to go across the organization and make sure that all the required documentation exists and it has been in place for at least 12 months (documented process, policies and procedures).  How many organizations in the Health Care field work well inter departmentally and have clears lines of responsibility which is documented and well maintained?  If you know of a few please let me know. So now the accreditation team (which is usually no more than a couple of people) begins the arduous process of going cross departmentally getting documentation from the various departments.  This can be monumental task in its own right. First you need to determine which departments should have the documentation you are looking for. Then you have to determine who you need to talk to in that department. Once that has been figured out then you need explain why and what you need for accreditation. This can be painful as everyone has their own assumptions on what is “needed”.  When in doubt always refer back to the requirements on what NCQA is asking for. Use the examples they provide as the baseline.