Consulting

As is the case with the other three delegation standards (Core 15-17), URAC proposes no substantive changes to Core 18, Delegation Oversight.  The new standard would read:

The organization establishes and implements an oversight mechanism for delegated functions within the scope of accreditation that includes: (--)
(a) A periodic review (no less than annually) of the contractor’s policies and procedures and documentation of quality activities for related delegated functions; (Wt = 3)
(b) A process to verify (no less than annually) the contractor’s compliance with contractual requirements and policies and procedures; and (Wt = 3)
(c) A mechanism to monitor financial incentives to ensure that quality of care or service is not compromised. (Wt = M)

What is significant about the scoring change is that (c) becomes a mandatory standard.  URAC has attached the "M" designation to a host of new elements that deal with consumer protection, and this is an example of that.  The import of this change is that those staff members charged with delegation oversight now will need to pay particular attention to documenting the method by which they assure that those contractors that have financial incentives in their compensation structures do not compromise quality of care. 

As a URAC news release of a few weeks ago indicated, there is a new certification program available for international vendors of credentialing services.  Aparently, URAC has detected a need for some URAC-accredited companies to have certification of its international vendors who take on some of the labor-intensive aspects of the provider credentialing process. 

To gain certification, an international credentialing vendor will go through a mini-accreditation review.  At least at first, it seems that such applicants will not face an onsite review.  Rather, in addition to a special application for this certification program, applicants will need to comply with all of the Core standards as well eight of the standards from the credentialing section of the current Health Plan standards, P-CR 5-10, 12, and 14.  

Integral Healthcare Solutions is in the midst of a conducting research into the phenomenon of international credentialing vendors.  We will release the results of our research within a few weeks.  Our early results are pretty interesting, but we'll not jump to any conclusions until we're a bit farther along in our research.  Let us know at info@integralhs.com if you would like to get a copy of our report.  Or, just subscribe to this blog (yes, it's still free!), as we'll be publishing those results here. 

This standard, while easy to comply with, is not a slam dunk.  It provides:
The organization:

(a) Requires utilization management staff to identify themselves by name, title, and organization name; and

(b) Upon request, verbally informs patients; facility personnel; the attending physician and other ordering providers; and health professionals of specific utilization management requirements and procedures.

It carries a weight of only 3, and neither of its subsections is primary.  So, it is surely true to say that you can miss this all together and still have a great shot at accreditation.  However, since it is our theory as URAC consultants that we should leave no points on the table, is worth just a little extra staff training time to sweep up these readily available points.

The most common mistake that we have found relating to this standard happens when utilization management staff members identify themselves only by name and organization, omitting the job title.  This, obviously, is both easy to detect and easy to fix.

Less common, but perhaps slightly more difficult to address is the requirement of subsection (b).  A good way to diagnose problems with the standard is periodically to pose such requests to the members of your utilization management staff.  The question might sound like this: “imagine that I am a patient, and I want to know what the procedures are to get my procedure approved, and I want you to tell me in writing.  What are you going to send to me?” 

Obviously, this presumes that you have something easy to send to providers and patients that summarizes utilization management procedures and requirements.  If these procedures are embedded in a larger document that you do not want to send, I recommend that you have a ready supply of copies of that section of the document available for your staff members to send out to requesting providers and consumers.

UM 7 provides:

For initial screening, the organization limits use of non-clinical administrative staff to:

(a) Performance of “review of service requests” for completeness of information;

(b) Collection and transfer of non-clinical data;

(c) Acquisition of structured clinical data; and

(d) Activities that do not require evaluation or interpretation of clinical information.

The standard is weighted “4”, and subsections (a) and (d) are primary elements.

Important relevant defined terms include:

• Initial Screening.  Automated or semi-automated screening of requests for authorization that may include: (1) collection of structured clinical data (including diagnosis, diagnosis codes, procedures, procedure codes); (2) asking scripted clinical questions; (3) accepting responses to scripted clinical questions; and (4) taking specific action (certification and assignment of length of stay explicitly linked to each of the possible responses). It excludes: (1) applying clinical judgment or interpretation; (2) accepting unstructured clinical information; (3) deviating from script; (4) engaging in unscripted clinical dialogue; (5) asking clinical follow-up questions; and (6) issuing non-certifications.

• Nonclinical administrative staff.  Staff who do not meet the definition of health professional (including intake personnel).

• Health professional.  An individual who: (1) has undergone formal training in a health care field; (2) holds a license in a health care field issued by a state and the license allows the professional to practice within the scope of the license without the supervision of another licensed professional; (3) has professional experience in providing direct patient care; and (4) holds a post-secondary degree in health care. A postsecondary degree is defined as any college, university, or nursing school diploma obtained after graduating from high school (nursing diploma or associates, bachelors, masters, or doctorate degree). 

• License.  A license or permit (or equivalent) to practice medicine or a health profession that is (1) issued by a state regulatory body or jurisdiction in the United States; and (2) required for the performance of job functions.

• Review of service requests. Review of information submitted to the organization for health care services that do not need medical necessity certification nor result in a non-certification decision.

• Structured clinical data.  Clinical information that is precise and permits exact matching against explicit medical terms, diagnoses or procedure codes, or other explicit choices, without the need for interpretation.

This standard is the first of a trio of standards designed to set clear restrictions on the use of non-clinical personnel in the review process.  As the Program Guide notes, it applies to all review processes, regardless of the degree of automation, that do not involve clinical judgment and that do not result in non-certification determinations.

Documentation for desktop review includes a very clear policy and procedure that explicitly outlines the responsibilities of non-clinical review staff, their reporting relationships, and scope of work.  Job descriptions and organization charts are also useful documents for submission on AccreditNet.    It also is a good idea to submit sample scripts or algorithms for non-clinical review.

The on-site review will focus on interviews, demonstrations of any automated systems, and a review of sample scripts or algorithms.  More importantly, the URAC reviewer will be examining case files or evidence that the policy and procedure regarding non-clinical staff involvement is strictly followed.

Do not be misled by the fact that the standard is weighted “4”.  It is inextricably linked to UM 9, which is weighted “5” and is therefore a mandatory standard.  Problems with compliance with UM 7 likely will trigger noncompliance with UM 9, destroying any chance your organization has of attaining full accreditation.

UM 1 provides:

The organization utilizes explicit clinical review criteria or scripts that are:

(a) Developed with involvement from appropriate providers with current knowledge relevant to the criteria or scripts under review;

(b) Based on current clinical principles and processes;

(c) Evaluated at least annually and updated if necessary by:

(i) the organization itself; and

(ii) appropriate, actively practicing physicians and other providers with current knowledge relevant to the criteria or scripts under review, and;

(d) Approved by the medical director (or equivalent designate) or clinical director (or equivalent designate).

The standard is weighted "4", and all subsections are primary elements.

A standard covers both internally-developed clinical criteria and commercial criteria.  However, the key distinction is in the review and approval process described in subsections (c) and (d).  For internally developed clinical criteria, the process is quite clear: the organization and actively-practicing physicians must review the criteria which, in turn, also must be approved by the medical director or clinical director.

For commercial criteria, the standard is a bit different in application, if not in general requirement.  Most commercial vendors of criteria update those criteria annually.  This annual updating process generally takes care of the requirements of subsection (c).   Of course, the criteria still need to be approved by the medical director.  However, if the organization does not receive annual updates from the commercial vendor, it is still incumbent upon the organization to put the criteria through the annual review required by subsection (c), including a review by actively practicing physicians.

The documentation required to be submitted for desktop review is straightforward: a policy and procedure describing the development and approval of criteria along with sample pre-review scripts or clinical criteria.

The real test, however, will be during the on-site review.  It is during that stage of the accreditation process that the reviewer will be asking to see specific documentation of the review process for the criteria.  The Program Guide outlines the process:

·         Documentation indicating medical director or clinical director development and approval of clinical review criteria or scripts

·         Documentation indicating annual evaluation of clinical review criteria and scripts

·         Clinical case records illustrating initiation of the review process, pre-review screening, and initial clinical review, concurrent review and retrospective review.

What will be important for companies undergoing the reaccreditation process to remember is that the documentation of the clinical criteria review process must show annual review and approval.  It will not suffice for a three-year accredited company to show merely that it looked at the criteria recently.  Rather, documentation only to demonstrate the annual review required by this standard.

UM 26 provides:

The organization, when conducting routine prospective review, concurrent review, or retrospective review:

(a) Accepts information from any reasonably reliable source that will assist in the certification process;

(b) Collects only the information necessary to certify the admission, procedure or treatment, length of stay, or frequency or duration of services

(c) Does not routinely require hospitals, physicians, and other providers to numerically code diagnoses or procedures to be considered for certification, but may request such codes, if available;

(d) Does not routinely request copies of all medical records on all patients reviewed;

(e) Requires only the section(s) of the medical record necessary in that specific case to certify medical necessity or appropriateness of the admission or extension of stay, frequency or duration of service, or length of anticipated inability to return to work; and

(f) Administers a process to share all clinical and demographic information on individual patients among its various clinical and administrative departments that have a need to know, to avoid duplicate requests for information from enrollees or providers.

The standard is weighted “4”, and only subsections (b) and (e) are primary elements.

The standard can best be understood as providing protection for the patient and providers from abusive and/or unnecessary requests for information upon which to base a certification determination.  In a nutshell, it requires that the organization use “all reasonable sources of information to collect only the information required,” and to share that information within the organization “so as to avoid repeated requests for information from enrollees or providers.”

This is one of those policies in which it is best to take the hint in the Program Guide: “UM organizations may take language from the URAC standards and weave it into their policies and procedures, evaluating it to make sure that it reflects their current way of doing business.”

In our experience as URAC consultants, the most common required change in organization’s policies and procedures on the subject is the elimination of a routine requirement numerically coded diagnoses or procedures.    The standard is quite clear in stating that such a routine requirement is simply not allowed.

UM 19 provides:

For concurrent review, the organization adheres to the following time frames:

(a) For reductions or terminations in a previously approved course of treatment, the organization issues the determination early enough to allow the patient to request a review and receive a review decision before the reduction or termination occurs: and

(b) For requests to extend a current course of treatment, the organization issues the determination within:

(i) 24 hours of the request for a utilization management determination, if it is a case involving urgent care and the request for extension was received at least 24 hours before the expiration of the currently certified period or treatments; or

(ii) 72 hours of the request for a utilization management determination, if it is a case involving urgent care and the request for extension was received less than 24 hours before the expiration of the currently certified period or treatments.

The standard has a weight of “4” and all elements are primary. 

A few definitions are in order here:

• Concurrent Review: Utilization management conducted during a patient’s hospital stay or course of treatment (including outpatient procedures and services). Sometimes called “continued stay review.”
• Case Involving Urgent Care: Any request for a utilization management determination with respect to which the application of the time periods for making non-urgent care determinations a) could seriously jeopardize the life or health of the consumer or the ability of the consumer to regain maximum function, or b) in the opinion of a physician with knowledge of the consumer’s medical condition, would subject the consumer to severe pain that cannot be adequately managed without the care or treatment that is the subject of the case.
• Utilization Management:  Evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan; sometimes called “utilization review.”

The required documentation is relatively straightforward: a policy and procedure describing your process, and a sample template of a written notice to the patient.  The on-site review, while straightforward, is substantially more rigorous: the reviewer will go through case files to make sure that you are meeting all of these timelines.

A few other pointers are worth noting.  First of all, this standard applies both to inpatient and outpatient services.

Second, UM 19(a) applies to all terminations or reductions in previously approved services.  So, it applies not only to a decision to send the patient home from the hospital sooner than you originally certified, but also to shorten outpatient treatments such as physical therapy to a lower number of visits or a shorter time period for those visits.

Third, UM 19(b) applies specifically to situations where a patient and/or the ordering provider ask for an extension of inpatient or outpatient services before the end of the originally-approved services.  One tricky question is not explicitly covered by the standard, that is, where the patient or provider, in a case not involving urgent care (e.g., physical therapy) , asks for an extension of services before the last of those services has been provided.  For example, imagine that your organization has approved six physical therapy visits, and before the sixth visit, the patient or provider asks for another four visits.  Nothing in the standard specifically addresses of this situation.  However, in our experience, it is a safe bet that the reviewer will interpret UM 19(b) this way:

1. Urgent and received at least 24 hours before certification expires: within 24 hours of receipt of the request
2. Non-urgent and received at least 24 hours before certification expires: within 72 hours of receipt of the request
3. Urgent or non-urgent and received less than 24 hours before certification expires: within 72 hours of request.

As with all issues regarding utilization management time frames, it is worth spending some time with the interpretive information in the Program Guide.  The tips I provide here, as extensive as they are, only scratch the surface of what you need to know to clear this hurdle.

CM 2 provides:

The organization:
(a) Establishes guidelines for reasonable case manager caseload with supporting rationale based on factors such as severity of cases, complexity of cases, role requirements of case managers, and other relevant factors; and
(b) Applies a process to monitor caseload based on guidelines developed by the organization; and
(c) Consistent with the guidelines established in CM 2 (a), employs/contracts with an adequate number of case management personnel to provide services to the consumers of the program.

The standard is weighted “4”, and all subsections are considered to be primary elements.

On the one hand, the standard does not appear to be particularly onerous, as URAC is quite explicit in not specifying what an appropriate caseload is for a case management organization.  However, this is a bit deceptive, as the standard does have a certain degree of rigor embedded in it.

At the outset, the organization must define “caseload”, and be consistent in its application of that definition throughout its policies and procedures.  In our experience as consultants, many first-time applicants for accreditation do not meet this basic requirement at the outset of their accreditation process.

Second, the organization must develop caseload criteria which must reflect mindfulness about cases severity, complexity, and what role the case managers will play.  URAC reveals its deep respect for and association with the Case Management Society of America (“CMSA”) by referring applicants to that organization’s website (www.cmsa.org) for assistance in developing such criteria.

Third, the organization must have a mechanism for monitoring caseload with reference to these criteria.  Most organizations with which we have dealt as consultants use electronic case management tracking systems for this purpose.  Absent such software, simple spreadsheet analysis will suffice.  However, this tracking should be an ongoing activity of the case management supervisor, as the expectation of this standard is that the organization be prepared to adjust its staffing to accommodate any changes in caseload.

Fourth, the client/consumer complaint log should be sufficiently sophisticated to pick up any trends that might indicate that the caseload is getting too high.  Indicators in this category might include complaints about slow responsiveness from case managers, poor coordination, or even rude treatment by case managers.

The Program Guide suggests that an organization submit the following for purposes of the desktop review:

• Policy and procedure for determining case manager case load/staffing pattern.
• Consumer/client complaint log.
• Number of case managers/number of cases managed over the last year.

However, we recommend to our clients that they also submit any analyses or reports of caseload that they can submit.

The on-site review, the Program Guide tells us, will focus on:

• Interview with case management organization administrator(s) and supervisors.
• Interviews with randomly selected case managers.
• Review of consumer/client complaint log.
• Interview with appropriate quality management personnel.
• Caseload monitoring tool

What is interesting to note about this list of activities is the interview with appropriate quality management personnel.  This speaks to URAC’s commitment to interdepartmental coordination and integration of quality management throughout the program.  It also suggests that case manager caseload might be the subject of a Quality Improvement Project (see Core 35-37).

CM 1 provides:

The case management program’s description and/or written policies and procedures include a definition of case management consistent with these Standards.

The standard is weighted “4”, and the entire standard is a primary element.

The applicant has some flexibility about what documentation to submit for desktop review. The Program Guide suggests that the reviewer will accept either a policy and procedure or some other document that constitutes a program description. In addition, organization charts and descriptions of case management staff members and their positions should be submitted.

However, we have noted that, at least among some URAC reviewers this year, a tendency to construe quite strictly in the last four sentences of this standard, “consistent with these Standards.” While the Program Guide makes it clear that the “definition of case management does not have to be the same as the definition in URAC’s Case Management Standards,” interpretations by reviewers in some recent reviews suggest that your definition better be pretty close to URAC’s:

A collaborative process of assessment, planning, facilitation and advocacy for options and services to meet a consumer’s health needs through communication and available resources to promote quality cost-effective outcomes.

This should not be surprising, given this language, also found in the Program Guide:

It is extremely important that the applicant’s definition of case management is consistent with URAC’s definition of case management. If you do not have a member centric, collaborative approach model you will struggle to meet the intent of the case management standards.

There is another hint within the Program Guide about the particular language URAC finds important:

If the organization also uses a case manager for making benefits determinations the advocacy role is clearly defined.

The emphasis on “advocacy” is in the Program Guide, and should be considered part of the “tea leaves” used to predict have a reviewer at will apply this standard to your organization’s case management program.

Once you get past the desktop review, however, the on-site review should pose few problems, unless, that is, you have a member or members of your staff not on board with the collaborative approach required by the standards. This is pretty rare in our experience, but is certainly something to emphasize in staff training.

NM 8 provides:

The organization’s written agreements with participating providers do not include:
(a) Any clauses or language that could restrict participating providers from discussing matters relevant to consumers’ health care; nor
(b) A definition of “medical necessity” that emphasizes cost/resource issues above clinical effectiveness.

This is a mandatory standard, and all elements are primary.  It is the same for both Health Plan and Health Network accreditation programs.

This standard is quite straightforward, and yet is often missed, at least on desktop review.  It is the classic example of the “it is not enough that you do it right, you must have a policy and procedure that requires that you do it right” philosophy discussed in another blog on this site (http://integralhs.com/doing-right-not-enough-having-policy-do-it-right-required-too).

Very simply, submitting provider contracts that, in accord with the standard, do not include the two prohibited types of the language, is not enough.  You must also have a policy and procedure that prohibits the inclusion of such language in all provider contracts.  So, in your application, submit both a template agreement and the policy and procedure.