URAC Promoting Quality

URAC Promoting Quality November 13, 2012 Christine G. Leyden, RN, MSN, Chief Accreditation Officer and SVP/GM, Client Services, URAC

Presenters Christine Leyden, MSN, RN SVP & Chief Accreditation Officer, URAC

Fast Facts About URAC Nonprofit, independent organization founded in 1990; originally chartered to accredit utilization review services URAC offers almost 30 distinct accreditation programs across the entire continuum of care 22 of the top 25 U.S. health plans hold URAC Accreditation URAC currently accredits over 600 organizations operating in all 50 states and internationally Government references to URAC Accreditation appear in statues, regulations, agency publications, Requests for Proposals and contract language URAC is now recognized by 46 states, District of Columbia, and 6 federal agencies (OPM, Department of Defense, VA, CMS, Department of Labor)

URAC and North Carolina LME s MeckLINK Behavioral Healthcare URAC is proud to provide accreditation services for the following LME s located in North Carolina: CenterPoint Human Services East Carolina Behavioral Health Smoky Mountain Center Western Highlands Healthcare Sandhills Center Alliance Behavior Healthcare Partners Behavioral Health Management Eastpointe Coastal Care

URAC Standards Development Process Committee of Health Care Stakeholders Drafts Standards Public Input: Open Comment Period / Public Forums Draft Standards Revised Organization Beta Testing Draft Standards Revised Again Final Standards Approved by URAC s Board

Government Recognition of URAC Accreditation Recognized by 6 Federal Agencies, 46 States & the D.C. Recognition Vehicles: Statute Regulation Agency Publication Request for Proposals Contract Language Recognition Avenues: Alternative avenue for proving compliance with government requirements (e.g., quality, credentialing, network access) Registration, licensure or contract requirement Reduced filing fees for accredited companies

The Trends Accreditation and measurement by independent organizations such as URAC is more important than ever to assure the highest value, quality and protection for consumers: The Affordable Care Act (ACA) mandates the "gold seal" of accreditation of qualified health plan issuers in order to participate on Health Insurance Exchanges. Heightened emphasis on the value of patientcentered health care homes, employing clinical guidelines to benchmark performance and quality improvement. The ACA promotes medical homes as critical care coordination hubs under its Medicare Shared Savings/ Accountable Care Organizations program - including a set of quality reporting measures - and in Qualified Health Plan provider networks under its Health Insurance Exchange program.

Quality Practices for Health Care Management URAC Copyright 2012 Enhance continuity of care Engender support for evidence-based decision making Encourage transparency of cost & performance/ quality data Enhance operational management effectiveness Engage consumers in their health care management

Enhanced Patient Safety, Quality Improvement Central to Standards How URAC Accreditation Promotes the Institute of Medicine (IOM) Six Aims of Quality Healthcare URAC Copyright 2012 Quality aims How URAC Accreditation promotes IOM quality aims 1. Safe Medication reconciliation, medication dispensing, triage performance, consumer safety quality improvement projects, utilization review and credentialing processes, provider suspension, evidence based practice guidelines, case and disease management triggers, privacy 2. Effective Provider feedback, peer review, quality management programs 3. Patientcentered 4. Timely Individualized focus, informed decision-making, patient satisfaction, consumer education, health literacy Definitions of time frames/case loads, access to care, enhanced coordination of care 5. Efficient Organizational structure, policies and procedures, total quality management 6. Equitable Appeals and grievances, review criteria, cultural sensitivity *Crossing the Quality Chasm, National Academy of Sciences, 2003. On January 1, 2006, URAC formally adopted IOM s definition of patient safety. Organizations seeking accreditation are now required to include a specific patient safety/consumer quality improvement program. 1. URAC s consumer safety standards. www.urac.org/resources/consumersafety.aspx. Accessed October 6, 2008.

Quality Domains URAC Quality Domains Patient-centeredness Coordination of care Efficiency Effectiveness of care Patient safety Health care administration System/HIT integration Health care disparities National Quality Priorities Patient & family engagement Care coordination Making quality care more accessible & affordable Promote use of best practices & healthy living Prevention Making care safer

URAC s Accreditation Programs Health Care Management, Operations and Patient Centered Health Care Home URAC Copyright 2012

URAC Copyright 2012 2012 Major Differences Between Health Plan and Health Network Accreditations Health Plan v7.0 Health Plan & Health Network Include network management and credentialing modules Health Network Does not include member relations, network operations, and marketing Health UM - optional separate module for HN. HN does not require direct access to covered persons Include member relations, network operations, marketing, and other modules Health UM (HUM) - required module 3-year accreditation

Health Plan Version 6.0 to 7.0 Health Plan, v6.0 URAC Quality Standards Health Plan, v7.0 URAC Quality Standards Performance Measures Health Plan Innovation & Accreditation Domains Network Adequacy & Access Care Coordination & Mental Health Parity Pharmacy & Therapeutics Management Wellness & Health Promotion Health Plan with Case Management (Optional) Patient-Centered Health Care Home (PCHCH) Health Plan with Disease Management (Optional) Rewarding Quality & Quality Management Health Plan with Patient Centered Health Care Home Network (Optional) Enrollee Satisfaction & Patient Experience

Network Management N-NM 1 - Scope of Services N-NM 2 - Provider Network Access and Availability N-NM 3 - Provider Selection Criteria N-NM 4 - N/A N-NM 5 - Participating Provider Representation N-NM 6 - Participating Provider Relations Program N-NM 7 - Participating Provider Written Agreements N-NM 8 - Participating Provider Written Agreement Exclusions N-NM 9 - Written Agreement Inclusions N-NM 10 - Written Agreement Subcontracting N-NM 11 - Other Participating Provider Agreement Documentation N-NM 12 - Provider Network Disclosures N-NM 13 - Participating Provider Violation Mechanism N-NM 14 - General Requirements for Provider Dispute Resolution Mechanisms N-NM 15 - Disputes Concerning Professional Competence or Conduct N-NM 16 - Disputes Involving Administrative Matters N-NM 17 - Participating Provider Suspension Mechanism for Consumer Safety URAC Copyright 2012 URAC Standards-At-A-Glance Health Network, Version 7.0 14

URAC Standards-At-A-Glance Recognizes NC Credentialing Application Credentialing N-CR 1 - Practitioner and Facility Credentialing N-CR 2 - Credentialing Program Oversight N-CR 3 - Credentialing Committee N-CR 4 - Credentialing Program Plan N-CR 5 - Credentialing Application N-CR 6 - Credentialing Confidentiality N-CR 7 - Review of Credentialing Information N-CR 8 - Credentialing Communication Mechanisms N-CR 9 - Primary Source Verification N-CR 10 - Consumer Safety Credentialing Investigation N-CR 11 - Credentialing Application Review N-CR 12 - Credentialing Time Frame N-CR 13 - Credentialing Determination Notification N-CR 14 - Participating Provider Credentials Monitoring N-CR 15 - Recredentialing N-CR 16 - Recredentialing and Participating Provider Quality Monitoring N-CR 17 - Credentialing Delegation N-CR 18 - Credentialing Phase-In URAC Copyright 2012 15

Health Utilization Management [HUM] Accreditation HUM is URAC s flagship program, developed in 1990, URAC s founding year. URAC s HUM Accreditation has also been used in developing many of URAC s other programs, including Health Plan and Health Network Accreditations. URAC s HUM Accreditation is recognized by nearly 30 states and is used as a foundation for HUM regulations nationwide.

URAC Standards-At-A-Glance Health Utilization Management, Version 7.0 Review Criteria HUM 1 - Review Criteria Requirements Accessibility of Review Services HUM 2 - Access to Review Staff HUM 3 - Review Service Communication and Time Frames HUM 4 - Review Service Disclosures On-Site Review Services HUM 5 - On-Site Review Requirements HUM 6 - N/A Initial Screening HUM 7 - Limitations in Use of Non-Clinical Staff HUM 8 - Pre-Review Screening Staff Oversight HUM 9 - Pre-Review Screening Non-Certifications Initial Clinical Review HUM 10 - Initial Clinical Reviewer Qualifications HUM 11 - Initial Clinical Reviewer Resources HUM 12 - Initial Clinical Reviewer Non-Certifications Peer Clinical Review HUM 13 - Peer Clinical Review Cases HUM 14 - Peer Clinical Reviewer Qualifications Peer-to-Peer Conversation HUM 15 - Peer-to-Peer Conversation Availability HUM 16 - Peer-to-Peer Conversation Alternate Time Frames for Initial UM Decision HUM 17 - Prospective Review Time Frames HUM 18 - Retrospective Review Time Frames HUM 19 - Concurrent Review Time Frames

URAC Standards-At-A-Glance Health Utilization Management, Version 7.0 Notice of Certification Decisions HUM 20 - Certification Decision Notice and Tracking HUM 21 - Continued Certification Decision Requirements Notice of Non-Certification Decisions HUM 22 - Written Notice of Non-Certification Decisions and Rationale HUM 23 - Clinical Rationale for Non-Certification Requirements UM Policy HUM 24 - Prospective Review Patient Safety HUM 25 - Reversal of Certification Determinations HUM 26 - Frequency of Continued Reviews Information upon which UM is Conducted HUM 27 - Scope of Review Information HUM 28 - Prospective and Concurrent Review Determinations HUM 29 - Retrospective Review Determinations HUM 30 - Lack of Information Policy and Procedures UM Appeals HUM 31 - Non-Certification Appeals Process HUM 32 - Appeals Process HUM 33 - Appeal Peer Reviewer Qualifications HUM 34 - Reviewer Attestation Regarding Credentials and Knowledge HUM 35 - Expedited Appeals Process Time Frame HUM 36 - Standard Appeal Process Time Frame HUM 37 - Written Notice of Upheld Non- Certifications HUM 38 - Appeal Record Documentation

URAC Standards-At-A-Glance Health Call Center, Version 5.0 Fast Facts about URAC s Health Call Center Accreditation One of URAC s first programs, created in 1997. URAC is currently the only accreditor for Health Call Center. Measures are to be added to Health Call Center in 2012. Who Currently Holds URAC s Health Call Center Accreditation? VA Health Care Network NurseWise, Inc. Kaiser Permanente Alere Health OptumHealth Care Solutions Health Call Cen ters /helth/ /kôl/ /ˈsentərs/ (noun, pl.) 1. Organizations that provide clinical triage and health information services to enrollees in health plans and patients in a variety of health care settings.

URAC Standards-At-A-Glance Health Call Center, Version 5.0 Confidentiality HCC 1 - Provider Specific Confidentiality Staff Qualifications HCC 2 - Clinical Director Consultation HCC 3 - Limitations in Use of Non-Clinical Staff HCC 4 - Training and Policies of Use of Non-Clinical Staff HCC 5 - Clinical Triage Staff Qualifications Clinical Decision Support Tools HCC 6 - Clinical Decisions Support Tool Requirements HCC 7 - Clinical Decisions Support Tool Documentation HCC 8 - Clinical Decisions Support Tool Update Requirements

URAC Standards-At-A-Glance Health Call Center, Version 5.0 Communication Handling HCC 9 - Clinical Triage Staff Disclosures HCC 10 - Telephone Performance Monitoring HCC 11 - Telephone Performance Thresholds HCC 12 - Non-Telephonic Communications HCC 13 - Clinical Staff Response Requirements HCC 14 - Handling of Triage Calls HCC 15 - Health Education Communications HCC 16 - Triage Dispositions Information Upon Which Clinical Activity is Conducted HCC 17 - Information Sharing HCC 18 - Information Collection Limitations Communication Documentation HCC 19 - Non-Automated Communication Documentation HCC 20 - Follow-Up Communication Documentation HCC 21 - Feedback to Physician HCC 22 - Health Education

URAC s PCHCH Comprehensive Program Overview URAC PCHCH Program Toolkit Designed to educate and guide health care practices and/or sponsoring health plans, insurers, and pilot programs on how to transform a practice into a truly patient centered health care home PCHCH Educational Resources/Support Survey and Performance Measures Information Resources Webinars Conferences and discussion groups URAC PCHCH Auditor Certification Available to health care organizations who conduct audit and verification of practice s capabilities to meet PCHCH standards. URAC PCHCH Practice Achievement Provided to practices who meet assessment requirements URAC-branded achievement or third-party achievement Onsite review

10 Principles Foundation of PCHCH Program URAC PCHCH Principles Principle 1: Patient Centered Care Team Culture Principle 2: Appropriate Access to Care Principle 3: Individualized Care Planning Principle 4: Effective and Timely Care Coordination and Follow-up Principle 5: Eliminating Health Care Disparities Principle 6: Promoting Care Quality and Continuous Quality Improvement Principle 7: Stewarding the Cost-effective Use of Health Care Resources Principle 8: Excellence In Customer Service Principle 9: Commitment To Transparency Principle 10: PCHCH Infrastructure and Operations

Focus On Closing

URAC s Accreditation Process Summary of the Steps URAC Application Agreement Executed Application Submitted Desktop Review (DTR) Request for Additional Information The Sharing of Best Practices! Interactive Education Onsite Review Accreditation Committee Review Three Year Accreditation Cycle Begins Measurement Reporting

Value of Accreditation Value to Consumers and Employers Assures that consumers will receive due process (e.g., patient appeals process). Guarantees that confidential information will be appropriately and securely handled. Provides employers a measure of comparison to select health care vendors. Provides access to performance data. Reduces burden of oversight of health care vendors operations. Value to Policymakers Standards keep pace with health care advancements more readily than if undertaken by legislation/regulation. Affords a cost effective supplement to state oversight of MCO compliance with state regulations. Ensures that consumer protections are incorporated into managed care operations. Provides transparency and accountability through nationally recognized and publicly available standards. Value to Health Insurers Allows multi-state MCOs to meet different states requirements through a single accreditation process. Differentiates among health insurers, giving accredited companies a marketing advantage. Encourages operational efficiencies that improve results and reduce costs. Provides evidence that the insurer is keeping current with quality benchmarks and best practices. Value to Health Care Providers Promotes appropriate clinical oversight of clinical processes. Assures same specialty peer-to-peer decision-making for physicians engaged in dispute resolution. Incorporates provider protections and ensures a timely credentialing process. Gives providers a voice throughout the health care system.

URAC Education and Consumers Education Educating Consumers New initiative that focuses on educating consumers of health care HealthCare Communication Toolkit - Set of 8 tip sheets Topic Area 1 - Understanding the basics of health care quality and the importance of evidence-based information Topic Area 2 - Tips for getting good quality care before, during, and after a health care appointment care Topic Area 3 - Help in using the internet to find health information you can trust Understanding Your Health Insurance elearning course Go to www.urac.org to access these resources

URAC s Upcoming Accreditation Workshops

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Contact URAC Christine Leyden cleyden@urac.org 202-962-8815 URAC 1220 L Street NW, Suite 400 Washington, D.C. 20005 Phone: 202-216-9010 Fax: 202-216-9006 www.urac.org