Contracts

Reversing a long-standing interpretation of Core 17(b), URAC now requires contracts of delegation to mention URAC by name.

The standard reads:

The organization enters into written agreements with contractors that . . . (b) Require that services be performed in accordance with the organization’s requirements and URAC standards. . ..

While the standard's content has not changed, the interpretation has.   Version 2.0 of the Core standards contain the following language in the "Points to Remember": "the written agreement might require sub-contractor compliance with “national accrediting standards that the organization is required to meet.” While that note, on its face, applies to the subdelegation provisions of (g) and (h), it has, for several years, been applied to the primary delegation requirement of (b).  So, this is new.

The subsection is a secondary element of a mandatory standard, so while, under the current scoring system, missing this will cost a URAC applicant points, it will not, by itself, force the applicant into a conditional accreditation status.

HOWEVER . . ., this subsection is proposed as a primary element in the new v. 2.1 standards, so future applicants should expect to get this right or face a conditional accreditation.

It's time to send out those delegation agreement amendments, folks!

The proposed change in Core 14 is barely perceptible, even to the trained eye.  The new standard would read:

Core 14 – Written Business Agreements
The organization maintains signed written agreements with all clients describing the scope of the business arrangement. (Wt=2)

The scoring weight's the same, the language is the same --  then what is it?

Ah, there it is!  The title would change.  The current standard is called "Business Relationships."  This simply makes the title of the standard more closely depict the content of the standard -- a requirement that applicants have contracts with their clients.  

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.

My colleagues and I have noticed, as have some veteran URAC reviewers to whom we've spoken lately, that some folks are still misinterpreting Core 14. Let me see what we can do to help sort out the confusion.

The standard reads: "The organization maintains signed written agreements with all clients describing the scope of the business arrangement."

"For which organizations does your organization work"? The answer to this question should guide your response to Core 14. The key to understanding this is to focus on what a "client" is. In "URACLand", a client is a company for which your organization performs services. If your company is an insurance plan for health coverage, "clients" may be employer groups, or the state if providing Medicaid services, or CMS if providing Medicare services. If your organization is a vendor, such as an independent review organization (IRO), your "clients" may be insurance companies, such as Blue Cross Blue Shield Plans.

This standard requires your organization to enter into written agreements with "clients" that describe the terms of the business arrangement. Requiring the terms of these business relationships to be in writing is a safeguard for your organization, as it ensures that the services you provide to an organization is not based on verbal agreements or a "gentleman's handshake", which could result in legal issues down the road.

So, what's the confusion? Many applicants have mistaken this standard as addressing or including "delegation". It does not. Delegated entities are organizations that "perform services for your organization". In other words, "which organizations are working for your organization"? Delegation is addressed in significant detail in Standards Core 15- Core 18. So please, do not address delegated entities in your responses to Core 14.