URAC HCP 4 -- Proposed v. 2.1 Revision -- NEW STANDARD -- Physician and Other Provider Performance Measurement Appeals Process

HCP 4, a proposed new standard, would read:

The organization shall have a reasonable, prompt, and transparent appeals process to address physician and provider performance measurement issues that provides: [4]
(a) A written response back to the physician or other provider regarding the outcome of the appeal that includes: [--]
(i) A reason for the appeal decision; and [4]
(ii) An indication of the next actions that the organization will take as a result of the appeal decision. [4]

This standard creates an appeal mechanism for providers who are aggrieved by an organization's performance measurement with the right to appeal. That right includes a right to a written response that explains the decision on appeal and what response, if any, the organization has to the appeal.

Documentation requirements at the AccreditNet phase of the application process, while not yet published, are likely to be the submission of a policy and procedure describing the appeal mechanism. The onsite review process is likely to involve providing the reviewer with a list of all appeals submitted, from which the reviewer will select a sample in order to look at the documentation of the appeal, and particularly the written response to the provider.

Because this standard has a couple of technical issues with it, I today submitted the following comment to URAC about this standard:

First, I'd like to make a comment that applies to all the HCP standards. "Physicians" are a subset of "provider", so all references to "physicians and other providers" or, as in the case of HCP 4, "physicians and providers", offer superfluous language. "Provider" should suffice.

Second, a basic rule of outlining is to not create numbered or lettered lists out of only one item. In this case, the standard has an "(a)" without a "(b)".

I recommend, therefore, that this standard read as follows:

The organization shall have a reasonable, prompt, and transparent appeals process to address provider performance measurement issues that provides a written response back to the provider regarding the outcome of the appeal that includes: [4]

(a) The reason for the appeal decision; and [4]

(b) An indication of the next actions that the organization will take as a result of the appeal decision. [4]