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IBM Global Services

AHM 250
Day - 3
IBM Global Services

Topic 11
Network Structure & Management

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IBM Global Services

Topic 11 : Network Structure & Management

 IBM Global Services

Course Content

 Day 3
Topic 11 : Network Structure & Management
• Market Analysis
• Structure, Composition & Size of Network
• Network Composition
• Adding Providers to Network
• Orientation
• Peer Review
• Provider Services

Topic 11

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Designing a Provider Network

 Primary function of health plan is to arrange for the delivery of

High – Quality, Cost – Effective Health care services to plan members
 Health Plan members Interact with Organization Primarily through
its providers, steps the health plan takes to design, assemble,
monitor and maintain its network are critical to its success.

 Market Analysis
 Market Maturity
-- The level of Health Plan activity in a market is often an indicator of
how knowledgeable providers and consumers are about health plan
 Provider Community
-- Health plan needs an accurate estimate of the number and location
of physicians, hospital beds, pharmacies and other health services
available in the service area. …Cont

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-- Health plan also needs information about accessibility of providers,

such as distance between a providers location and plan members
home or workplaces.
-- Most PCP’s have established relationships with particular Healthcare
Professionals in the community and refer patients to unfamiliar
practitioners.

 Competitive Analysis
-- Assessment is based on Provider panel sizes, Premium levels, Cost-
Containment strategies used by competing health plans.
-- Physician-to-member ratios in existing networks of competing health
plans
-- Levels of provider satisfaction or dissatisfaction with Other health
plans

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 Economic Conditions
-- The level of growth or decline in the economy and the size
of employers in the market can also influence network design.
-- Larger employers tend to adopt health plans more quickly
than do small companies and more likely to offer a choice of
health plans.
 Characteristics of service area
-- Provider network is influenced by whether service area is
primarily rural, suburban or Urban.
-- Urban areas offer more flexibility in provider contracting
and a large number of primary care and specialty physicians.

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 Population Characteristics
-- Mix of providers and facilities included in the network is often
influenced by the ages, income levels of the members included in the
health plans service area.
Eg : health plans that serve Medicare and Medicaid recipients often
need to include a variety of non-physician medical professionals ( ie
like social workers , occupational and speech therapists etc)
 Health Plan Characteristics
-- Health plan characteristics include number and types of products
offered, its geographic Scope, market focus and particular population it
serves.
 Current and Proposed Regulatory Requirements
-- Patient access to medical services, quality of care, mandated
benefits and providers rights to contract.

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Determining the Structure, Composition & Size

of the Network
 Network Structure
 Closed Panel : Providers are either employed directly by the
health plan or belong to a group of providers that hold contract
with the health plan.
-- Providers see only health plan members.
 Open Panel : any physician who meets the health plans
standards of care may be eligible to contract with the health
plan.
-- Providers see both plan members and nonmembers.
…Cont

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 Network Composition
 Primary care providers : PCP’s include general practitioners,
family practitioners, internists, Pediatrician’s, Some health plans
classify OB/ Gyn as PCP’s, while others view them as
specialists.
 Specialists : Whose practice is limited to a certain branch of
medicine, specific procedures, certain age categories of the
patients.
 Hospitalists : PCP who maintains busy office practice may lack
Sufficient time to effectively coordinate I/P care for his patients.
As a result some health plans have begun to include
hospitalists in their networks to manage I/P care for plan
members.
 Health care Facilities : Health plans also contract with a variety
of health care facilities, including hospitals, sub acute care
facilities, SNF, ambulatory surgery facilities.

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 Network Size
 Plan Characteristics : More closely the plan manages, fewer the
providers are needed in the network, Thus an HMO typically requires
fewer providers than does a PPO or POS.
 Provider Access : Staffing requirements in closed panel are often
determined by staffing ratios.
-- Staffing ratios relate the number of providers in the network to the
number of enrollees in the health plan.
 Purchaser and consumer preferences : Perceptions of quality, access
to services, and cost are the three primary factors that influence
customers.
 Plan Goals : When developing provider networks, health plans must
balance quality and access goals with goals for cost savings.
-- Narrower panels with stricter requirements on members access to
care achieve greater cost savings, but may affect member satisfaction.

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 Adding Providers to the Network

 Recruiting Providers : To determine which providers should be
recruited for inclusion in its provider network, health plan
gathers additional information from sources as
-- Hospitals already included in the health plans network
-- Provider directories from competing health plans
-- Local state or national medical societies
-- Purchasers, plan members, plan personnel or other providers
 Selecting Providers : Selection of Individual providers is based
on an evaluation of the provider’s ability to meet the needs of
the plan and its members.
 Credentialing : Information on the application form is reviewed
and verified in order to determine the current clinical
competence of the provider.

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 Why is Credentialing Important ?

Employers want to know that the health plans they offer to their
employees offer high quality providers.
 Who Performs Credentialing ?
Some organizations use a credentialing committee.
In some cases, external entities called credentials verification
Organizations (CVOs) are hired to perform the credentialing
functions.
 Credentialing Standards for Organizational Providers.
As health plans manage members access to organizational
providers, such as hospitals, nursing homes and home
healthcare agencies, it is important for health plan to evaluate
the quality of these organizations before adding them to
provider networks.

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 Contracting
Contracts relating to providers responsibilities.
 Provider Services : Generally describes the services that the
provider agrees to furnish.
 Administrative Policies : Generally requires providers to agree
to follow the health plan’s administrative policies and
procedures.
 Credentialing and Recredentialing : Generally requires
providers to cooperate with the health plans credentialing and
recredentialing efforts.
 Maintenance and submission of Medical Records : Generally
requires providers to maintain complete and accurate medical
records and to allow the health plan access to them when
needed.

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 No Balance Billing and Hold Harmless Provisions : Generally

includes a no balance billing provision which requires providers
to accept the amount the plan pays for medical services as
payment in full and not to bill plan members for additional
amounts ( except copay, ded & coins).
 Provisions commonly found in provider contracts relating to the
health plan’s responsibilities.
 Payment : Specifies how the health plan will compensate the
provider.
 Risk-Sharing and incentive Programs : it describes any
incentive or risk-sharing plans, such as withhold arrangements.
 Timely Payment : it describes the time period within which the
health plan will provide payment to the provider for services
rendered.

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 Eligibility Information : it affirms the health plans responsibilities

to provide information on member eligibility and benefit levels.
 One type of provision that applies to both the health plans and
the provider is the termination provision.
 Termination without cause : either the health plan or provider
may terminate the contract without providing a reason or
offering an appeal process.
-- Terminating party is often required to give notice of at least
90 days.
 Termination with cause : Occurs when one party does not live
up to its contractual obligations.
-- Provider fails to provide required services.
-- Health plan fails to compensate Provider
-- Usually 60 – 90 days.

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 Due Process Clause : Which gives providers that are terminated

with cause the right to appeal the termination.
 Network Maintenance and Provider Services
 Orientation : As health plan brings new providers into its
network, it is important that the health plan give the providers an
Orientation or introduction to its system.
 Peer Review : Evaluation of a providers performance, usually by
other providers who practice in the same medical specialty and
within the same geographic area.
 Provider Services : Provider services area is also responsible
for designing and implementing the health plan’s strategies for
ensuring provider satisfaction with the health plan.

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Key Terms

Market Analysis
Structure, Composition & Size of Network
Orientation
Peer review
Adding Providers to Network

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IBM Global Services

Topic 12
Basics of Utilization Management

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IBM Global Services

Topic 12 : Basics of Utilization

Management
 IBM Global Services

Course Content

 Day 3
Topic 12 : Basics of Utilization Management
• Utilization Management Function
• Self - Care Programs
• Utilization Review
• Case Management
• Disease Management
• Clinical Practice Guidelines

Topic 12

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Overview

 In order to operate effectively an health plan must be

able to manage both cost and quality of health care
services.

 Medical Management activities can be divided into 3

categories
 Utilization management
 Clinical practice management
 Quality management

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Utilization Management Function

 Affects all components of plan’s delivery system.

 Primary care, specialty care, hospital care, pharmaceutical
services, emergency care, ancillary services
 Option to conduct their own UM or contract with external
organization that specialize in UM to perform some or all
of plan’s utilization management.

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Utilization Management Techniques

 Preventive care
 Studies have shown that 70% of healthcare treatment costs
result from preventable disease and injuries. 12% of
hospitalizations are avoidable.
 Preventive care programs help members stay healthy.
• Reduce healthcare cost by reducing need for diagnostic and
therapeutic services and need for inpatient hospital care.
• Type of programs depends on member populations and
members healthcare needs.
• MCOs identify member needs based on assessment of
member’s health risk.

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Preventive Care

 Health risk assessment

 Health risk appraisal process by which MCO uses information
about a plan members health status, personal and family health
history and health related behaviors to predict member’s
likelihood of experiencing specific illnesses or injuries
 Information source: Providers, surveys, health plan records
 By identifying members at risk, specific programs are developed
to reduce risk, improve health outcomes, reduce need for
complex long term care.
 Preventive care initiatives
 Immunizations
 Health promotion programs – Wellness programs
 Screening programs

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Self Care Programs

 Minor problems on regular basis – may be treated by
member themselves without any assistance from medical
professional.
 Not intended to supercede or eliminate physician
services, but to complement those services
 Educate members
 How to distinguish between minor illnesses and injuries and
serious conditions
 How to effectively treat minor problems with readily available
methods (diet, application of heat etc)
 Information provided in variety of sources
 Member newsletter – tips on how to lower cholesterol
 Detailed self care guides for specific medical conditions –
Diabetes, Arthritis – ongoing management

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Decision Support Program

 Frequently, members are aware that medical care is required but unable
to determine which services are most appropriate for their situation.
 Result : unnecessary, inadequate services
 Telephone triage program
 medical help line or nurse line
 Provides information to members and care-coordination service
 Shared decision making program
 Exchange of information about procedures and treatment options is a
routine part of provider-patient interaction – patient becomes active
participant in his/her program of care
 A step further on this philosophy – provide in depth information about
disease, treatment alternatives, procedures, expected outcomes –
encourage them to participate in decision making.
 Printed material, personal/group counseling, audio/video tapes, websites,
support groups, interactive computer programs
 Results show that improved patient decision making and reduce utilization
of healthcare services.

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Utilization Review

 Refers to evaluation of medical necessity,

appropriateness and cost effectiveness of healthcare
services an treatment plan for a given patient.
 Review can be done before, during or after treatment is
completed.
 Performed by healthcare professional – physicians or nurses
 Contract with outside organizations – Util. Review Org. (URO)

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Case Management

 Process of identifying plan members with special

healthcare needs, developing a healthcare strategy that
meets those needs, coordinating and monitoring care.
 Case management is designed to :
 Improve or stabilize members overall health by preventing
complications and deterioration of medical conditions
 Optimize the use of healthcare resources
 Improve member compliance with provider recommendations
for care
 Improve coordination and continuity of cares
 Ultimate goal is to achieve optimum healthcare outcome
in an efficient and cost effective manner.

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Case Management

 Used for high risk – high-cost, chronic cases

 Case management process

 Case identification
 Assessment
 Planning
 Implementation / monitoring
 Evaluation

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Disease Management

 Disease state management is a coordinated system of

preventive, diagnostic and therapeutic measures intended
to provide cost-effective quality healthcare for patient
population who have or are at risk for a specific chronic
illness or medical condition.

 Driving force for disease management – high level of

spending for chronic, complex cases

 Designed as voluntary outreach and support program

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Case Mgmt. – Disease Mgmt. Differentiated.

Case Management Disease Management

 Goal  Reduce per case cost, improve  Reduce per disease cost, improve
episodic care patient outcome
 Emphasis  Appropriate treatment of illness,  Improve management of chronic
use of alternative settings care, prevention and education for
patients, family, and physicians
 Scope  Patient often has multiple  Patient is initially evaluated for a
disease single disease
 Review  Periodic concurrent review  Prospective and concurrent review
 Guidelines  Generic, externally imposed  Customized to diagnosis, internally
designed
 Caregivers  Generalists, nurses  Specialist, multidisciplinary team

 Data  Primarily inpatient (tracks length  All point of services (tracks annual
Sources of stay, profit margin per episode of care cost, medication
confinement, mortality) compliance, functional status)
 Integration  Isolated medical management  Integrated medical management
 Risk  Lacks ability to bear financial  Increased ability to bear financial
risk risk.

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Clinical Practice Management

 Clinical practice guidelines involves development and

implementation of parameters for the delivery of
healthcare services to plan members.

 Designed to aid providers in making decisions about

appropriate course of treatment for specific conditions.

 Expected to reduce variation in clinical practice from

provider to provider and patient to patient.

 Includes recommendations on processes; how to

implement a treatment approach in order to obtain best
results.
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Key Terms

 Utilization Management Function

 Self – Care Programs
 Decision Support Programs
 Case Management
 Disease Management
 Clinical practice management

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Topic 13
Utilization Review and Authorization Systems

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Topic 13 : Utilization Review and

Authorization Systems
 IBM Global Services

Course Content

 Day 3
Topic 13 : Utilization Review and Authorization Systems
• Reasons for Conducting Utilization Review
• Types of Utilization
• Utilization Review Process
• Managing the Utilization Review Process

Topic 13

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Utilization Review

 During the past decade cost of providing health care service

has risen dramatically.
 UR offers health plans a means of managing these costs by
-- Managing the overall cost-effectiveness of health care
services.
-- Managing the cost of paying healthcare benefits.
 Reasons for conducting Utilization Review :
• Reducing Unnecessary Practice Variation
• Authorizing Payment of Benefits
• Improve the quality and cost effectiveness of Patient care

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 Services That Require Utilization Review for

Authorization

 Access Requirements : Health plan members are allowed to

access primary care providers without formal health plan
authorization.
-- HMOs and Non-HMO plans that use a gatekeeper system do
require members to select a PCP.
 Frequency of Utilization : Certain Services are delivered so
frequently and for such consistent reasons that they are
considered part of providers normal practice.
-- Eg : PCPs routinely perform certain laboratory tests in
conjunction with annual physical examinations and so on.
Note : Only Routine services get waiver of Utilization review
and authorization requirements. …Cont

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-- Provider recommendations for complex or expensive procedures

require review and authorization.
-- Eg : a PCP is free to order X-rays to treat a plan member’s broken
leg, but the PCP would have to obtain plan authorization to order
complex tests such as MRI.
 Cost per Procedure : Low-cost, low-risk procedures can
generally be ordered without prior approval from the health plan.
High-Cost or high-risk procedures and treatments, such as
hospital admissions, transplant surgery generally require UR
and authorization.
 Level of Inappropriate Utilization : Denial of payments is
frequently as indication that services are being used
inappropriately.
As a result the higher the denial rate is for a particular service,
the more likely it is that the service will require UR and auth.

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Types of Utilization Reviews

 Prospective review
 Review and possible authorization of proposed treatment plan
for a patient before the treatment is implemented.
 Accomplished through pre-certification requirement.
 A number of tools are available to assist UR staff in making
precertification decisions.
 Utilization Guidelines : accepted approaches to care for
common uncomplicated healthcare services.
 Site appropriateness listings : Indicate the most appropriate
settings for common procedures.
-- many surgical procedures such as carpal tunnel surgery
which use to perform only in hospitals are now routinely
performed on an O/P basis
…Cont

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 Experienced-based criteria : Generally accepted community

standards of practice and the overall experience and expert
opinion of medical directors and other healthcare providers.
 Length-of-stay guidelines (LOS) : is defined as number of
days, counted from the day of admission to the day of
discharge.
 Concurrent review
 Review occurs while the treatment is in progress; applies to
services that continue over a period of time.
 Evaluate patient’s course of care (e.g. chemotherapy)
 In most Health plans concurrent review for I/P care is
coordinated by a UR nurse, who serves as a liaison between
physicians, hospital staff and the health plan’s medical
management and UR staff.
…cont

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 However UR nurses typically performs following activities.

 Gathering information about member’s progress : UR nurse
collects information regarding patients admission date,
diagnosis etc.
-- Eg : Information gathered during concurrent review may
show that acute I/P care is no longer required, In this case plan
member may be transferred to an intermediate nursing facility or
discharged.
 Tracking total length and cost of care : LOS have a significant
impact on overall utilization of services. It is important, therefore,
to monitor LOS to identify factors that might contribute to
unnecessary hospital days.
 Continuing discharge planning : as members care progress, the
UR nurse is in a position to refine initial LOS estimates and
track outcomes of prescribed treatments & procedures

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 Retrospective review
 Carried out after treatment is completed.
 The decision to authorize payment occurs after the fact
 Although retrospective review does not allow health plans to
direct the course of patient care at the point of delivery, it does
allow plans to identify areas where utilization can be improved.
-- Eg : retrospective analysis of provider practice patterns might
reveal that certain specialists unnecessarily prescribe expensive
prescription drugs, where comparable outcomes can be
achieved using less expensive drugs.
 Retrospective review can often reveal potential errors, falsified
or misleading information such as
….Cont

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 Coding Errors : In which a treatment is miscoded or the codes

used to describe procedures do not match those used to identify
the diagnosis.
 Upcoding : Which involves using a code for a procedure or
diagnosis that is more complex than the actual procedure or
diagnosis and that results in higher reimbursement to the
provider.
 Unbundling : Which involves separating a procedure into parts
and charging for each part rather than using a single code for
entire procedure.

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Alternative Care settings

 Emergency Departments : Emergency services are often essential to
the immediate diagnosis and treatment of critical illness or severe
injuries.
 Appropriate care in an ED can improve clinical outcomes and reduce
over utilization of resources.
 Lack of access to appropriate care in emergency departments can
result in high financial costs.
 To avoid liability of payment for unnecessary emergency services or
repeated visits to ED, health plans often require members or providers
to obtain plan authorization within 24 hrs of treatment.
 Prudent Lay person Standard : According to this standard, a condition
is considered to be emergency if a prudent lay person could
reasonably expect the absence of immediate medical attention.

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 Urgent care centers : Patient with problems that require immediate

attention but are not considered to be life threatening, such as cuts
or sprains etc.
 Observation care Units : It is designed to address the immediate
needs of patients whose conditions require continuous monitoring.
Such as cardiac irregularities who are waiting for test results.
 Subacute care facilities : It is designed to address the continuing
care needs of patients who are too sick to be cared for at home, but
who do not need intensive treatment and supervision provided in a
hospital.
 Step-down Units : It is a ward or selection of a ward in a hospital that
is devoted to delivering subacute care to patients following a period
of acute care.
-- Eg : Heart attack patient who no longer needs the services of a
critical care unit but who still needs more monitoring.

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 Home Health Care : It is designed to provide care for patients who

need intermittent rather than 24 - hr care who are unable to travel to
a provider’s location.
Eg : Although majority of home health care patients are older adults
(Age 65 and older) and disabled persons covered by Medicare
program, Healthcare is also being used by younger patients
recovering from acute episodes such as surgery or birth of a baby.

 Hospice Care : It is a set of specialized healthcare services that

provide support to terminally ill patients.
-- Mostly Benefits are available only to patients who have a life
expectancy of six months or less.

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The Utilization Review Process

 Data Collection : Data collection typically begins during prospective review,
but it can also be initiated during other types of UR.
 Data collection during prospective review typically focuses on satisfying
the plan’s precertification requirements.
 Data collection during concurrent review is used to document patient
progress and monitor the course of care.
 Data collection during retrospective review addresses utilization of
services, patient outcomes and costs.
 Data Transmittal : Once information is collected, it is transmitted to the
health plan, using one of the following 3 methods.
 Manual Transmittal : It Requires a provider to complete an
authorization form and send it to health plan.
-- A major advantage of manual transmittal is its high degree of
physician acceptance.

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 Telephone Transmittal : It requires providers to call a central

number and relay authorization by telephone, often thru IVR.
-- from a provider perspective, well designed telephone
transmittal systems are faster & less labor than manual
transmittal.
 Electronic Transmittal : It allows provider to transmit UR
information over computers linked to health plan’s network or
over the internet.
-- It is generally faster and effective than other methods.
 Managing the Utilization Review Process
 Because authorization can impact all of health plans core
functions, health plans devote considerable time and effort in
managing the utilization of health care services using tools as

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 Single-visit authorization.
 Limited-visit authorization.
 Prohibition of secondary referrals.

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Key Terms

 Reasons for conducting UR

 Types of Utilization
 Alternative Care Settings
 Utilization Process Review
 Managing the Utilization Process Review

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Topic 14
Quality Assessment and Improvement

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Topic 14 : Quality Assessment and

Improvement
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Course Content

 Day 3
Topic 14 : Quality Assessment and Improvement
Importance of Quality
Assessing Quality in a Health Plan
•Quality Measures
•Assessing Service Quality
•Assessing Health Care Quality
Quality Improvement
Strategies and tools for Improving Quality
Topic 14

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 What is Quality ?
Quality is a health plan context refers to an health plan’s success in
providing healthcare and other services in such a way that plan member’s
needs and expectations are met.
 Service Quality
 Health care Quality
 The Importance of Quality.
 Mission of health plan is to provide top-quality healthcare at an
affordable price.
 A factor that helps organization compete successfully with other health
plans for business.
 Importance of Quality for Patient Safety
-- A Medical Error
-- An Adverse Event
 Important Factors that play a part in medical errors
• Faulty or Inadequate communication
• Inconsistent quality Oversight
• Lack of compliance with internal and external incident reporting
requirements
• Lack of verification procedures
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Assessing Quality in a health plan

 It is more complex task for a health plan to define what quality is

and, based on that to determine whether the health plan is delivering
quality. Performance measurement can help a health plan needs to
improve its performance and effectively allocate resources.
 Quality Measures.
 Structure Measures
-- Nature, quantity and quality of the resources that a health plan has
available.
 Process Measures
-- Methods and procedures a health plan has available for member
service and patient care.
 Outcomes Measure
-- Gauge the extent to which services succeed in improving or
maintaining satisfaction and patient health.

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 Assessing Service Quality : Service quality refers to a health plan’s

success in meeting plan members nonclinical needs and
expectations.
-- Provider service quality issues includes
 The Ease with which members can get thru to a clinician’s office by
phone.
 The length of time patients must wait in the office to be seen by
provider.
 Service quality delivered by the health plan’s administrative staff
includes
 Phone wait times when calling health plan
 The accuracy and timeliness of claims payments and providers
reimbursements

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 Assessing Healthcare Quality : Healthcare quality relates to the

types of services providers deliver to plan members and the way
those services are covered.
 Service quality, healthcare quality can be evaluated thru structure,
process and outcome measures.
•Structure Measures
 The number of primary care providers in the plan’s network
 The education, training and experience of plan providers
 Emergency room access
•Process Measures
 The percentage of children receiving immunizations
 The percentage of members who receive advice on smoking cessation
or other risk-reducing programs.

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• Outcomes Measures
 Clinical Status – biological (Eg % of cancer patients survival after
receiving treatment)
 Functional Status – Patients ability to perform daily activities
 Patient Perception – how patient feels after receiving treatment
 Collecting, Analyzing & Reporting Quality Assessment Data
 Financial data – Costs of physical, technological and human resources
needed to provide administrative and healthcare services to members
 Clinical data – Provides in in-depth view of outcomes associated with
particular healthcare process and structures
 Customer satisfaction data – describes how a health plan members,
providers, and purchasers view the way health plan deliver services
 Quality Improvement
 It is based on making changes to existing structures and processes
that will lead to changes in outcomes.
 Haphazard change : it is unplanned and uncontrolled and produces
unpredictable results.
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 Reactive Change – it is controlled, but rarely planned and it can lead

to positive, negative or even unintended results.
 Planned Change – it is deliberate, controlled, collaborative and
proactive

 In Order to be effective, changes to structures and processes must

be carefully
• Planned
• Communicated
• Implemented
• Documented
• Evaluated

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 Tools for improving quality

 Benchmarking
•Identify and replicate best practices in industry
 Provider profiling
•Analyzing information about provider practice patterns
 Peer review
• Appropriateness of healthcare services delivered by a
provider to plan member is evaluated by a panel of medical
professionals.
• Can focus on single episode or entire program of care.

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Key Terms

Importance of Quality
Assessing Quality in a Health Plan
• Quality Measures
• Assessing Service Quality
• Assessing Health Care Quality
Quality Improvement
Strategies and tools for Improving Quality

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Topic 15
Quality Standards, Accreditation and Performance
Measures

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Topic 15 : Quality Standards

Accreditation and
Performance Measures

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Course Content

 Day 3
Topic 15 : Quality
Standards, Accreditation,
and Performance Measures
•Quality Standards
•Accreditation
•Performance Measures

Topic 15

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Quality Standards

 Standards defined by Institute of medicine

 Minimum level of acceptable performance or results
 Excellent levels of performance or results
 Range of acceptable performance or results
 Plan can develop internal or use external standards to
measure quality level of services.

 Accreditation
 Evaluation process in which a healthcare organization
undergoes an examination of its operating procedures to
determine if they met designated criteria as defined by
accrediting body and to ensure that they meet specific level of
quality.

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Accrediting Organizations
 JCAHO – Joint commission on accreditation of healthcare organizations
 Hospitals
 Home healthcare agencies
 Networks
 Managed care organizations
 Accreditation Process : JCAHO’s accreditation process for health plans and
healthcare networks consists of complete on-site surveys conducted every 3
years. During this Evaluators review
 Organizations central office and any non-JCAHO accredited network
services.
 All high-risk services provided by the organization and a sample of low-
risk.
 A sample of practitioner’s offices and records

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Quality Standards & Accreditation Decisions of JCAHO

 Quality Standards.
 Rights, Responsibilities and ethics
 Education and communication
 Health promotion and disease prevention
 Leadership
 Accreditation decisions
 Accreditation without type 1 recommendations
 Accreditation with type 1 recommendations
 Provisional accreditation
 Conditional accreditation
 Preliminary denial of accreditation
 Accreditation denied

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NCQA & Accreditation process

 National Committee for Quality Assurance (NCQA)

 NCQA is a nonprofit group that accredits health plans, managed

behavioral health organizations (MBHOs), credential verification
Organizations, PPOs, disease management organizations and
physician organizations.

 NCQA’s accreditation program consists of 2 parts

 Onsite Survey of administrative and health care services
 Offsite evaluation of audited results.

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Quality Standards & Accreditation Decisions of NCQA

 Quality Standards.
 Program structure
 Program operations
 Physician contract requirements
 Availability of practitioners
 Accreditation decisions
 Access and service
 Qualified Providers
 Staying Healthy
 Getting better
 Living with Illness

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American Accreditation HealthCare Commission

 It Provides the following organizational and accreditation Programs
 Health Plans
 Health networks
 Health call centers
 Case management Organizations
 Credential Verification Organizations
 Health Provider Credentialing
 Health Utilization Management
 Worker’s Compensation Networks
 Utilization Management for worker’s compensation
 External Review

 Accreditation Process – It offers separate accreditation programs for health

plans and health networks, it consists of documentation of plan policies and
procedures and an On-Site visit to verify the accuracy of the documentation
and the plans compliance with accreditation standards

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Quality Standards & Accreditation Decisions of AAHC

 Quality Standards.
 QM structure, organization and staffing
 Nature and scope of the QM program
 Systems for addressing complaints, corrective action and
disciplinary action
 Accreditation decisions
 To receive full accreditation
 Plan must satisfy 100% of applicable “shall” standards
 60% of “should” standards
 AAHC accreditation remains in effect for three years

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Performance measures
 It is a quantitative measure of quality of care provided by a health plan or
provider that consumers, payors, regulators and others can use to compare
the plan or provider with other plans or providers.
 Foundation for accountability ( FACCT)
 It organizes Information about healthcare quality into five areas
 The basics – Delivering the basics of good care, including access, skill,
communication, coordination of care
 Staying Healthy – Helping people to avoid illness and stay healthy with
education, prevention and risk-reduction
 Getting Better – Helping people get better when they become sick with
appropriate treatment and follow-up
 Living with illness – Helping people with ongoing, chronic illness reduce
symptoms, avoid complications and maximize quality of life.
 Changing needs – Caring for people and their families when healthcare
needs functional abilities change dramatically.

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HEDIS (Health Plan Employer Data and Information Set)

 This is administered by NCQA, it’s a performance-measurement tool

designed to help healthcare purchasers and consumers compare quality
offered by different health plans.
 HEDIS divides performance measures into eight domains.
 Effectiveness of care – focuses on whether members receive specific
health services during stated time periods and whether the health plan
meets the need of sick members and helps well members avoid
sickness.
 Accessibility/availability of care – whether member obtain services in a
timely manner without undue burdens or inconvenience.
 Satisfaction with the care experience – Summarizes what current
members think about their health plan and care provided.
 Cost of care – Premiums, ded and coins amounts that an HMO
charges for health benefits.
…Cont

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 Health Plan stability – indicates changes in a health plan’s provider

network, membership size, organizational structure and financial
condition.
 Informed Healthcare choices – focuses on the health plan’s efforts to
educate members and involve them in healthcare decisions.
 Use of Services – documents the rates at which members utilize
various health services.
 Health plan descriptive information – describes the health plan’s
operating characteristics, such as provider networks, utilization
management strategies, physician compensation arrangements and
quality improvement activities.
 ORYX – in response to the demand for outcomes measures, JCAHO
introduced the ORYX initiative which incorporates outcomes and other
performance measures into the accreditation process.

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THANK YOU!
Questions?
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