Healthcare

Every once in a while I need to remind our clients that our ultimate audience in a URAC review -- the reviewer herself -- does not know what we know about our client's P&Ps, operations, and personnel.  Because we're human, we often cannot see all the assumptions we make about what the reviewer must know.  Often, these assumptions are misplaced and lead to a miscommunication between applicant and reviewer.

In this 5-minute video, I talk a bit about these blind spots and the need to overcome them by making a counter-assumption -- the reviewer knows nothing about your company.

Compliance 360, providers of a governance, compliance, accreditation, and audit software solution, have just added a new module to the already impressive array of features.  The new module helps healthcare organizations navigate the increasingly important world of claims audits.  As many of our readers will know, CMS rolled out a pilot program to attempt to get back a portion of the billions lost to overstated Medicare Claims through a program known as "Recovery Audit Contractor" ("RAC").  As the company's Web page on the module notes, the new module "has been designed for managing a wide variety of claims audits including the Medicare Recovery Audit Contractor (RAC) program, Medicare Program Safeguard Contractor (PSC) audits, Medicare Comprehensive Error Rate Testing (CERT) audits, Medicaid Integrity Contractor (MIC) audits, Medicaid Fraud Control Unit (MFCU) audits and other forms of claims audits."  Click here to see the full description of the audit.

In the 5-minute video, below, I talk a bit about how I came to know Compliance 360's compliance and accreditation software in some of its earliest iterations, and why I continue to recommend the product and the people to my clients who need a comprehensive compliance software solution.  

So, you've finally hit "submit" on your URAC AccreditNet application. 

In the following 3 minute video, I explain why you shouldn't be worried that URAC wants more information from you, even after you've spent months assembling the perfect URAC application.

The newer modules (like PBM and DTM) have a new citation system that I've written about elsewhere.  The new system is in many ways an improvement, but has one problem I've identified so far: when you click "Remove Evidence" to delete a document, it may not delete it completely.

In the following 2-minute video, I talk about this issue, which I consider a glitch, and how to work around it when you want to remove a document.

I got a quick note from Kristin Goudreau, in URAC's business development department.  Applicants for accreditation have an opportunity to lock into the current standards and pricing by submitting an Application Agreement and fees by December 20th at the latest. The organization would have 12 months from the date of the Agreement to submit the full application on AccreditNet. As of January 1, all organizations will need to apply for the new standards and pay the 5% price increase.

Organizations interested in this should contact Kristin at 202.962.8804 or email her at kgoudreau@urac.org.

For a 7-minute video on URAC training, click here.

In any event, read on:

It is useful to think about the issue of "training" in two compartments -- (1) training required by URAC and (2) training for the onsite review.  I will handle them separately.

1.  Training required by URAC

As you know, URAC has specific requirements for staff training that relate both to the content of staff training and its administration:

Content
Most of the explicit training requirements in the URAC standards are found in the Core and Pharm Core standards: 

• Initial orientation and/or training for all staff before assuming assigned roles and responsibilities; (Core 7(a))
  • Training in the P&Ps that apply to one's job is implied by Core 3(a), too
• Ongoing training, at a minimum annually, to maintain professional competency; (Core 7(b))
• Training in current URAC Standards as appropriate to job functions; (Core 7(c))
• Training in state and regulatory requirements as related to job functions; (Core 7(d))
• Conflict of interest; (Core 7(e))
• Confidentiality (Core 7(f)) and specifically HIPAA (Core 24)
• Training on identification and prevention of fraud and abuse, as appropriate to job functions; (Core 7(g))
• Delegation oversight, if necessary; and (Core 7(h))

In addition, training of employees in how to do their job consistent with company P&Ps and URAC standards  is implied throughout the standards, via Core 3(a), 7(a), and 7(c).

Administration

• There must be documentation of all training provided for staff (Core 7(i))
• There must be a signed document acknowledging training on confidentiality issues (Core 24)

Some of this is company-wide training (e.g., confidentiality); some is department-specific (e.g., P&Ps on how to follow DM P&Ps.)  Company-wide training is typically handled either through:

1. company-wide meetings
2. computer-based training modules required of all employees, or
3. smaller, face-to-face trainings required of all employees. 

Department-specific training is typically handled through

1. modular computer-based training programs or
2. departmental staff meetings

2.  Training for the URAC Review Process

The best preparation for the URAC review is the substantive training described in the previous section.  A staff member who knows his/her job as described by the applicable P&Ps, knows the URAC standards and state/federal regulations that apply to the job, and can retrieve the documents to be sought by the URAC reviewer is unlikely to get tripped up in a URAC review, even if they have no specific preparation for the onsite review process.

Additionally, the mock onsite review we conduct for our clients is valuable for staff members likely to be either interviewed or pulling documents during the onsite review.  We spend a good portion of our time onsite not only conducting document-pulls and interviews as realistically as possible, but also counseling staff members on how to improve their performance for the actual review.

Here's a glitch for URAC to fix and for applicants to know about until they do. 

We were just reviewing the "Program Specific Data" tab in AccreditNet (URAC's online application-submission application) for a client about to submit an application for reaccreditation.  This is more of a quality-check than anything, making sure everything's spelled right and that all the blanks are filled in. 

This client contracts with only one client, as we indicated in the "Group 9" part of this tab.  When we hit the magic button, "Save as Final", we were rejected, with the explanation that we had left mandatory areas blank.  The only areas left blank, though, were the spaces for the 2nd and 3rd largest clients.  Apparently AccreditNet is not that familiar with single-client applicants.

Our workaround?  Fill in the information about "Client #2" and "Client #3" with the same information as in the spaces for "Client #1."  

One of the new features of the scoring methodology in v. 3.0 is that Core will always be 30% of of the total points available for accreditation, regardless of the accreditation program.  This is a change from previous versions, when the percentage of total points allotted to Core depended upon the program.  For example, previously, Core was a smaller factor for Health Plans than it was for a single module program, such as Utilization Management or Independent Review Organization.

One of the changes in v. 3.0 has to do with policies applicants are expected to submit with their application. 

Previously, what was requried to be submitted to document compliance with standards was "policies and procedures."  URAC has changed this to allow for "written policies and/or documented procedures." 

The purpose of this change is to distinguish between policies, which provide direction and guide decision-making from procedures, which map out the steps for staff to follow to perform a particular function.  "Procedures" could include a process flowchart, escalation matrix, guidelines, etc.

URAC is starting to clarify its new Core standards, v. 3.0, which will be known as "Module I" for all the healthcare accreditation programs.  The new standards have a release date of November 2008, and were the subject of extensive interest at the 2008 URAC Summit.

Core 1-23 and 25-29 apply to all applicant organizations regardles of the accreditation program.  On the other hand, Core 30-35 apply only when clinical staff is required to perform the function covered by the accreditation.  The programs in this category are:

• Health UM
• Workers Compensation UM
• Independent Review Organization
• Provider Credentialing
• Claims Processing
• Credentials Verification Organization

Core 24 and 36-40 apply when clinical staff interface with consumers.  This includes:

• Case Management
• Disease Management
• Health Call Center
• Health Plan
• Health Network
• Consumer Education and Support