URAC

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.

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.

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.

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

This standard reads:

The wellness organization has the ability to incorporate the use of participant incentive structures into its
wellness program(s) and it designs the incentive in a manner to collect data that will support evaluation of the
impact of the incentive. (3)

As the interpretive notes indicate, URAC fully expects the initiative for participant incentives to come from the employer/client, not from the wellness program.  Consistent with that notion, URAC requires the applicant for accreditation to have the capacity to respond to an employer/client request for the inclusion of incentives for wellness program participants in its wellness program.  However, URAC does place upon the wellness program the obligation, once asked by the employer/client to include an incentive, to design it in such a way as to support the collection of data and evaluation of those data to help assess the impact of the incentive.

Documentation for the desktop review level likely will be a policy and procedure which directs the program's staff to be responsive to employer requests for incentives, and to guide program staff in the development of interventions that lend themselves to data collection and evaluation.  The onsite review no doubt will involve an examination of documents demonstrating implementation of that P&P and an interview of senior clinicians involved with the incentive program(s).

This standard, which carries a weight of "4", reads:

The wellness organization includes additional interventions that focus on participants with disproportionate
risk factors. (4)

Borrowing from the world of disease management, URAC places a high value on stratification of the participants in the wellness program according to risk factors.   This standard requires an evaluation, along the spectrum of health risk factors, of the target population with an eye toward providing more intensive interventions for those at greatest risk. 

Documentation for purposes of the desktop review should include an official, approved document that describes the stratification process.  In addition, documentation should address how additional interventions for high-risk participants match the high-risk categories identified through this stratification process.  The onsite review will combine a closer examination of documents demonstrating the implementation of the stratification process, as well as an interview of senior clinicians associated with the stratification process to assure a full understanding of both the risk identification methodology and the administration of the interventions for high-risk participants.

This standard reads:

If the wellness organization implements new or innovative practices that are not evidence-based, it designs
the intervention to collect data that will support evaluation of the impact of the new or innovative practice. (L)

This is a leading indicator standard.  It reflects URAC's commitment to the use of data collection, measurement and evaluation to guide healthcare organizations as they navigate uncharted waters.  

While the current draft doesn't say what evidence would be required, one can extrapolate from other standards that an applicant would submit, for desktop review, something akin to a Quality Improvement Project Description Form, which outlines baseline measurements, clearly stated objectives, a complete description of the intervention, and a plan for remeasurement and evaluation of results.  The onsite review will involve an examination of the background data underlying that description form combined with the clinical and administrative leaders of the innovative intervention.

This particular subsection (formerly Core 33(e)) provides:

The organization has a quality management committee that. . . (e) If applicable, includes at least one participating provider or receives input from a participating provider committee (such as a Physician Advisory Group); (Secondary)

This subsection applies to Health Plans and Health Networks.  The question comes up, "if we don't have a participating provider on the QMC itself, how do we make sure that the input from the participating provider committee is adequate?"

Our answer to this question is, "make sure that anything that is the responsibility of the QMC to receive reports about, or do, or issue reports on, gets to this physician group."  That can be a lot.  As our blog post on QMC responsibilities shows (click here), that may involve a lot of activity.

So, if your physician advisory group is not particularly active, either gear it up to meet the full range of the QMC's clinical responsibilities or play it safe and appoint a participating provider to your QMC.