NCQA setting standards for accreditation of PPOs
Here are some pitfalls to avoid
If you’re part of a preferred provider organization, (PPO) you may find that you’re required to go through the National Committee on Quality Assurance (NCQA) accreditation process by this time next year.
The Washington, DC-based organization is extending its accreditation program to include PPOs. The final standards for PPO accreditation will be released in July 2000, according to Brian Schilling, spokesman for the NCQA.
In the meantime, physician practices that are part of PPOs can prepare for future NCQA accreditation by learning from the experiences of doctors who are involved in the health plan accreditation process, Schilling says.
"We have had health plans that do not do well for a whole range of different reasons, from poor data control and management systems to not being able to measure and re-measure how they’re doing in terms of quality improvement," Schilling says.
Even if they aren’t immediately involved in the NCQA certification process, studying and meeting the standards can be beneficial, he adds. "There will come a time when a group practice that can measure performance and show they are doing a good job will have a distinct advantage in marketing," Schilling says.
For instance, if an HMO is considering contracting with one of three group practices, it is likely to contract with the group that has the most up-to-date data information system, he adds.
He suggests that physician practices move toward an electronic medical record system to avoid having to pull out paper records for data collection. "If you have a good information system, it’s going to make you a more attractive partner for a health plan," he says.
Do you have a quality improvement system?
Many health plans and group practices run into problems when they try to piggyback their quality improvement programs onto a system that is designed to pay bills, Schilling notes.
"If a health plan doesn’t have a system for quality improvement and utilization management, it’s not going to do well on the NCQA accreditation program, and it won’t do well in the marketplace, either," he adds.
One common reason that physician organizations fail to achieve accreditation is credentialing, Schilling says. Physicians either run into trouble with the NCQA or with the health plans they contract with because their credentialing process is not thorough enough or recent enough, he adds.
The NCQA provider credentialing process involves 10 different areas, including malpractice history, licensure, sanctions, and prescription privileges.
"There is a whole range of things that the health plans or medical groups are required to look into so there are no surprises in the provi der panel," Schilling says. The problem usually arises not because there is a problem with the physician but because the recredentialing is not up to date, he adds.
For instance, each practice or plan has to check on any Medicare and Medicaid sanctions against each physician every two years.
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