Challenges with Health Plan Re-accreditation

As NCQA Health Plan re-accreditation quickly approaches for many health plans this year, in addition to ensuring certain areas are accreditation ready, the quality and clinical teams at your health plan have the confounding variability of meeting the new Population Health Standards. As re-accreditation approaches, we’ve listed below some areas for awareness and readiness.


In 2017, NCQA introduced the new Population Health Standards, and as with the introduction of any new standards, understanding the requirements by the time your organization’s re-accreditation is a challenge.

Population Health Strategy Organizations must provide a new population health management strategy which outlines how they plan to meet the care needs of its member population and address the needs across the continuum of care.

An organization should submit its program descriptions for each accreditation program it is pursuing. However, store the program descriptions for both Health Plan (HP) and Population Health Plan (PHP) accreditation in the same document, provided it’s clear which portions of the program description applies to relevant elements for HP and PHP accreditation.

NCQA does not specify product lines (e.g., Medicare, Medicaid, Commercial) in the PHP program. For Health Plan Accreditation, it depends on whether the organization is bringing forward more than one product line and if it manages these the same way or differently. If the organization is bringing forward more than one product line, it can submit a single program description for all product lines if it manages them the same; identify the product lines  in the program description. If the organization is bringing forward more than one product line and it manages each differently, then it must submit a program description for each product line’s relevant elements (e.g., reports, assessments, or authorizations).

A statement in the program description should link to a relevant product line. The program descriptions for all product lines can also be housed in the same document provided it is clear which portions of the document apply to a specific product line.

  • Has your organization outlined its goals and targeted populations for these four areas?
    1. Keeping members healthy
    2. Managing members with emerging risks
    3. Patient safety or outcomes across settings
    4. Managing multiple chronic illnesses
  • Are the goals measurable and are they being measured by your organization? Does the measure include a targeted population, and does it address programs and services offered by your organization? If these aren’t currently measured, you may want to choose one that is being measured to ensure there are no challenges when attempting to evaluate the effectiveness of interventions to improve the goals.

Member Data Assessment To support its population health management programs, organizations must collect, integrate and assess member data. NCQA is looking for actionable categories for appropriate interventions. There is a ‘laundry list’ of data elements required by NCQA, which includes medical, behavioral, and pharmacy claims and encounters; electronic health records (EHRs), and advanced data sources, such as regional health information exchanges (HIE) and other community collaboratives.

NCQA has clarified that health appraisal results include data from any health evaluation distributed to individuals that provide insight into their health behaviors and needs. Integration from one practice or provider’s EHRs is sufficient to meet the requirement. EHRs include data that the organization can access regarding the individuals’ medical history, chronic conditions, age, height and weight, allergies and relevant medications. Organizations may link to EHRs or may integrate data through readable outputs, such as Clinical Document Architecture (CDA) compliant data files. NCQA has also stated that if the health plan does not have access to this data, the organization only needs to show integration of six types of data to score 100%.

Working with ProvidersHow is your organization working with providers to achieve their population health management goals? Can you describe and demonstrate your organization’s value-based payment (VBP) arrangement(s) and report the percentages of total payments tied to value-based arrangements? Many health plans are contracting with integrated delivery networks (IDNs) for Shared Risk Arrangements. This may include development of patient-centered medical homes (PCMHs), focusing on patients developing ongoing relationships with a primary care physician in order to produce patient-centered care, and increase coordination between the primary care physician and specialist.

Population Health Strategy Effectiveness Are you able to evaluate whether your organization achieved its goals and determined the areas still needing improvement? Ensure you are measuring the goal and there have not been any changes to your measurement from when your goals were initially developed (i.e., ensure you are measuring ‘apples to apples’ and not ‘apples to oranges).’ Also, are you able to demonstrate oversight of delegated parties?


In more than one organization, HighPoint clinical consultants have seen the responsibility for areas or issues under the scope of NCQA accreditation ‘walk out the door,’ along with dedicated staff. Unfortunately, it’s not unusual to miss these issues until it’s time to prepare for re-accreditation. When the efforts to focus on re-accreditation begin, it may be identified several months later that an NCQA required process or requirement is not in place, as this was previously a function under the scope of someone who is no longer with the organization.

Care Management (Utilization Management/Care Management) Inter-rater Reliability –  Does your organization have a process to consistently (i.e., annually) test whether your care management clinicians — such as your pharmacists, physicians, and nurses— are applying the clinical criteria and your health plan’s internal medical policies appropriately?

Desk-top Level Processes  Your organization’s policies and procedures are impressive and “tied with a bow ready for show” for any accreditor or regulator. However, are your staff desk-top level processes/workflows aligned with your policies and procedures? If so, do you perform case quality audits of your clinical and non-clinical staff’s work to ensure the team is complying with the desk-top level processes/workflows (and thereby complying with your policies and procedures) as written?

Updated Licenses Are the licenses for all of your clinical staff up-to-date and do you have processes in place to ensure these are regularly monitored? In some states, clinically licensed managers are held accountable by state licensure boards to ensure licensed staff working under their purview maintain their current licensure.

Orientation/Training –  Do you have evidence that each staff member received orientation and has on-going training? Is this training tracked in a database and is it searchable? Often this is handled at the corporate level through a learning management system (LMS). For example, most organizations track HIPAA compliance training in an LMS. However, HighPoint clinical consultants have observed when it comes time to track department level training, such as training on care management medical necessity clinical criteria, there is no system available to track this information.


In the best of worlds, the clinical team is in a “constant state of readiness” for NCQA re-accreditation, although with other business priorities, this is often difficult. Paying attention to these items can save time, resources, and reduce the stress when it comes to preparing for re-accreditation.

HighPoint’s Accreditation Specialists will conduct an onsite assessment and analyze your current population health models and programs. They will identify potential process and data gaps, which may pose a challenge in complying with the new NCQA PHM Standards. After identifying any gaps, our Accreditation Specialists can assist your team with providing a road map to assist with the transition to the new PHP standards. They will assist with providing clinical business and technical support to accommodate the PHP accreditation requirements. Highpoint’s Accreditation Specialists can also assist with re-designing your current program, and, if necessary, developing new, cost-effective managed care solutions designed for your members’ unique needs, while also meeting the NCQA PHM Standards.

To learn more about the Highpoint Population Health practice and what we can do to help organization with NCQA Accreditation needs , please reach out to Chris McShanag, vice president, population health.