2015 Complete Overview of the NCQA Standards Session Code: TU13 Time: 2:30 p.m. 4:00 p.m. Total CE Credits: 1.5 Presenter: Frank Stelling, MEd, MPH

Transcription

1 2015 Complete Overview of the NCQA Standards Session Code: TU13 Time: 2:30 p.m. 4:00 p.m. Total CE Credits: 1.5 Presenter: Frank Stelling, MEd, MPH

2 Introduction to NCQA Credentialing Standards NAMSS Educational Conference & Exhibition October 6, 2015 Anatomy of a Standard All materials 2015, National Committee for Quality Assurance Anatomy of a Standard Standard statement Statement about acceptable performance or results Intent statement Sentence describing importance of standard Summary of changes Changes from year to year 3 1

3 Anatomy of a Standard Scoring Level of performance necessary to receive specified percentage of points Data source Documentation organizations use to demonstrate performance Scope of review Lists the survey types and the type of documentation NCQA reviews for each type. Look-back period Period for which the organization must demonstrate performance, measured back from submission date 4 Anatomy of a Standard Explanation Specific requirements that the organization must meet, and guidance for demonstrating performance against the element (by factor if appropriate) Related information Additional information that may assist the customer, but not required. Examples Demonstrations of how requirements can be met. 5 Anatomy of a Standard Explanation Specific requirements that the organization must meet, and guidance for demonstrating performance against the element Related information Additional information that may assist the customer, but not required. 6 2

4 Data Sources to Show Compliance Documented process - Policies and procedures, process flow charts, protocols and other mechanisms that describe the operating guidelines or methodology used by the organization to complete a requirement 7 Data Sources to Show Compliance Reports - Aggregated sources of evidence of action or performance, including management reports; key indicator reports; summary reports from member reviews; system output giving information like number of member appeals; minutes; other documentation of actions an organization has taken 8 Data Sources to Show Compliance Materials - Prepared information that the organization provides to its members and practitioners, including written and electronic communication, Web-sites, scripts, brochures, reviews and clinical guidelines; contracts or agreements with practitioners, delegates and vendors 9 3

5 Data Sources to Show Compliance Records or files - History of cases, proceedings, verification of actions involving members or practitioners, such as documentation of completion of denial, appeal, complex case management or credentialing activities 10 Credentialing Standards All materials 2015, National Committee for Quality Assurance CR 1A: Practitioner Credentialing Policies Written policies/procedures address: 1. Types of practitioners to credential 2. Verification sources 3. Criteria 4. Decision-making 5. File management 6. Delegation 7. Non-discrimination 12 4

6 CR 1A: Practitioner Credentialing Policies Written policies/procedures address: 8. Notifying practitioners if verification source information is different 9. Notification of the CR decision within 60 days 10. Medical director or other practitioner directly responsible for the CR program 11. Ensuring confidentiality 12. Ensuring the directory is accurate 13 Factor 1: Types of Practitioners Written policies/procedures require credentialing of all practitioners with whom the organization has an independent relationship! Even those not included in the NCQA file review process 14 Factor 1: Types of Practitioners Licensed independent practitioners (physicians and nonphysicians) who provide care for members AND: Have an independent relationship with the organization See members outside of an inpatient hospital setting or ambulatory free-standing facilities Are hospital-based AND see members as a result of independent relationship with organization Are oral surgeons providing care under the medical benefit 15 5

7 Factor 1: Types of Practitioners Credentialing not required for practitioners meeting ANY of the following criteria: Practice exclusively in inpatient setting or freestanding facility AND provide care to members directed to the facility, not the individual practitioner Pharmacists who work for a Pharmacy Benefits Manager Practitioners who do not provide care for members in a treatment setting (e.g. board certified consultants) 16 Factor 2: Verification Sources The primary source, the entity that originally conferred or issued the credential, or A contracted agent of the primary source, or Another NCQA-accepted source listed for the credential 17 Factor 2: Verification Sources Use of an agent Entity that contracts with an approved source to provide requested credentialing information This contractual relationship must entitle the agent to provide verification of specific credentials on behalf of the primary source 18 6

8 Factor 3: Criteria The decision-making criteria the organization uses to assess the practitioner s ability to deliver care Examples Must be board certified Malpractice insurance at 1M-3M No sanctions 19 Factor 4: Decision Making Clean files: Medical Director or the Credentialing Committee Files that do not meet criteria: Credentialing Committee only 20 Factor 5: Managing Files How are the files managed and who manages them How are they kept secure How are they kept confidential 21 7

9 Factor 5: Managing Files Appropriate Documentation Actual copies of credentialing information A detailed signed/initialed and dated checklist. For each verification, the checklist must include: The name of the source used The date of verification The signature or initials of the person who verified the information The report date, if applicable Automated credentialing system 22 Factor 5: Managing Files Appropriate Verification Oral or verbal verification received by the organization Written verification in the form of a letter or cumulative report, NCQA uses the date of the official document (date on the letter or report), not the receipt date, to assess performance against timeliness requirements Internet and electronic verification, NCQA uses the date generated by the source when the information is retrieved The organization's staff person who verified the credentials must sign or initial the verification 23 Provisional Credentialing Applies to all practitioners applying for the first time, and only once Required Elements: PSV of current, valid license to practice, 5 years malpractice claims or settlements from carrier or NPDB query Current and signed application and attestation All conducted within 180 calendar days of Credentialing Committee decision or sign off by medical director/designee 60 calendar day maximum allowed 24 8

10 Factor 6: Delegation Describes the process the organization uses when delegating any part of credentialing to another entity If no delegating or no intent to delegate, the organization must state it in its policies and procedures 25 Factor 7: Non-discrimination Policies and procedures must address the following: Non-discrimination based on gender, race/ethnicity, age, sexual orientation or types of patients seen (e.g. Medicaid) Process for preventing discrimination Process for monitoring discrimination 26 Factor 8 & 9: Notification Factor 8: Notification of discrepancies Must have a policy or process for contacting practitioners when the information varies between what the practitioner has provided and what other sources state Factor 9: Notification of decision Must have a policy or process for notifying the practitioner within 60 calendar days of the final credentialing decision 27 9

11 Factor 10: Medical Director The organization must include in its policy who is directly responsible for the credentialing program. It may be: The Medical Director Designated physician 28 Factor 11: Confidentiality Policies and procedures must: State that information obtained in the credentialing process is confidential Describe the mechanisms used to keep credentialing information confidential State that practitioners can access their own credentialing information 29 Factor 12: Practitioner Directories Policies and procedures must describe the following The process the organization uses to ensure information in its directory is consistent with credentialing information Education, training, board certification and specialty 30 10

12 CR 1B: Practitioner Rights Policies & Procedures describe Practitioners right to: Review information submitted in support of application Correct any erroneous information Be informed of status of application upon request Notification of rights Materials used to communicate rights 31 CR 2A: Credentialing Committee Includes representation from the organization s participating practitioners Uses a peer review process Meeting minutes reflect thoughtful consideration of credentials NCQA calculates credentialing time frames based only on Credentialing Committee decision date 32 CR 2A: Credentialing Committee Medical Director or equally qualified practitioner may sign off on clean files Credentialing Committee must review files not meeting established criteria Process must be documented in organization s policies and procedures 33 11

13 CR 2A: Credentialing Committee Use of electronic signatures for sign-off is acceptable Meetings and decision-making may take place through real-time virtual meetings (e.g. video conferencing or WebEx with audio) Meetings may not be conducted through only 34 CR 3: Verification Procedures Primary Source Verification Information is obtained directly from the source organization Recognized Verification Sources Acceptable sources that are proven to primary source verify Agents of primary sources 35 CR 3: Documenting Verification Oral or Internet Information Source Dated and signed/initialed Source used Date of source Findings All hand written documentation and signatures for clean files must be written in ink 36 12

14 CR 3A: Factor 1: License Verification (Initial and Recred) Information Current Valid License Verification Source(s) State Licensing Agency 37 Web-Site Verification of License Accepted IF state licensing agency controls the Web-site Example: State agency maintains its own Web-site that includes the necessary information 38 Web-Site Verification of License IF the state does not maintain or control the Website or database The organization is responsible for verifying that the information on the Web-site or in a database (e.g., AIM) is as timely and accurate as the state s information 39 13

15 Web-Site Verification of License The organization must obtain a one-time letter from the state agency attesting to accuracy and timeliness of information on the Web-site or database (e.g., AIM, docfinder) 40 Web-Site Verification of License NCQA does not accept letters or documentation from third party databases, links, or sources (e.g., AIM, docboard, etc.) assuring the accuracy and timeliness of the information 41 Factor 2: DEA/CDS Verification (Initial and Recred) Information DEA or CDS Certificate For all states where the practitioner is providing care for the organization Verification Source(s) Copy of certificate Visual inspection of certificate DEA or CDS Agency confirmation NTIS database entry AMA Master file State pharmaceutical licensing agency 42 14

16 Factor 3: Verification of Education & Training (Initial Only) Initial Credentialing (Physicians) - The organization must verify only the highest level of credentials attained If a physician is board-certified, verification of that board certification fully meets this element Organization must verify board certification expiration date If a physician is not board certified, verification of residency training fully meets this requirement Fellowship verification is not required and does not meet educational verification requirements 43 Verification of Education & Training Non-physicians - The organization must verify only the highest level of education/training attained Board certification if written proof the primary source verifies education and training If not board certified or board does not PSV, verification of professional school Fellowship verification is not required and does not meet educational verification requirements 44 Verification of Education & Training Information Education and Training: Physicians (MD/DO) Board Certification Verification of certification Verification Source(s) ABMS entry AMA Masterfile AOA Profile Report or Physician Masterfile Confirmation from specialty board Confirmation from non-abms or non-aoa specialty board (w/proof of primary verification) Confirmation from state licensing agency (w/proof of primary verification) 45 15

17 Verification of Education & Training Acceptable ABMS Sources ABMS ABMS Licensed Agent *check ABMS web-site for list of agents 46 Verification of Education & Training Information Education and Training: Physicians(MD/DO) not board certified Completion of Residency Verification Source(s) Confirmation from residency program AOA Profile Report or Physician Masterfile AMA Masterfile Confirmation from state licensing agency (w/proof of primary verification) 47 Verification of Education & Training Information Education and Training: Physicians(MD/DO) no residency training Medical School Graduation Verification Source(s) Confirmation from medical school AOA Profile Report or Physician Masterfile AMA Masterfile ECFMG (international graduates after 1986) Confirmation from state licensing agency (w/proof of primary verification) 48 16

18 Verification of Education & Training Information Education and Training: Oral Surgeons Completion of Residency Verification Source(s) Confirmation from residency program Confirmation from state licensing agency (w/proof of primary verification) Dental board if proof of performing PSV 49 Verification of Education & Training Information Education and Training: Non-physician practitioners Professional School Graduation Verification Source(s) Confirmation from professional school Confirmation from state licensing agency (w/proof of primary verification) Confirmation from specialty board or registry that uses primary source 50 Factor 4: Verification of Board Certification (Initial and Recred) FS2 Whether certification meets education and training requirements or not Must be verified if practitioner states that he or she is board certified Use same sources as stated under education and training 51 17

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20 Primary Source Verification DEA/CDS Certificates If no certificate, need an explanation and a process for ensuring coverage for patients needing prescriptions requiring a certificate Board Certification If no expiration date, must verify certification is current Education - Use of sealed transcript for verification on education and training Must be in unbroken sealed envelope from institution 52 Factor 5: Work History (Initial Only) Information Work History Verification Source(s) Application/curriculum vitae 5 years of most recent work history Review any gap 6 months Clarify in writing any gap of > 1 year Verification timeframe 365 days (180 days for Medicare plans) 53 Factor 6: Claims Verification (Initial and Recred) Information Malpractice Claims History Verification Source(s) NPDB query or initial report from an NCQA recognized disclosure service, on new practitioner 5 years claims history from malpractice carrier 54 18

21 CR 3B: Sanction Information (Initial and Recredential) Sanction information required to be included in credentialing files: Information about sanctions and restrictions on licensure and limitations on scope of practice Information about sanctions by Medicare/Medicaid Within a 180 day timeframe 55 Sanction Information Sanction information required to be included in credentialing files: Information about sanctions and restrictions on licensure and limitations on scope of practice Information about sanctions by Medicare/Medicaid 56 Verification of Licensure Sanctions Review must cover Most recent five year period available through the data source All the states in which the practitioner has worked during that time period 57 19

22 Verification of Licensure Sanctions Practitioner Type Physician Chiropractor Verification Source(s) - NPDB - FSMB - State licensing agency - NPDB - State Board of Chiropractic Examiners - Federation of Chiropractic Licensing board (CIN-BAD) 58 Verification of Licensure Sanctions Practitioner Type Oral Surgeon Verification Source(s) - NPDB - State Board of Dental Examiners Podiatrist - NPDB - State Board of Podiatric Examiners - Federation of Podiatric Medical Boards 59 Verification of Licensure Sanctions Practitioner Type Non-physician Practitioner Verification Source(s) - NPDB - State Licensing Board or Certification Agency 60 20

23 Medicare/Medicaid Sanctions Acceptable sources NPDB FSMB List of Excluded Individuals and Entities (available over the Internet) Medicare and Medicaid Sanctions and Reinstatement Report State Medicaid agency or intermediary and Medicare intermediary Federal Employees Health Benefits Program department record published by OPM, OIG 61 Quiz: Medicare/Medicaid Sanctions For which practitioner type(s) is no query required? Chiropractor Podiatrist Oral Surgeon Non-physician health practitioner 62 CR 3C: Application/Attestation (Initial and Recred) Required Elements: Attestations Signature and date 63 21

24 Attestations Reasons for inability to perform essential job functions, with/without accommodation Lack of present illegal drug use History of loss of license and felony convictions History of loss or limitation of privileges or disciplinary actions Current malpractice coverage Affirmative statement re: correct/ complete application 64 Attestations What if The organization s application doesn t include an attestation about current malpractice insurance coverage? The organization may use a signed addendum or obtain a copy of the insurance face sheet 65 State Required Applications If state requires organization to use an application. And the application does not include all NCQA requirements And the organization cannot change the application NCQA will hold organization harmless 66 22

25 Application and Attestation Timeframes 365 days between verification and decision 180 days for Medicare plans 67 CR 4A: Recredentialing Cycle Length Occurs at least every 36 months The recredentialing decision date must be within 36 months of the previous credentialing date Recredentialing timeliness is a separate standard 68 CR 5: Practitioner Office Site Quality Organizations have a process to ensure that the offices of all practitioners meet their office site standards 69 23

26 Practitioner Office Site Quality Performance Standards and Thresholds Documented process must include the following: physical accessibility physical appearance adequacy of waiting and examining room space adequacy of treatment record keeping 70 CR 5B: Practitioner Office Site Quality Site Visit and Ongoing Monitoring Conduct visits of offices which meet the organization s established thresholds for member complaints pertaining to office site quality 1. Monitor complaints for all practitioners 2. Perform within 60 calendar days of meeting organization s established threshold of complaints 71 CR 5B: Practitioner Office Site Quality Site Visit and Ongoing Monitoring 3. Institute actions as needed for improvement with sites that reach the complaint threshold 4. Re-evaluates at least every 6 months until sites with deficiencies meet performance requirements 5. Document follow-up visits 72 24

27 CR 5B: Practitioner Office Site Quality Issues not part of office site quality: Appointment availability (evaluated in QI 5) Confidentiality and availability of records 73 CR 6A: Ongoing Monitoring of Sanctions, Complaints and Quality Issues Written policy and procedure for ongoing monitoring of: Medicare and Medicaid sanctions Sanctions/limitations on licensure Complaints Adverse events Appropriate interventions when issues identified 74 QI Ongoing Monitoring Sanctions Within 30 calendar days of the date the information becomes available for entities that do not release information on a set schedule query at least every 6 months for reporting entities that do not release sanction information query for any affected practitioner months after last credentialing cycle 75 25

28 Ongoing Monitoring Sanctions Subscription to an alert service of NCQArecognized source may be used Information must be reviewed within 30 calendar days of a new alert evidence of subscription must be provided Documented in checklist, log or initialed/dated report 76 Ongoing Monitoring Complaints Process to evaluate, at least every six months Process to investigate practitioner-specific complaints on receipt Evaluation of specific complaint AND history of issues, if applicable, must show evidence of this evaluation 77 Ongoing Monitoring Adverse Events injuries to members that happen while receiving care from a practitioner Process to evaluate, at least every six months Process to investigate practitioner-specific events on receipt of information Implementation of actions based on organization s policies and procedures, if applicable 78 26

29 CR 7A: Notification to Authorities and Practitioner Appeal Rights Written procedures for actions against practitioners: Range of actions that can be taken Reporting to authorities A well-defined appeal process Making the appeal process known to practitioners Aligns with HCQIA of 1986 which provides peer review protection 79 Notification to Authorities and Practitioner Appeal Rights Procedures for reporting serious quality issues to appropriate authorities State agencies NPDB Must provide evidence of following appeal process if it altered the conditions of practitioners participation Applies to physicians and non-physician practitioners 80 Practitioner Appeal Process Inform affected practitioners of the appeal process, including: Providing written notification that a professional review action has been brought, reasons for the action, summary of the appeal rights and process Allowing the practitioner to request a hearing and the specific time period for submitting the request Allowing at least 30 days after the notification for the practitioner to request a hearing 81 27

30 Practitioner Appeal Process Inform affected practitioners of the appeal process, including: Allowing the practitioner to be represented by an attorney or another person of the practitioner s choice Appointing a hearing officer or a panel of individuals to review the appeal Providing written notification of the appeal decision that contains the specific reasons for the decision 82 CR 8A: Organization Providers Written P&P for initial and ongoing assessment of organizational providers Determination of good standing with appropriate state/federal agencies Accreditation status verified or site visit with evaluation against quality standards Reconfirm every 3 years 83 CR 8A: Organization Providers Exception if: The provider is not accredited, and The state or CMS has not conducted a site review, and The provider is in a rural area, as defined by the U.S. Census Bureau Must identify excluded providers and include evidence that the above conditions are met 84 28

31 CR 8B-C: Provider Types Medical (8B) Hospitals Home health agencies Skilled nursing facilities Free-standing surgical centers Behavioral Health (8C) Inpatient 24 hour behavioral units in general hospitals Free standing psychiatric hospitals Residential treatment centers Ambulatory Mental health and substance abuse facilities 85 Site Visit Standards Example: Skilled nursing facility Accreditation Status - not accredited Standards for Participation (Example of a partial list of criteria) Has functional QI program in place 2 QI activities/year Has medical record-keeping standards Meets Health Plan s credentialing standards 86 Questions 87 29