URAC conducts accreditation to evaluate a company’s adherence to national standards. To maintain their licensure within a particular state, physicians and nurses are required to complete Continuing Medical Education (CME) courses annually after obtaining their degrees.
Physicians need to engage in continuing education to ensure they uphold and improve their knowledge, skills, professional performance, and relationships. This is vital for enhancing patient care and serving the public and profession effectively. It’s crucial to note that physicians are only eligible for credit in continuing education activities applicable to their specific field. There are several specialized committees and organizations available, including the National Committee for Quality Assurance (NCQA), Accreditation Association for Ambulatory Health Care (AAAHC), and Managed Behavioral Health Care Organizations (MBHCO).
Managed Care plans, such as Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs), are health insurance plans that partner with healthcare providers and medical facilities to provide discounted care for members. The plan’s network comprises these partnered providers (Medline Plus, 2013). The decision between HMOs and PPOs is subjective, as individuals have different preferences on which is preferable. Physicians commonly favor the plan that will attract more patients in their specific area. In regions with big businesses, physicians usually prefer HMOs.
Once physicians have chosen their specialty and preferred path, it is important for them to align themselves with managed care systems. The National Committee for Quality Assurance (NCQA) is a non-profit organization that plays a crucial role in promoting improvement within the healthcare system and emphasizing the significance of quality in national discussions. Since its establishment in 1990, the NCQA has been accrediting and certifying healthcare organizations to enhance healthcare quality. The widely recognized symbol of outstanding performance in the field of healthcare is the NCQA seal.
The NCQA requires organizations to undergo a thorough review process and submit yearly performance reports in order to use their seal in advertisements and marketing materials (NCQA). By collaborating with stakeholders such as large employers, doctors, patients, policy makers, and health plans, the NCQA determines priorities, establishes measurement criteria, and identifies areas for improvement. They have a crucial role in transforming the healthcare system by analyzing collected data. Health plans that aim for accreditation from the NCQA must meet comprehensive standards across different domains and report on their performance (NCQA). These standards evolve over time and become more rigorous, making the accreditation process itself challenging.
The AAAHC, founded in 1979 by six members of the American College Health Association, which include the American Group Practice Association, the Federated Ambulatory Surgery Association, the Group Health Association of America, the Medical Group Management Association, and the National Association of Community Health Centers. Their goal is to support and guide ambulatory health care organizations in delivering efficient and cost-effective high-quality care. The AAAHC accomplishes this through a program that includes peer-based assessment, consultation, education, and accreditation (AAAHC). Currently consisting of 17 member organizations from various ambulatory health care fields. The AAAHC consistently updates its Standards to encompass advancements in dentistry, behavioral health, health education, and wellness (AAAHC).
The MBHCO is an integral part of the NCQA and demonstrates to various stakeholders, including health plans, employers, regulators, and consumers, that the organization adheres to evidence-based practices in delivering high-quality care, ensuring access, and protecting consumer rights (NCQA). The MBHCO can earn accreditation by meeting five standards. These include quality management and improvement, whereby the organization establishes a system to monitor, evaluate, and enhance the safety and quality of care provided. Care coordination involves facilitating medical and/or behavioral care for members. Utilization management requires the organization to make coverage decisions known to members and practitioners within a specified timeframe. Credentialing and re-credentialing ensure that the organization verifies the credentials of practitioners in its network.
There is an existing policy at the organization outlining members’ rights and responsibilities. This policy outlines the duties and rights of members. Physicians must obtain accreditation from managed care facilities and have their licenses documented in each facility where they practice, similar to carrying a driver’s license when driving a car. Even if physicians are well-known in the community, this documentation is crucial for both the facility and physician. Managed care nurses can work under a physician’s license but also need to ensure their nursing licenses are up to date. The National Council of State Boards of Nursing emphasizes the importance of competent individuals practicing nursing to prevent harm to the public. Failure to properly maintain and document licenses could result in penalties for the facility, physician, or nurse if an incident occurs. In my personal experience working in a dialysis facility, I was responsible for overseeing all licenses within our establishment. I witnessed firsthand the consequences that could arise if our information was not kept up to date during a visit from a State Inspector.To prevent setbacks, I regularly performed monthly audits to ensure that all individuals maintained up-to-date licenses and Continuing Education Units (CEUs) recorded in our facility. CEU refers to Continuing educational “unit of credit,” which is a shorthand for 10 hours of participation in an accredited program designed for professionals with certificates or licenses in various fields (Peterson).
Many places offer classes for CEU’s for Physicians and Nurses to fulfill their continuing education requirements. These healthcare professionals must also graduate from an accredited school and pass rigorous individual board exams to demonstrate their competence. As new graduates, Physicians and Nurses need to submit a Licensure Application and meet specific requirements set by their state. These requirements can vary from state to state and may involve obtaining a certain number of CEU’s and practice hours. In order to become part of a managed care system like NCQA (National Committee for Quality Assurance), organizations must meet various quality management, utilization management, and credentialing requirements. Meeting these guidelines is a demanding process that involves completing specified tasks. The organization applying will be audited by the group both during and after the application process.
This text emphasizes the importance of treating the task at hand as a valuable learning experience. The experts will assess and evaluate your systems to ensure they adhere to state standards as well as any additional standards they deem important. As the person responsible for this area in the facility, maintaining open and respectful communication with your license holders is crucial. Physicians have their own offices and staff who will remind them about their Continuing Medical Education (CME) requirements. Fortunately, you only have to remind your nurses to complete courses that count towards their CMEs. Inadequate communication between offices can result in overdue licenses or receiving licenses from a different office affiliated with the physician. It is essential to remember that they have busy schedules, so you should avoid pestering them for information.
It is important to possess the skill of being able to assist when requested. One helpful aspect that not all facilities consider is assisting in finding classes for continuing education units (CEUs). This is particularly valuable for charge nurses who need to renew their licenses but have not had time to earn enough CEUs. Assisting them in locating classes in their respective fields is extremely beneficial. Although it may require additional time, you can explore options at local colleges and online; your nurses will be aware of approved areas for them to attend. In my opinion, an ideal solution for enabling offices to comply with managed care regulations and requirements is an access program that connects exclusively with the relevant company and can be updated by both parties.
A program exclusively for Managed Care and its affiliates, such as physicians and their offices, can utilize system updates to inform physicians of any newly implemented rules. In addition, this spreadsheet can remind physicians when the Managed Care organization requires updated licenses, CEU certificates, or liability insurance. Furthermore, a designated section within the access program allows for the uploading of pictures or copies of these documents, eliminating the need for constant check-ins and phone calls to offices. This system also provides physicians with insight into their standing within managed care, indicating whether they are in good standing or need improvements. By eliminating the need to send reminder letters to each physician or office, this system also reduces paper usage. However, implementing such a system comes with the cost of ensuring information security.
Some of the licensure information includes the physician’s date of birth and other sensitive details that should only be accessible to authorized individuals. To ensure privacy, a robust firewall must be established, granting login access solely to managed care providers. Additionally, an ongoing virus scan needs to be implemented to prevent any potential data breaches. By investing in reliable internet protection and safety measures, the risk of information leakage can be minimized. Although setting up this system would require a capable system administrator, it is achievable with the right expertise. Once this system is operational, both the managed care and physicians can exchange information more efficiently and avoid delays caused by traditional communication methods such as letters or emails. This real-time system will provide instant access to relevant information for both parties.
Physicians can stay informed about upcoming changes and updates in order to maintain their good standing with managed care. This system allows managed care to notify all physicians within their network of new changes without the need for physical letters or emails. Ultimately, adopting a system that updates each other’s needs can save both time and money for managed care and physicians. Furthermore, this system can reduce costs associated with postage for letters and faxes as smaller pieces of paper will not need to be copied for faxing. In today’s digital age, electronic communication is increasingly important, and this database facilitates better communication between these two parties.
Works Cited
Medline Plus. (2013, June 12). Retrieved from http://www.nlm.nih.gov/medlineplus/managedcare.html
AAAHC. (n.d.). Retrieved from Accreditation Association Ambulatory Health Care, INC.: http://www.aaahc.org/about/history/
ACCME. (n.d.). Retrieved from Accreditation Council for Continuing Medical Education: http://www.accme.org/requirements/accreditation-requirements-cme-providers/policies-and-definitions/cme-content-definition-and-examples
NCQA. (n.d.). Retrieved from Measuring quality Improving health care: http://www.ncqa.org/AboutNCQA.aspx
NCSBN. (n.d.). Retrieved from What you Need to know about Nursing Licensure and Boards of Nursing: https://www.ncsbn.org/Nursing_Licensure.pdf
Peterson, D. (n.d.). Continuing Education. Retrieved from About.com: http://adulted.about.com/od/professionalcertifications/p/ceu.htm
