Length: 2 Hours

Network Management standards have more requirements and points for quantitative and qualitative (Q&Q) analysis than any other standard set. Although the finer points of analysis are not covered in this session, the requirements of each of the standards is covered, including: 

1. Cultural Needs and Preferences (the most challenging requirement)
2. Availability assessment of the primary, specialty, and behavioral network
3. Accessibility assessment of the primary, specialty and behavioral network
4. Assessment of network adequacy, using information from the three areas above, out of network usage and member experience with the network (second most challenging requirement)
5. Continued access to care
6. Physician and hospital directory and evaluation of accuracy and usability

Length: 2 Hours

Utilization Management is the largest of all of the standards by pages and has the most rule-based requirements for denials and appeals.  These also contain almost all the must-pass requirements that can cause corrective action plans (CAPs) when the surveyors appropriately apply the rules. 

1. Content of the UM program
2. Inter-rater reliability of the UM department decisions
3. Communication Services
4. UM 4 – 7 denial decision overview/rules and language
5. Appeal denials overviews/rules and language (denials and appeal language covered together)
6. Pharmacy management
7. System controls
8. Recommendations for auditing and ongoing readiness for surveys

 Pharmacy management is occasionally separated due to different staff involvement and specificity of the requirements (1 hr)

Length: 2 Hours

Member experience includes standards that were formerly in quality improvement (QI) standards (member satisfaction), member rights and responsibilities (RR) standards, and member connections (MEM) standards (direct availability of information on internet and customer services). 

1. Distribution and content of member R&R statements
2. Distribution of subscriber information
3. Content for pharmacy benefits and UM requirements for members and prospective members
4. Evaluation of the quality and accuracy of content provided via the internet and by member services, including email responses
5. Evaluation of medical and behavioral complaints and appeals

Length: 2 Hours

PHM is the newest (2018) of standards that had not been previously required and measured. The population assessment (PHM 2B) previously lived under case management, which was under the QI standards. Many new requirements were added, which are covered in this presentation. This is a very challenging set of standards for every organization, and complex case management (CCM) assessment and care planning (file review) has four of the 18 points (Renewals, non-Medicaid, non-delegation), which is 22% of the standard set. Adding the two points for PHM 1A (strategy), these three elements have 33% of the 15 elements in this standard set. Having said that, case management is covered in a separate module due to the complexity and requirements of PHM 5. This presentation covers: 

1. PHM strategy and comprehensiveness needed
2. Using data to identify, assess and segment/stratify the population
3. Delivery system supports
4. Wellness and prevention tools
5. Evaluation of the effectiveness of the PHM program

Length: 2 Hours

The QI standards have greatly decreased in number over the last few years. However, they contain the standards that have the greatest challenges of all the standards – continuity and coordination of care. This presentation covers: 

1. Contents of the QI program, workplan, and evaluation, committee and practitioner involvement, and the 2022 additions of diversity promotion and training
2. Continuity and coordination of medical care over the span of three years and measuring effectiveness
3. Continuity and coordination between medical and behavioral health care over the span of three years and measuring effectiveness

Length: 2 Hours

Analysis is the single most difficult areas found in QI, NET, and ME and reflect the greatest amount of points per Element, which is also covered in the presentation. Qualitative and Quantitative (called Q&Q analysis by many) is explored in this presentation with what is required by NCQA and pitfalls that occur.  The different requirements by different standards is covered, using the MHR analysis grid that MHR updates annually.  MHR also developed a hands-on exercise for NET requirements, as that set has the most analysis requirements of all sets. Attendees are provided the exercise at least one week prior to the presentation to complete in order to attain the highest value of the presentation. Correct answers are covered, along with audience participation in challenging how the answers were made by the surveyor consultant.

Length: 2 Hours

Delegation is covered separately in the MHR suite of presentations, as delegation is an ongoing challenge in every organization as decisions are made regarding delegation, frequently by leadership with minimal to no input by the accreditation staff. This training is typically provided to a broader audience which frequently includes contracting and vendor management so that they understand the consequences of not integrating new delegation arrangements appropriately. This is partially a working session with the organization to target their specific challenges for different delegates and how to strategize, remove barriers, and prevent losing points, as delegation in each standard set is worth four points since NCQA quit reallocating 10% of the standard set points to delegation in 2020. For most of the standard sets, this increased the delegation points – and risk.

Length: 2 Hours

As stated under PHM, CCM file review has a large proportion of the PHM standards total. Therefore because of this, but primarily because this opt-out program is a service to the most vulnerable of the population, the CCM requirements need to be understood by CM staff. The presentation covers each of the evaluation areas, identification of members and timelines, identification of barriers, development of conclusions, PCS responses to most-asked questions, and problematic areas. MHR certified case management team members developed an exercise for staff to complete prior to the presentation, that would engender questions and fine points on whether the case manager’s documentation meets NCQA requirements, based on surveyor training and performance of case management and CM-LTSS surveys.

Length: 1.5 Hours

Every year the MHR President scans through all of the standards changes, including additions to the standards and clarification of the Scope, Data Sources, and Explanations. The presenter identifies specific implications of the major changes and relevant PCS questions and FAQs that have occurred since the last publication of standards.

Length: 3 Hours

Health plans can add LTSS Distinction to sit on top of their health plan accreditation. Some do this optionally, while others are mandated by state regulation to accomplish this. These standards are typically performed by staff who are new to the standards and do not understand the implications of them. Therefore, not only does the presenter go into the requirements of each standard, but also discusses basics of accreditation, such as data sources, look-back periods, scope of review, Explanations and scoring methodology.  This distinction has crossover with the standalone CM-LTSS standards, but has fewer requirements than the standalone.

Length: 3 Hours

Health Equity has gained great attention through the 2020/2021 COVID pandemic. Because of this, NCQA added health equity requirements to QI and PHM existing standards, which are covered under those presentations. Some organizations attain this distinction/accreditation optionally, while others are mandated by state regulation to accomplish this. As of this writing, six states mandate MHC/HE for either Medicaid or the Exchange product lines. This presentation is developed by the President, who not only conducts MHC surveys (and HE in the future), but also spoke nationally to health plans and provider groups for Pfizer Quality Forums on this subject and recently talked on Health Disparities for the National Association of Healthcare Quality (NAHQ). The presentation walks through the standards, identifying data needs, evaluation of the membership and comparison to the existing network, along with stratifying the membership by HEDIS metrics and identifying the opportunities by race and ethnicity and addressing the opportunities. Similarities to the health plan accreditation requirements is identified to prevent duplication of effort. Either the President or a consultant presents this subject, who not only surveys this product, but took through the very first organization to attain distinction in 2011 worked for NCQA as an Assistant Director, and is now consulting on this product.

Length: 2.5 Hours

This presentation is a type of “boot camp” for those new to the NCQA accreditation process. It walks the listener through the basics of accreditation, including:

When standards are published and when the standards year begins

1. Differences between Interim, First, and Renewal Surveys
2. Contents of the standards (Front Matter, Policies and procedures, Standard sets, Appendices)
3. Standard composition (heading, intent statement, summary of changes, scoring, elements and factors, Data Sources, Scope of Review, Explanation, Exceptions, Examples)
4. Where to find information on specific topics (walks through the Appendices)
5. What is Policy Clarification Support (PCS) and who should be asking questions of them
6. The Report Card site
7. Survey process
8. Use of the consultant and information flow