2015 Complete Overview of the NCQA Standards Session Code: … · 2015-09-23 · – Fellowship...

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

1

Introduction to NCQA Credentialing Standards

NAMSS Educational Conference & ExhibitionOctober 6, 2015

Anatomy of a Standard

All materials © 2015, National Committee for Quality Assurance


Standard statementStatement about acceptable performance or results

Intent statementSentence describing importance of standard

Summary of changesChanges from year to year

3

2


ScoringLevel of performance necessary to receive specified percentage of points

Data sourceDocumentation organizations use to demonstrate performance

Scope of reviewLists the survey types and the type of documentation NCQA reviews for each type.

Look-back periodPeriod for which the organization must demonstrate performance, measured back from submission date

4


ExplanationSpecific requirements

that the organization must meet, and guidance

for demonstrating performance against the

element (by factor if appropriate)

Related informationAdditional information

that may assist the customer, but not

required.

5

ExamplesDemonstrations of how

requirements can be met.


ExplanationSpecific requirements

that the organization must meet, and guidance

for demonstrating performance against the

element

Related informationAdditional information

that may assist the customer, but not

required.

6

3

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


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


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

4


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

1. Types of practitioners to credential

2. Verification sources

3. Criteria

4. Decision-making

5. File management

6. Delegation

7. Non-discrimination

Written policies/procedures address:

CR 1A: Practitioner Credentialing Policies

12

5

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

Written policies/procedures address:

CR 1A: Practitioner Credentialing Policies

13

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

Factor 1: Types of Practitioners

14

Licensed independent practitioners (physicians and non-physicians) 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

6

Credentialing not required for practitioners meeting ANY of the following criteria:• Practice exclusively in inpatient setting or free-

standing 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

• 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

Factor 2: Verification Sources

17

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

Factor 2: Verification Sources

18

7

• 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

Factor 3: Criteria

19

•Clean files: Medical Director or the Credentialing Committee

•Files that do not meet criteria: Credentialing Committee only

Factor 4: Decision Making

20

How are the files managed and who manages themHow are they kept secureHow are they kept confidential

Factor 5: Managing Files

21

8

Appropriate DocumentationActual copies of credentialing informationA 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 applicableAutomated credentialing system


22

Appropriate VerificationOral or verbal verification received by the organizationWritten 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

Applies to all practitioners applying for the first time, and only onceRequired 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

Provisional Credentialing

24

9

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

Factor 6: Delegation

25

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 discriminationProcess for monitoring discrimination

Factor 7: Non-discrimination

26

Factor 8: Notification of discrepanciesMust 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 decisionMust have a policy or process for notifying the practitioner within 60 calendar days of the final credentialing decision

Factor 8 & 9: Notification

27

10

The organization must include in its policy who is directly responsible for the credentialing program. It may be:The Medical DirectorDesignated physician

Factor 10: Medical Director

28

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

Factor 11: Confidentiality

29

Policies and procedures must describe the followingThe process the organization uses to ensure information in its directory is consistent with credentialing information

– Education, training, board certification and specialty

Factor 12: Practitioner Directories

30

11

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

CR 1B: Practitioner Rights

31

Includes representation from the organization’s participating practitioners

Uses a peer review processMeeting minutes reflect thoughtful consideration of credentials

NCQA calculates credentialing time frames based only on Credentialing Committee decision date

CR 2A: Credentialing Committee

32

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

12


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 e-mail 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

Oral or Internet Information Source

−Dated and signed/initialed

−Source used

−Date of source

− FindingsAll hand written documentation and signatures for clean files must be written in ink

CR 3: Documenting Verification

36

13

Information

Current Valid License

Verification Source(s)

State Licensing

Agency

CR 3A: Factor 1: License Verification (Initial and Recred)

37

Accepted IF state licensing agency controls the Web-site

• Example: State agency maintains its own

Web-site that includes the necessary

information

Web-Site Verification of License

38

IF the state does not maintain or control the Web-site 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

14

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

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

Information

DEA or CDS Certificate

For all states where the practitioner is providing care for the organization


• Copy of certificate

• Visual inspection of certificate

•DEA or CDS Agency

confirmation• NTIS database entry

• AMA Master file

• State pharmaceutical licensing agency

Factor 2: DEA/CDS Verification (Initial and Recred)

42

15

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

Factor 3: Verification of Education & Training (Initial Only)

43

Non-physicians - The organization must verify onlythe 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

Verification of Education & Training

44

Information

Education and Training:Physicians (MD/DO)

_________________

Board Certification

Verification of certification


• 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

16

Acceptable ABMS SourcesABMSABMS Licensed Agent*check ABMS web-site for list of agents


46

Information

Education and Training:

Physicians(MD/DO) not board certified

__________________

Completion of Residency


• Confirmation from residency program

• AOA Profile Report or Physician Masterfile

• AMA Masterfile• Confirmation from

state licensing agency (w/proof of

primary verification)


47

Information

Education and Training:

Physicians(MD/DO) no residency

training__________________

Medical School Graduation


• 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

17

Information

Education and

Training:Oral Surgeons

__________________

Completion of

Residency


• Confirmation from

residency program• Confirmation from

state licensing

agency (w/proof of primary verification)

• Dental board if

proof of performing PSV


49

Information

Education and Training:Non-physician practitioners

_________________

Professional School Graduation


• 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

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

Factor 4: Verification of Board

Certification (Initial and Recred)

51

FS2

FS2 Remove thisFrank Stelling, 6/5/2015

18

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

Primary Source Verification

52

Information

Work History


•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)

Factor 5: Work History (Initial Only)

53

Information

Malpractice Claims History


•NPDB query or initial report

from an NCQA recognized disclosure service, on new

practitioner

•5 years claims history from malpractice carrier

Factor 6: Claims Verification (Initial and Recred)

54

19

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

CR 3B: Sanction Information(Initial and Recredential)

55

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

Sanction Information

56

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

Verification of Licensure Sanctions

57

20

Practitioner Type

Physician

Chiropractor


- NPDB- FSMB- State licensing agency

- NPDB - State Board of Chiropractic

Examiners- Federation of ChiropracticLicensing board (CIN-BAD)


58

Practitioner Type

Oral Surgeon

Podiatrist


- NPDB- State Board of Dental Examiners

- NPDB

- State Board of Podiatric Examiners- Federation of Podiatric Medical Boards


59

Practitioner Type

Non-physician Practitioner


- NPDB- State Licensing Board

or Certification Agency


60

21

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

Required Elements:

− Attestations

− Signature and date

CR 3C: Application/Attestation(Initial and Recred)

63

22

Reasons for inability to perform essential job functions, with/without accommodation

Lack of present illegal drug useHistory of loss of license and felony convictionsHistory of loss or limitation of privileges or disciplinary actions

Current malpractice coverageAffirmative statement re: correct/ complete application

Attestations

64

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

Attestations

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

23

365 days between verification and decision180 days for Medicare plans

Application and

Attestation Timeframes

67

Occurs at least every 36 months

The recredentialing decision date must be within 36months of the previous credentialing date

Recredentialing timeliness is a separate standard

CR 4A: Recredentialing Cycle Length

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

24

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 complaints71


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

25


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 ongoingmonitoring 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 12-18 months after last

credentialing cycle

75

26

Ongoing Monitoring

Sanctions

– Subscription to an alert service of NCQA-recognized 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 informationImplementation of actions based on organization’s policies and procedures, if applicable

78

27

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 practitionersAligns with HCQIA of 1986 which provides peer review protection

CR 7A: Notification to Authorities and

Practitioner Appeal Rights

79

Procedures for reporting serious quality issues to appropriate authorities

– State agencies

– NPDBMust provide evidence of following appeal process if it altered the conditions of practitioners’ participation

Applies to physicians and non-physician practitioners

Notification to Authorities and

Practitioner Appeal Rights

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

28

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

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

CR 8A: Organization Providers

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

29

Medical (8B)HospitalsHome health agenciesSkilled 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

CR 8B-C: Provider Types

85

Example: Skilled nursing facilityAccreditation 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

Site Visit Standards

86

Questions

87

2015 Complete Overview of the NCQA Standards Session Code: … · 2015-09-23 · – Fellowship...

Documents

Transcript of 2015 Complete Overview of the NCQA Standards Session Code: … · 2015-09-23 · – Fellowship...