The growing role of technology in NCQA accreditation for health plans

A stamp of approval from the National Committee for Quality Assurance (NCQA) indicates a health plan has met performance measures for matters like quality, access to care, and member experience. Two key trends have emerged related to NCQA accreditation over the past 10-15 years. First, NCQA accreditation has gone from a nice-to-have to a must-have for health plans – particularly for certain lines of business. Second, payers are increasingly using technology to manage member experiences and communications that fulfill the requirements – both online and offline.

Is NCQA accreditation required?

The answer to this question depends on the line of business:

  • For commercial group coverage – NCQA accreditation is not required. However, many groups (especially large companies and organizations) will only consider an accredited health plan.
  • For Medicare Advantage plans –The Centers for Medicare & Medicaid Services deems plans if they have met NCQA accreditation requirements. In addition, NCQA is contracted with CMS to evaluate Medicare Advantage Special Needs Plans (SNPs).
  • For Medicaid plans – Most states have modeled their standards for managed Medicaid plans on the NCQA accreditation standards (in full or in part). Like with Medicare, some states deem plans if they have met some or all of the NCQA accreditation requirements. Others specifically require NCQA accreditation for managed Medicaid plans. There are now a number of Medicaid payers currently gearing up for NCQA’s “look-back period” that starts July 1 so they can go through the accreditation process. (View the state-specific Medicaid requirements here. Note that this list is as of July 2015, but updates are issued regularly so check the NCQA website for the latest information.)
  • For Exchange plans, including co-ops – While the Exchange regulations do not specifically require NCQA accreditation, they call for Exchange plans to follow standards that align with NCQA – making NCQA accreditation a quasi-regulatory requirement.
Requirement   Required by NCQA  Required to participate in Marketplace
  • Local performance on clinical quality measures such as HEDIS
  • Patient experience ratings on a standardized CAHPS survey
  • Consumer access
  • Utilization management
  • Quality assurance
  • Provider Credentialing
  • Complaints and appeals
  • Network adequacy and access
  • Patient information programs that help enrollees find a doctor

Using technology to meet NCQA accreditation requirements

Over the years, NCQA has evolved its accreditation requirements to reflect changes in the healthcare system and consumer needs. The 2016 requirements will put increased scrutiny on narrow networks, which have become more commonplace in recent years. Other new requirements for 2016 will focus on accuracy of provider directories and handling of coverage decisions and appeals (including communication of appeal rights). To follow the new requirements, plans will need to update their technology or develop new systems – in some cases by using a vendor like Healthx to provide a robust online provider directory.

In addition, plans are increasingly relying on technology to meet requirements related to member connections. NCQA’s “MEM” requirements set the bar in terms of getting health plans to go beyond just putting claim and benefit information online (and doing so only as a way to reduce phone calls). They include:

  • Health appraisals – Ability to survey members’ current conditions and having some kind of clinical assessment about things they can do to be healthier. Healthx works with our customers to be the integration platform that knits point solutions together to meet this requirement.
  • Self-management tools – The ability to basically go in and manage your own accounts and profile with the health plan. Healthx provides this functionality in our member portals and mobile apps.
  • Claims – Giving members access to specific data elements for claims including status, allowed amount, paid amount, and member out-of-pocket. This functionality is also part of our portals and apps.
  • Pharmacy benefit – Communicating clearly what members’ pharmacy benefits are. Healthx provides this functionality by integrating with customers’ pharmacy systems and vendors.
  • Detailed information about health plan benefits and related services – A wide range of requirements related to operations and communications. Healthx provides many of the requirements such as giving members the ability to ask for replacement ID card and change PCP online.

These guidelines aren’t revolutionary – they simply set a baseline for what payers should do. And yet, sometimes even a simple requirement can be challenging to implement with your current systems. That’s when a technology partner who can offer a solution that connects payers/provider/members, moving access to data online as well automates day-to-day transactions can help you not just in meeting the requirements but exceeding them.

Mike Gordon is the Chief Product and Strategy Officer at Healthx. He has more than 23 years of software and information technology experience, with extensive expertise in product development for healthcare payer organizations.