A Closer Look at Accrediting Organizations; the Strengths of NCQA, URAC

Co-authored by: Suzanne Kunze, Norita Wilson, and Lori Harris

Health plans will look to two prominent and nationally recognized organizations, NCQA or URAC, when they are seeking accreditation. Accreditation provides an impartial opinion on a health plan’s quality. URAC or NCQA accredit a health plan when it has been determined its practices meet national standards.

As you evaluate one accrediting body over the other, here’s some background on URAC and NCQA, and the strengths each brings to the accreditation process.  

An accredited health plan has received the accreditation organization’s “seal of approval,” showing it meets national quality standards.

1. What is NCQA Accreditation?

NCQA is an independent 501(c)(3) non-profit organization that works to improve health care quality through the administration of evidence-based standards, measures, programs, and accreditation. NCQA, which was formed in 1990, has helped to build consensus around important health care quality issues by working with large employers, policymakers, doctors, patients and health plans to decide what’s important, how to measure it, and how to promote improvement.

NCQA accreditation supports quality improvements and value, and helps organizations meet regulatory requirements. As part of its evaluation and assessment, NCQA looks at clinical performance (i.e., Healthcare Effectiveness Data and Information) and the consumer experience (i.e., Consumer Assessment of Healthcare Providers and Systems measurements).

NCQA accreditation confirms the organization’s commitment to quality care management. It also supports the organization in providing consistent care management practices to its members.

One component of the accreditation process is the NCQA Utilization Management Certification program, now referred to as the NCQA Utilization Management (UM) Accreditation program. NCQA released the new UM Accreditation program in July 2017, and it takes effect on July 1, 2018. Organizations planning to perform a survey on or after July 1, 2018, must apply under the new UM Accreditation program. 

NCQA accreditation ensures:

  • Fair and timely utilization evaluations using objective, evidence-based criteria
  • Collection and use of relevant clinical information to make UM decisions
  • Qualified health professionals assess requests and make UM decisions 
  • Alignment with state requirements 

NCQA accreditation demonstrates the quality of the health plan’s UM programs to employers, regulatory agencies, health plans and managed behavioral health organizations. 

The new UM Accreditation survey includes an evaluation conducted by physicians and managed care experts. An independent review oversight committee of physicians then analyzes the team’s findings and assigns an accreditation status based on the organization’s performance against the UM, Care Management, and other NCQA standards. 

Another new process as of July 1, is the addition of Population Health Management (PHM) to NCQAs 2018 Health Plan Accreditation standards and guidelines. The new PHM category combines data analytics with wellness and adding complex case management standards. In addition, the new PHM standards eliminate disease management and some practice guidelines.

2. What is URAC Accreditation?

URAC, which was formed in the 1980s, is an independent, nonprofit organization, is well known as a leader in promoting health care quality through its accreditation, education, and measurement programs.

URAC’s health plan accreditation ensures organizations meet standards and measurements of quality and operational integrity, with a focus on consumer protection and empowerment. Organizations achieving URAC accreditation demonstrate their commitment to quality and continuous improvement.

URAC case management (CM) accreditation

URAC’s Case Management (CM) accreditation standards require organizations to establish policies, procedures and structures needed for solid CM performance.

  • URAC’s CM standards and performance measurements focus on care coordination, including improving consumer engagement, achieving positive health outcomes, and managing transitions of care.
  • By achieving URAC accreditation, CM programs demonstrate leadership through a commitment to quality and accountability.
  • Transitions of care – Organizations that achieve CM accreditation can also obtain the URAC Transitions of Care (TOC) designation. TOC recognizes organizations making safe continuity of care the focus for quality improvements that reduce errors, preventable readmissions, and poor health outcomes.

URAC’s Disease Management Accreditation program aligns with national efforts to control chronic diseases and co-morbidities by improving and maintaining an individual’s health status. The accreditation standards support development of a comprehensive program for consumers for care engagement, improved health outcomes, and satisfaction.

With URAC’s Health Utilization Management (UM) standards, organizations get consistency and maintain the highest confidentiality in UM processes.

The URAC-accredited Health UM program:

  • Provides an independent, unbiased determination of medical necessity beginning with an initial clinical review, then moving to a peer clinical review, if needed.
  • Uses evidence-based treatment guidelines for quality and effectiveness of patient care while eliminating excessive treatment and expense.
  • Adheres to timeframes outlined in the standards for urgent and non-urgent review determinations.
  • Understands and adheres to applicable state and federal regulations.
  • Employs drug UM mechanisms that address therapeutic appropriateness, over and underutilization, dosage, duration of treatment, duplication, and drug allergies.
  • Is prepared to address any risk to patient safety, such as contraindicated treatments, adverse drug interactions, or inappropriate treatment during the review process.

URAC’s UM accreditation standards are recognized by state and federal entities, are applicable to stand-alone UM organizations and to the UM functions within health benefits programs.

In our next blog, you will learn about the work HighPoint performs to assist health plans in preparing for NCQA or URAC accreditation.

Co-authors: Suzanne, Norita, and Lori are associate directors with HighPoint’s Population Health Management practice.