NCQA STANDARDS & SURVEY PROCESS UPDATES

Transcription

1 NCQA STANDARDS & SURVEY PROCESS UPDATES Presenter: Tammy L. White, CPCS CPMSM President, Gemini Diversified Services, Inc. Partner, Optimal Revenue Cycle Management, LLC Partner, MyAPPSTAT Provider Enrollment

2 AGENDA NCQA Standards Overview & Updates NCQA Survey Process Overview Ensuring a Successful Survey 5 Common Mistakes & Staying ahead of the next Survey

3 NCQA STANDARDS OVERVIEW & UPDATES CREDENTIALING (CR) CR1 Policies CR2 Committee CR3 Verifications CR4 - Recredentialing Cycle CR5 - Ongoing Monitoring CR6 - Notifications to Authorities / Practitioner Appeals CR7 Assessment of Organizational Providers CR8 - Delegation of Credentialing Activities

4 CR1 CREDENTIALING POLICIES Element A Practitioner Credentialing Guidelines WHAT do your policies say? i. Do you have a process to select & evaluate practitioners? ii. Verification sources used iii. Clean Files vs. Non Clean Files iv. Delegating credentialing? v. Provisional Credentialing vi. Termination & Reinstatement vii. NCQA has clarified appropriate documentation requirements Element B Practitioner Rights i. Review information submitted ii. Correct erroneous information iii. Receive status updates

5 CR2 CREDENTIALING COMMITTEE Element A Committee i. Using participating providers to sit on the committee ii. Process for Clean files iii. Process for Non-Clean files No NCQA updates at this time

6 CR3 CREDENTIALING VERIFICATION Element A Verification of Credentials i. Current/valid license ii. Valid DEA iii. Education & Training iv. Board Certification v. Work History vi. History of Professional Liability Claims vii. NCQA updates on file documentation, Query Results, and Reporting Board Cert results on NP s Element B Sanction Information i. State Sanctions ii. Medicare / Medicaid iii. NCQA update on using information from CR5 to meet this requirement Element C Credentialing Application i. 6 MUST have Attestation questions

7 CR4 RECREDENTIALING CYCLE LENGTH Element A Recredentialing Cycle Length i. Length of time in between cycles = 36 months ii. Termination / Reinstatement w/in 30 days No NCQA updates at this time

8 CR5 ONGOING MONITORING & INTERVENTIONS Element A Ongoing Monitoring & Interventions Collecting and reviewing the following: i. Medicare/Medicaid sanctions ii. Sanctions or limitations on licensure iii. Complaints iv. Information identified from adverse events NCQA update Eliminated CR5: Practitioner Office Site Quality and now replaced with the above.

9 CR6 NOTIFICATION TO AUTHORITIES & PRACTITIONER APPEAL RIGHTS Element A Actions Against Practitioners i. Do P&P s address Range of actions, reporting authorities & appeals process? ii. How do you make the appeals process know to your practitioners? NCQA update Due to elimination of CR5 Office Site Quality, the above was formerly CR7 and has now been moved to CR6

10 CR7 ASSESSMENT OF ORGANIZATIONAL PROVIDERS HDO S Element A Review & Approval of Provider i. Good standing with state/federal regulatory bodies ii. Reviewed and approved by an accrediting body iii. Onsite quality assessment performed Element B Medical Providers to be included i. Hospitals, Home Health, SNF, Free-standing Surgical Centers Element C Behavioral Healthcare Providers Mental or Substance Abuse i. Inpatient, Residential, Ambulatory Element D Assessing Medical Providers Element E Assessing Behavioral Health Providers NCQA Updates Clarified the organization conducts a site visit if the CMS or state review is older than 3 years. Due to elimination of CR5 Office Site Quality, the above was formerly CR8 and has now been moved to CR7

11 Element A Delegation Agreement Element B Provisions for PHI Element C Predelegation Evaluation Element D Review of Delegate s Credentialing Activities Element E Opportunities for Improvement CR8 DELEGATION OF CREDENTIALING No NCQA Updates. Due to elimination of CR5 Office Site Quality, the above was formerly CR9 and has now been moved to CR8

12 1. When to start preparing for your upcoming survey 2. Tools you will need NCQA SURVEY PROCESS OVERVIEW 3. Working with your Applications & Scheduling Account Rep (ASAR) 4. Working with your Accreditation Survey Coordinator (ASC) 5. What to expect when the Surveyor is on-site

13 ENSURING A SUCCESSFUL SURVEY Buy the standards Know the standards Get familiar with the Online Survey Tool Use the online support & FAQ s when you need to Rely on your ASC for assistance during preparation Security, security, security it s a MUST!

14 TOP 5 COMMON MISTAKES Not reading & understanding the NCQA Standards Not having P&P s in place Not having an efficient Credentialing Committee in place Not monitoring providers in between credentialing cycles Not overseeing delegated credentialing Agreements (CVO s)

15 STAYING AHEAD OF YOUR NEXT SURVEY Don t wait until the last minute Update policies annually Document Quality Activities Make sure management knows the Standards

16 FAQ S Standards Survey Process

17 There are two kinds of people, those who do the work and those who take the credit. Try to be in the first group; there is less competition there. - Indira Gandhi