Health Network

This new standard provides:

At least 45 days prior to releasing performance data to the public, the organization must disclose to physicians and other providers an explanation of and provide access to: [--]
(a) How physician and other provider perspectives were incorporated in the development of the health care performance reporting program; [4]
(b) Data used for physician and other provider ratings; [4]
(c) The methodology and measures used to assess physicians and other providers, including attribution; [4]
(d) How the data will be utilized; [4]
(e) The physician’s and other provider’s right to make corrections; and [4]
(f) The physician’s and other provider’s right to: [--]
(i) A reconsideration with the organization; and [4]
(ii) To make an appeal to the organization; [4]

This standard offers a blend of transparency and due process, requiring the plan or network to notify affected providers of  a variety of elements of the program to use provider performance data.  Much is suggested by this standard, not the least of which is a process to assure that there is effective notification 45 days prior to use or publication.  I predict that this will be a sticking point for some organizations who fail to plan ahead and find market pressures to get a tiered network to market pushing up against this requirement to do so in a way that encourages provider input.

Again, URAC has not yet developed (or at least published) its review process information, but my guess is that the desktop reviewer will want to see a full policy and procedure describing this process, and that the onsite reviewer will ask for documentation of launch dates of tiered networks or published performance data, then look for documentation of full notice to providers 45 days prior. 

For the most part, the proposed changes to Health Plan and Health Network in v. 5.1 are modest -- too modest for my taste in the case of provider dispute resolution as I discussed in an earlier post.  However, what ought to get the attention of HMOs and PPOs that publicly report physician or other provider performance and/or establish tiered networks or differentiating physicians based upon quality and cost data is that URAC proposes eight new standards called "Health Care Performance."  I will devote this and the next several posts to explaining these standards, which are the first significant modification to the Health Plan and Health Network Standards since the late-1990s and v. 2.0.

The proposed HCP 1, which would be in both Health Plan and Health Network accreditation programs, would read as follows:

If the organization creates programs for physician or other provider performance measurement, reporting and tiering (including rating, ranking or measurement designations), the organization will display prominently in its communications to consumers: [--]
(a) Where its physician or other provider performance ratings are found; [4]
(b) A statement that performance ratings are only a guide to choosing a physician or other provider and such ratings have a risk of error and should not be the sole basis for selecting a physician or other provider; [4]
(c) Information explaining the rating system; [4]
(d) Any limitations of the data the organization uses; [4]
(e) How physicians or other providers are selected for inclusion or exclusion in a tier; [4]
(f) Details on the factors and criteria used in the organization’s rating systems; [4]
(g) How consumer and purchasers’ perspectives were incorporated in the development of the physician or provider reporting program; and [4]
(h) How a consumer may register a complaint or comment on the ranking or quality information of a physician or other provider to the organization. [4]

What jumps out with this standard is that it has eight subsections, each weighted 4, for a total of 32 weight-points for this one standard.  None of the subsections is mandatory, but you get a sense of how important transparency to consumers is to URAC from these choices about scoring.

URAC has not fleshed out its interpretive information completely (still no statement about what kind of documentation would be required).  However, one comment that URAC does provide are worth repeating here:

The unit of measure for performance measures may be an individual physician, a group practice or practice location, as well as other types of health care practitioners and delivery systems (e.g., clinics, IPA, PHO, etc.).

As we'll see in subsequent posts, these new HCP standards are not only about transparency.  They also provide due process for aggrieved providers and specific requirements regarding what kind of measures may be used in these reporting or tiering systems. 

The existing standard in both the Health Plan and Health Network standards reads:

The organization provides written notification to providers of the
determination of the providers’ credentialing application within 60
calendar days of the determination. (Secondary) [Wt = 3]

The new standard reads:

The organization provides written notification to providers of the
determination of the providers’ credentialing application within 10
business days of the determination. [4]

This revision carries two important changes. The substantive change is to reduce the notification requirement deadline from 60 calendar days to 10 business days, slicing about 6 weeks off the process. While most of our clients will meet the new timeline, some applicants will have to tighten up their processes.

The second change is an increase in the weight from 3 to 4. Because this is a single-element standard, however, we believe that it will carry less relative weight in the new system than it does now.

In amending this standard, which describes an aspect of the provider dispute resolution process for clinical and quality disputes, URAC simply clarifies that its use is limited to participating providers. It does so by amending subsection (b) to read, “Includes the right to consideration by a second-level panel and the methods to request such consideration, and a mechanism for participating providers to present relevant information.” The new language is simply the word “participating”.

The standard now reads:

The dispute resolution mechanism required under Standard NM 16: (Primary)
(a) Specifies that all disputes are referred to first-level panels consisting of at least three qualified individuals, of which at least one must be a participating provider who is not otherwise involved in network management and who is a clinical peer of the participating provider that filed the dispute; (Primary)
(b) Includes the right to consideration by a second-level panel and the methods to request such consideration, and a mechanism for participating providers to present relevant information; and (Primary)
(c) Provides for consideration to a secondlevel panel consisting of at least three individuals that comply with Standard NM 17(a) and that were not involved with the first-level panel. (Primary)

For a more complete discussion of URAC's provider dispute resolution standards, see my earlier blog.

In what some will call a Band-Aid for a serious wound, URAC merely renamed the standard which, in both the Health Plan and Health Network accreditation standards describes the requirements for participating provider dispute resolution where the dispute is merely administrative (and neither clinical nor quality-related). The old title for the standard is “Participating Provider Dispute Resolution Process: Type A”, while the new one adds “ – Administrative” at the tail end of the title.

For the sake of context, this is the standard that was added in v. 5.0 to bring some order to the mess created by the drafting of the comparable standard in v. 4.0. As I outlined long ago in a blog to describe the long and unhappy history of these standards, the v. 5.0 standards only compounded the problem, and renaming this one seems like less than a half-measure.

The best way to understand this whole series of standards dealing with participating provider dispute resolution is still to read an explanatory note that was posted on the URAC website a few months after I posted my initial blog on the issue. You can read that note in my blog.

One can only hope that the clarity expressed in that Web site note will be replicated in v. 6.0, whenever URAC issues that version.

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.

This standard, which is the same for both Health Plan and Health Network accreditation programs, provides:

With respect to both access and availability of providers to provide care to consumers, the organization:
    (a) Establishes goals;
    (b) Measures actual performance in comparison to those goals: and
    (c) Makes improvements where necessary for the provider network.

The standard has a weight of 4, and all of the elements are primary.

It is useful to think of this standard as having six subsections, not three.  Here is how I would rewrite it to reflect this view:

(a) With respect to access (i.e., geographic dispersion or travel time) of providers to provide care to consumers, the organization:
    (i) Establishes goals;
    (ii) Measures actual performance in comparison to those goals: and
    (iii) Makes improvements where necessary for the provider network.
(b) With respect to availability of providers to provide care to consumers (i.e., ability of consumers to receive care in a timely fashion), the organization:
    (i) Establishes goals;
    (ii) Measures actual performance in comparison to those goals: and
    (iii) Makes improvements where necessary for the provider network.

If you think about the standard this way, you are far less likely to make the most common NM 2 error, to submit documentation that relates only to geographic dispersion, and not the ability of consumers to receive care in a timely fashion.

So, what kind of documentation are we talking about here?

For “access”, since your goals will be expressed either geographically (e.g., “2 providers per specialty per county”) or drive-time (e.g., “no more than 30 minutes drive to a primary care provider in urban areas and no more than 45 minutes in rural areas”), documentation of measurement of your performance against those goals will be in the form of a GeoAccess or similar report.

On the other hand, for “availability”, since your goals will be expressed in terms of hours of availability (e.g., “office open at least 30 hours per week”) , wait times for appointments (e.g., “no more than a two week delay for a non-urgent appointment”),  or customer satisfaction regarding the ability to receive care in a timely manner (e.g., “85% customer approval of provider availability”),  documentation of measurement of your performance against those goals are likely to be in the forms suggested by the Program Guide:

•    Member surveys addressing provider availability
•    “Secret shopper” calls testing provider availability during “off-hours” times and testing ability of member to get timely appointment
•    Reports of onsite examination of appointment records

As much as is humanly possible, however, in any event, you should strive to present performance measurement in the same units of measurement as you express your goals for both access and availability.

One of the two biggest controversies in URAC Health Plan and Health Network standards interpretation in the last 5 years just got more confusing: provider dispute resolution.

A little history helps. Back in 1998-2000, v. 2.0 listed every conceivable type of provider dispute and said that the URAC two-appeal, par provider on each appellate panel, dispute resolution system applied to all of them. Version 3.0 complicated matters by getting rid of the list of dispute types. When, as URAC’s main reviewer for the NM sections of the Health Plan and Health Network programs, I continued to apply the requirement to all provider disputes, URAC applicants complained that I was applying it too broadly.

At my recommendation, one such complaining applicant appealed to the URAC Accreditation Committee, arguing that the URAC-required dispute resolution system should apply only to clinical matters. The Accreditation Committee agreed with the applicant, and instructed me to draft language for the Interpretive Guide that explicitly limited its application to the kinds of disputes that are the subject of Quality Act reporting requirements. I did so, and my language ended up in the v. 3.2 Interpretive Guide.

The URAC Standards Committee then took my language and, with an apparently minor tweak, turned it into a standard in v. 4.0. However, the “minor” tweak was huge: by substituting its “or” for my “and”, the Committee extended the scope of the requirement back to a breadth reminiscent of v. 2.0 – any dispute that was related either to a termination/suspensions or quality/professional conduct. At first, I thought it was a typo, but an examination of minutes of that meeting revealed that it was a conscious choice by the committee.

Well, applicants started to complain as I (and the URAC Accreditation Committee) applied the v. 4.0 standard. A joint meeting of the Standards and Accreditation Committees in late 2004 did not resolve the issue. The committees and URAC staff asked me to draft language to make two appeals processes, with the current process limited to “quality-related” disputes and a new, less cumbersome process for administrative issues. That language was adopted, with very minor change, by the Standards Committee and sent “upstairs” to the URAC Board for ratification.

Instead of ratifying the Standards Committee solution, the Board sent it back to the Committee to rework. I was not privy to the Board meeting, and cannot say why. I trust there were good reasons for doing so. The Committee, at that point, decided to give up on fixing the v. 4.0 standards and, instead, to take up the issue in v. 5.0 discussions.

In July 2005, I stopped doing my 25-reviews-per-year for URAC as a reviewer and turned my attention to other healthcare consulting adventures. Somewhere in there, the committee took a completely different approach and created the new system, which bears none of my two-track draft language from the ill-fated 4.0 fix.

Here's the way it reads now:

P-NM 13 – Participating Provider Violation Mechanism
The organization implements a mechanism consistent with its written agreements to address alleged violations by participating providers of the requirements of the organization.

P-NM 14 – Participating Provider Dispute Resolution Scope
The organization implements a mechanism to resolve disputes with participating providers regarding actions by the organization that relate to either: (Secondary)
(a) A participating provider’s status within the provider network; or (Primary)
(b) Any action by the organization related to a provider’s professional competency or conduct. (Primary)

P-NM 15 – Participating Provider Dispute Resolution Process: Type A
The dispute resolution mechanism required under NM 14: (N/A)
(a) Is available to any participating provider that wishes to initiate the dispute resolution mechanism; (Secondary)
(b) Relies on written policies and procedures that: (Secondary)
(i) Are developed and reviewed at least annually with the involvement of participating providers; (Secondary)
(ii) Clearly describe the dispute resolution process, including the right to consideration by an authorized representative of the organization not involved in the initial decision that is the subject of the dispute; (Primary)
(iii) Include the methods to request such consideration; and (Secondary)
(iv) Include a mechanism for providers to present relevant information; and (Secondary)
(c) Provides for explicit time frames. (Secondary)

P-NM 16 – Participating Provider Dispute Resolution Process
The dispute resolution mechanism required under Standard NM 15 offers a review dispute resolution process (described in Standards NM 17) for participating providers if: (Primary)
(a) The organization and the participating provider agree by mutual consent to use the review dispute resolution process described in Standards NM 17; or (Primary)
(b) The participating provider presents information to challenge the findings of the process described in Standards NM 15. (Primary)

P-NM 17 - Participating Provider Dispute Resolution Process: Type B Peer Review Panel
The dispute resolution mechanism required under Standard NM 16: (Primary)
(a) Specifies that all disputes are referred to first-level panels consisting of at least three qualified individuals, of which at least one must be a participating provider who is not otherwise involved in network management and who is a clinical peer of the participating provider that filed the dispute; (Primary)
(b) Includes the right to consideration by a second-level panel and the methods to request such consideration, and a mechanism for providers to present relevant information; and (Primary)
(c) Provides for consideration to a second-level panel consisting of at least three individuals that comply with Standard NM 17(a) and that were not involved with the first-level panel. (Primary)

I confess that for some time I did not understand this new approach. It retains the “or” language in the new NM 14, and thereby on its face creates no separate track for administrative disputes. Several folks I’ve talked to who attended the June URAC workshop that covered this standard report that the word is that, despite the clear failure of the language to create a separate track for such disputes, that the intent of the standard (and the application by URAC reviewers of the standard) is that the full 2-tiered appellate system apply only to quality-related disputes.

In September, after a meeting of the Standards Committee that devoted at least part of the agenda to straightening this issue out, URAC updated its AccreditNet Program Guide on the subject, and, as a result, here's what we now believe to be true about URAC's interpretation of these standards:

The intent of the v. 5.0 version of these standards, as we suspected, is to establish a two-track system of provider dispute resolution processes. One track, the clinical track (“Type B”), requires two levels of appeal, each of which has a clinical peer of the disputing physician. The other track (“Type A”) is for administrative disputes, such as claims payment, availability for appointments, and the like. Finally, the posting makes it clear that the URAC-required “due process” is not required where licensure revocation or conviction of claims fraud serve as the grounds for the provider’s termination.

This interpretive posting, we believe, should be given more weight than the literal reading of the standards themselves, which we believe will need to be revised again in order to reflect the intent of the drafters.