MHR GRADES NCQA ON PROPOSED 2025 CHANGES

MHR’s President & CEO Susan K. Moore welcomed over 100 attendees, clients, and non-clients, to a complimentary webinar on May 17, 2024, when she reviewed some of NCQA’s proposed changes to the 2025 standards and graded the general areas based on her opinion of the value that it will bring to organizations and its members. Grades were high!

If you attended the webinar and did not receive our detailed slides, please let us know. Here are a few highlights.

QI 3 & 4                                                                     B

Among the proposed changes is merging QI 3 and 4 and placing a heavier reliance on HEDIS measures from Health Plan Ratings. The issue of continuity and coordination is long-standing and difficult to address. Changes will reduce the burden of these standards while maintaining rigor on an important issue. However, the bar is set low: not having to improve quality until July 2026, with perceived “double-dipping” for crediting HEDIS and standards, thus a grade of B.

Information Integrity                                               A-

Kudos to NCQA for refocusing system control standards on inappropriate modifications, providing clear definitions, and moving must-pass requirements to audit and analysis instead of a documented process. Organizations previously accredited with system control requirements in the 2022 or 2023 standards will eventually need to transition to the new, more stringent requirements for information integrity.  

Credentialing for HPA and MBHO                          A

Among multiple changes to the credentialing standards, we call out the following:

• The timeframe for notification of committee decisions is reduced from 60 days to 30 days, and the timeframe for reviewing ongoing reports is reduced from 30 days to 10 days.
• Composition of the credentialing committee should align with the needs and diversity of the membership.
• A field for race, ethnicity, and language must be added to practitioner applications
• Documentation in files and committee minutes is enhanced throughout

Credentialing                                                           A

Credentialing Verification Organizations (CVO) Certification will become Credentialing Certification (CRC) if the proposed standards are adopted. Requirements align between CRC and Credentialing Accreditation (CRA).

• The need for governing body approval is maintained.
• SMART goals and annual analysis are required for Quality Improvement
• Information integrity standards replace system controls
• The timing for primary source verification changes from 120 days to 60 days

Standardization and alignment of scores support a grade of A.

Susan’s Key Takeaways

MHR is on high alert for the final adopted changes and will be ready to guide you through as needed. What you can do now:

• Prioritize your delegation agreements and system integrity changes
• Determine changes needed in your quality improvement plan based on QI 3 metrics
• Begin drafting changes to credentialing policies and minutes
• Begin moving up timeframes for credentialing
• Determine if IT system changes will be needed for practitioner data on applications

GET TO KNOW MORE ABOUT

DENA Y REEVES, BSN, RN

MHR’s clinical consultants come to MHR on unique paths, from working in clinically related roles in organizations to managing NCQA surveys, where they gain detailed knowledge of NCQA standards. While working as a leader within the managed care arena and diving deep into the NCQA standards, Dena developed a strong interest in consulting, which eventually led her down the path to consulting with MHR.

Dena joined MHR in 2022, bringing her clinical expertise in high-risk maternity, case management (CM), and utilization management (UM) and various experiences leading NCQA activities.  Dena consults on NCQA Accreditation for Case Management, Utilization Management, and Health Plans. Working with the MHR team, she enjoys the camaraderie and the ability to share and learn from each other.  We laugh together, celebrate successes, and support each other when challenges arise.

Dena’s commitment to her clients is rooted in trust and nonjudgmental feedback. She is always there to listen and respond to their needs. What truly drives her is the satisfaction of guiding her clients through their NCQA journey, witnessing increased employee engagement in their organizations, and ultimately, enhancing the quality of care and services they provide to their members.  

To help ensure the success of her clients, Dena focuses on three things. She ensures optimal time in her schedule to give attention to clients and meet their needs. She leans on her own years of direct experience in managed care and consulting and experiences shared by her MHR colleagues to help inform her feedback and recommendations for client success. If clients’ unique situations need policy clarification, Dena reaches out to NCQA’s Policy department for answers.

Dena's transition from managed care to consulting was not the only change she embraced. Born and raised in New York City, she now resides in rural Pennsylvania, helping to manage a homestead farm with her family and honing her gardening skills at the same time! Being adaptable and flexible allows Dena the ability to balance her professional commitments to her MHR clients with her roles as a wife, mother of two adult children, and proud grandmother of three.

Read more about Dena and MHR’s other consultants, where we profess that Experience Matters when it comes to your NCQA Survey preparation!