Consultant

The proposed changes to Core 9, which deals with the staff assessment program, could not be more insignificant.  There are no substantive changes, and the only scoring change elevates, ever so slightly, the significance of the "review of relevant documentation produced by that individual staff member" over the annual performance appraisal, which, in the current version, are of equal weight. 

I'm guessing few people will be submitting searing comments on this proposed change.

The new standard would read:

The organization maintains a formal assessment program for individual staff members that includes: (---)
(a) An annual performance appraisal; and (Wt = 2)
(b) A review of relevant documentation produced by that individual staff member. (Wt = 3)

Version 2.1 of Core amends subsection (a) of Core 16, a primary element of this 4-weighted standard. The original language was:

Prior to delegating functions to another entity, the organization: (N/A)

(a) Conducts a review of the potential contractor’s policies and procedures and capacity to perform delegated functions; (Primary)

The new, v. 2.1 language now reads:

Prior to delegating functions to another entity, the organization: (N/A)
(a) Establishes and implements a process to conduct a review of the potential contractor’s policies and procedures and capacity to perform delegated functions; (Primary)

This seems to echo what I said in an earlier blog, that even if you are doing something correctly, URAC prefers that you also have a policy and procedure that instructs you to do it correctly. In this case, this means that not only must you conduct a review of the potential conctractor's P&Ps and ability to perform the tasks you delegate to them, you must have that review be part of a process that you've implemented. This assures URAC that it is not a one-time thing, but that, instead, you'll be conducting these reviews on all future contractors.

As a practical matter, this means that your documentation must not only include evidence that you've conducted such reviews on your contractors, but also have a policy and procedure that clearly outlines that required process.

The change in Core 11 from v. 2.0 to v. 2.1 could not be more technical -- changing the first word from "The" to "A".  It now reads:

A senior clinical staff person: (N/A)

   (a) Provides guidance for all clinical aspects of program; (Primary)

   (b) Is responsible for clinical aspects of program; and (Primary)

   (c) Has periodic consultation with practitioners in the field. (Primary)

The only possible significance that I can imagine of this change is that it takes the heat off the senior-most clinical staff member for doing the things required by the standard -- i.e., he/she can have a less senior clinician handle these tasks.  This is suggested in Core 10 (both the old and new versions), so one might argue that this change is unneeded.  I'll not be the one arguing that, though.

Documentation to support this standard is straightforward:  job description, verification of licensure, and CV are the minimum, while a program description describing the senior clinician's roles  and documentation of activities conducted in the field by this clinician are helpful, too.

The changes from v. 2.0 to v. 2.1 in Core 7 (Staff Training Program) are two:

Subsection (c), a secondary element, which originally read, "The organization has a training program that includes training in URAC standards as appropriate to job functions" added the word "current" before "URAC Standards." Therefore, one can surmise that it will not be sufficient that your staff members have been trained in URAC standards at some point, but that they have been trained recently enough for that training to reflect any recent changes in standards. Since URAC almost never makes changes more frequently than every couple of years, and usually less frequently than that, you should be safe if you have your staff go through URAC training once per year.

The other change is the addition of a new primary element, now labeled (g) (and pushing the 2.0 (g) and (h) back to (h) and (i): "The organization has a training program that includes training on identification and prevention of fraud and abuse, as appropriate to job functions." Most of our clients' regulatory compliance training (already required by Core 7(d)) includes training on fraud and abuse, but this standard makes it explicit. Note, however, that this is a primary element of a mandatory standard. In other words, if you don't specifically show that your staff has been trained on this topic, you cannot achieve full accreditation.

There are three version 2.1 changes to the standard, which is a particularly with important one because it is a mandatory standard. This standard governs the organization's policies and procedures.

1. The first change, to subsection (a), narrows the required scope of the applicant's policies and procedures. In version 2.0, the organization was required to maintain and comply with written policies and procedures that govern all aspects of its operations. The new version requires only that the submitted policies and procedures govern "core business processes of its operations related to the scope of the accreditation." In other words, if you are a multidimensional organization that is seeking accreditation for only one of those dimensions, the policies and procedures that you submit to URAC need only cover the accreditation program under which you are applying.
2. The second change, to subsection (d), liberalizes the requirement regarding where the organization indicates effective dates, review dates, and the date of the most recent revision, as well as the identification of approval authority. The original version required that this information be on the policies themselves. Version 2.1 requires that this information be either on the policies or on the master list of policies and procedures that is required to be maintained under subsection (b). By making this change, URAC has harmonized the language of the standard with the interpretation that URAC's reviewers have been applying for some time.
3. Version 2.1 adds requirement that the policies and procedures must be available to members of the applicant's staff.

URAC recently revised standards in most of its modules. The vast bulk of the standard revisions are minor, even technical. However, a whole world of accreditation is technical, so they're all worth talking about. This is the first of a long series of short blogs dedicated to updating you on those changes.

The first of the changes is to Core 2, regarding organizational documents. The old, ver. 2.0 standard required a number of items in the organization's document, including "(c) a description of the services delivered by the organization and how those services are delivered." Version 2.1 no longer requires this description. We find this rather interesting, as a few of our clients have been dinged on this subsection in their desktop reviews, for reasons not always clear to us.

This is one subsection I will not miss.

So what are the mandatory standards?

URAC has always had mandatory standards. However, only with version 1.0 of the Core standards developed in the early part of this decade did the current notion of “mandatory standard” emerge. Mandatory standards typically, but do not always, have to do with consumer protection. A mandatory standard is any standard that has a weight of “5”.

In order to be fully accredited, an applicant must score at least 2 out of a possible 4 points on every mandatory standard. You can only get a score of two if you pass all of the “primary” elements of a standard. Therefore, what really is mandatory is that an applicant pass all of the primary elements of all of the mandatory standards.

The mandatory standards for the Health Call Center module are:

HCC - 2 - Clinical Director Consultation
HCC - 3 - Limitations in Use of Non-Clinical Staff
HCC - 5 - Clinical Triage Staff Qualifications
HCC - 6 - Clinical Decisions Support Tool Requirements
HCC - 7 - Clinical Decisions Support Tool Documentation
HCC - 13 - Clinical Staff Response Requirements
HCC - 14 - Handling of Triage Calls
HCC - 21 - Feedback to Physician

Naturally, an applicant for HUM also will have to meet all the mandatory standards for Core, v. 2.1, posted here.

So what are the mandatory standards?

URAC has always had mandatory standards. However, only with version 1.0 of the Core standards developed in the early part of this decade did the current notion of “mandatory standard” emerge. Mandatory standards typically, but do not always, have to do with consumer protection. A mandatory standard is any standard that has a weight of “5”.

In order to be fully accredited, an applicant must score at least 2 out of a possible 4 points on every mandatory standard. You can only get a score of two if you pass all of the “primary” elements of a standard. Therefore, what really is mandatory is that an applicant pass all of the primary elements of all of the mandatory standards.

The mandatory standards for the Health Plan (v. 5.1) module are:

Network Management
P-NM 3-Provider Selection Criteria
P-NM 4-Out of Network and Emergency Services
P-NM 6-Provider Relations Program
P-NM 7-Participating Provider Written Agreements
P-NM 8-Participating Provider Written Agreement Exclusions
P-NM 18 – Participating Provider Suspension Mechanism for Consumer Safety
Credentialing
P-CR 1 – Practitioner and Facility Credentialing
P-CR 10 – Consumer Safety Credentialing Investigation
P-CR 14 –Participating Providers Credentials Monitoring

Naturally, an applicant for Health Plan accreditation also will have to meet the mandatory standards for both the Core module, found here, and the Health Utilization Module, found here. 

So what are the mandatory standards?

URAC has always had mandatory standards. However, only with version 1.0 of the Core standards developed in the early part of this decade did the current notion of “mandatory standard” emerge. Mandatory standards typically, but do not always, have to do with consumer protection. A mandatory standard is any standard that has a weight of “5”.

In order to be fully accredited, an applicant must score at least 2 out of a possible 4 points on every mandatory standard. You can only get a score of two if you pass all of the “primary” elements of a standard. Therefore, what really is mandatory is that an applicant pass all of the primary elements of all of the mandatory standards.

The mandatory standards for the Health Utilization Management (v. 5.1) module are:

HUM - 9 - Pre-Review Screening Non-Certifications
HUM - 10 - Initial Clinical Reviewer Qualifications
HUM - 12 - Initial Clinical Reviewer Non-Certifications
HUM - 13 - Peer Clinical Review Cases
HUM - 14 - Peer Clinical Reviewer Qualifications
HUM - 22 - Written Notice of Non-Certification Decisions and Rationale
HUM - 30 - Non-Certification Appeals Process
HUM - 31 - Appeals Process
HUM - 32 - Appeal Peer Reviewer Qualifications
HUM - 33 - Expedited Appeals Process Timeframe

Naturally, an applicant for HUM also will have to meet all the mandatory standards for Core, v. 2.1, posted here. 

So what are the mandatory standards?

URAC has always had mandatory standards. However, only with version 1.0 of the Core standards developed in the early part of this decade did the current notion of “mandatory standard” emerge. Mandatory standards typically, but do not always, have to do with consumer protection. A mandatory standard is any standard that has a weight of “5”.

In order to be fully accredited, an applicant must score at least 2 out of a possible 4 points on every mandatory standard. You can only get a score of two if you pass all of the “primary” elements of a standard. Therefore, what really is mandatory is that an applicant pass all of the primary elements of all of the mandatory standards.

The mandatory standards for the Core (v. 2.0) module are:

CORE - 3 - Policy and Procedure Maintenance, Review, and Approval
CORE - 6 - Credentialing
CORE - 10 - Senior Clinical Staff Requirements
CORE - 13 - Information Management
CORE - 17 - Delegation Contracts
CORE - 19 - Regulatory Compliance
CORE - 23 - Consumer Safety Mechanism
CORE - 24 - Confidentiality of Individually-Identifiable Health Information
CORE - 26 - Access to and Monitoring of Services
CORE - 27 - Complaint and Appeal System
CORE - 28 - Appeal Process
CORE - 30 - Quality Management Program