Network Management

The proposed revisions to URAC's clinical standards are extensive and the deadline for comment draws near. At the very least, however, I'm going to submit one comment. The proposed revisions do nothing substantive to the provider dispute resolution problem that has been getting worse with each revision. I'm surprised -- I would have thought this would be a good time to fix a fundamentally broken series of standards, P-NM and N-NM 13-17. I have written about this at some length (click here to read my blog on the subject of the mess), and URAC has tried to put a bandage on the problem with explanatory notes posted on its website and in AccreditNet. Hardly an elegant solution, when a simple revision of the standards is all that is needed.

So, here's what I'll be sending URAC on this topic:

The problem with NM 13-17 is this – the titles of the standards, as well as the clarifying information of URAC, suggests that this is intended to design a two-track system, one process for administrative disputes and another for clinical conduct disputes. A close reading of the standards, however, demonstrate that the standards actually create a single 3-level process. A simple way of describing the standards, as written, is to say it this way:
Any dispute that involves either network status (termination or suspension) or professional conduct/quality must afford the disputing provider 3 levels at which he/she can seek redress:
(a) An authorized person in the organization who was not involved in the first decision;
(b) A first-level appeals panel with at least three people including a clinical peer not involved in the earlier decisions;
(c) A second-level appeals panel with at least three people including a clinical peer not involved in the earlier decisions.

It is clear from URAC's labels for NM 15 ("Type A - Administrative") and NM 17 ("Type B -- Peer Review Panel") that this is not what URAC is trying to do with these standards.

The proposed modification for v. 5.1 makes no effort to modify the language of the standards to achieve URAC’s intent. This disconnect between intent and language is not only bad for URAC and URAC’s accredited companies, it is unnecessary. The following modification would accomplish what URAC says it intends, but would do so in the body of the standards themselves:

Standard 1 – Disputes Concerning Professional Competence or Conduct
The organization implements a mechanism to resolve disputes with participating providers regarding actions by the organization that relate to a participating provider’s status within the provider network and any action by the organization related to a provider’s professional competency or conduct. That mechanism:
(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;
(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
(c) Provides for consideration to a second-level panel consisting of at least three individuals that comply with Standard 1(a) and that were not involved with the first-level panel.

Standard 2 – Disputes Concerning Administrative Matters
The organization implements a mechanism to resolve disputes with participating providers not covered by Standard 1 that offers the disputing provider the right to consideration by an authorized representative of the organization not involved in the initial decision that is the subject of the dispute.

Standard 3 – General Requirements for Provider Dispute Resolution Mechanisms
The dispute resolution mechanisms described in Standards 1 and 2:
(a) Are available to any participating provider that wishes to initiate the dispute resolution mechanism;
(b) Rely on written policies and procedures that:
i. Are developed and reviewed at least annually with the involvement of participating providers;
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;
iii. Include the methods to request such consideration; and
iv. Include a mechanism for providers to present relevant information; and
(c) Provides for explicit time frames.

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.

Resemblance to URAC's Plan and Network Standards

Not surprisingly, the 13 standards in this module look a lot like the Network Management (NM) standards from URAC’s Health Plan and Health Network accreditation programs. Indeed, there is an almost standard-to-standard relationship, e.g., PHARM-DC 1 with P-NM 1, PHARM-DC 2 with P-NM 2, and so on.
Thus, these standards cover what URAC has long thought to be the nuts-and-bolts of network management

• Defining the scope of services and provider selection criteria
• Working to achieve for access and availability
• Implementing policies for out-of-network services
• Provider relations program requirements
• Minimum components of provider agreements and subcontracts
• Provider dispute resolution

Of some interest to those of us who have closely followed the drama around URAC’s provider dispute resolution standards is that their correlates in the PBM standards avoid all the complications of their Plan and Network counterparts. Don’t look for much controversy here.

PBM-Specific Standards

The last two standards of this module, PHARM-DC 12 and 13, break from the Network Management pattern set by the first 11 standards. PHARM-DC 12 requires that the PBM’s claims processing comply with NCPDP transaction standards, while PHARM-DC 13 requires the PBM to disclose to consumers “the exceptions to refilling prescriptions (which would otherwise be limited by benefit design) in order to ensure access to the types of drug therapy needed.” This last standard doesn’t seem to fit in this module, and it wouldn’t surprise me in the least if PHARM-DC 13 were moved in the final draft to hang out with its closer cousins in consumer education in Module 2.