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Achieving and Maintaining Accreditation in Managed Care

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    Achieving and Maintaining Accreditation in Managed Care

    Accreditation is a process by which an impartial organization (URAC) will review a company’s operations to ensure that the company is conducting business in a manner consistent with national standards. For a physician and a nurse after they receive their degree they have to do continuing education courses every year to maintain their licensing with that particular state. These classes are generally known as CME’s (Continuing medical education).

    They serve to “maintain, develop, or increase the knowledge, skills, and professional performance and relationships that a physician uses to provide services for patients, the public, or the profession” (ACCME). That being said physicians cannot do continuing education that does not relate to their profession and receive credit from them. There are committees and Organizations depending on what area they work in. There is the National Committee for Quality Assurance (NCQA), Accreditation Association for Ambulatory Health Care (AAAHC) and Managed Behavioral Health Care Organizations (MBHCO), just to name a few.

    Managed Care plans are “health insurance plans that contract with health care providers and medical facilities to provide care for members at reduced costs. These providers make up the plan’s network” (Medline Plus, 2013). We have all had to choose at one point with HMO’s (health Maintenance Organization) and PPO’s(Preferred Provider Organizations), and each person will have a difference in opinion on what they consider the best. Physicians want to work with the one that will help them get more business in their specific area. If there are large businesses in the area, they typically want to use an HMO.

    So once the physician has decided on their area and picked which way they would like to go, they must now become a part of the managed care systems. NCQA is a non-profit organization dedicated to improving healthcare quality, it accredits and certifies a wide range of health care organizations. Founded in 1990, “it has been a central figure in driving improvement throughout the healthcare system, helping to elevate the issue of health care quality to the top of the national agenda” (NCQA). The NCQA has a seal that is widely recognized as a symbol of quality.

    “Organizations incorporating the seal into advertising and marketing materials must first pass a rigorous, comprehensive review and must annually report on their performance” (NCQA). The NCQA works with large employers, doctors, patients, policy makers and health plans to figure out what should be important, how they measure it and how it could be improved. They help transform the healthcare system, by using collected data. Health plans that would like to become accredited through the NCQA have to “face a rigorous set of more than standards and must report on their performance in more than areas” (NCQA). These standards change throughout the years and become more stringent, making it a process in itself.

    The AAAHC was founded in 1979 by six members of the American College Health Association; they are 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. They “encourage and assist ambulatory health care organizations to provide the highest achievable level of care for recipients in the most efficient and economically sound manner. The AAAHC accomplishes this by the operation of a peer-based assessment, consultation, education and accreditation program” (AAAHC). Today the AAAHC has 17 member organizations that span a wide spectrum of ambulatory health care. They have added “new standards in areas such as dentistry, behavioral health, and health education and wellness while continuously updating existing Standards to reflect cutting-edge ambulatory care knowledge and practice” (AAAHC).

    The MBHCO can be seen as a part of the NCQA, demonstrating to “health plans, employers, regulators and consumers that an organization follows evidence-based practices for providing high-quality care, access and consumer protections” (NCQA). MBHCO accreditation can be earned by proving their proficiency across five standards. Quality management and improvement, where the organization has a process that will monitor, evaluate and improve the quality of safety of the care that is provided. Care coordination, where the organization coordinates the medical and/or behavioral care for its members. Utilization management entails that the organization with let their members and practitioners know about coverage decisions within a required time frame. Credentialing and re-credentialing, being where the organization will check the credentials of the practitioner’s network.

    Also there is the members’ rights and responsibilities being where the organization has written members’ rights and responsibilities policy. You might wonder why physicians need to have accreditation with managed care facilities and have their licenses at the facilities that they work under. This is a legal matter, being almost the same as you always having your license in any car that you drive. Although the physician may be well known in the community, they have to have their licenses on file in each facility they work under. This is for the facility and well as the physician. Nurses will work under the physician’s license for the managed care, but they also need to have their nursing licenses up to date. “Nursing is one of the health professions that can cause harm to the public if practiced by someone who is unprepared and/or incompetent” (NCSBN). If something were to happen and they did not have their licenses on file, the facility, physician or nurse could be at fault and receive a fine. I have worked in a dialysis facility and was in charge of all the licenses in our facility. Having seen what can happen to the company if a State Inspector came in and you did not have updated information I would always do a monthly audit to insure that no one fell behind on their CEU’s and their licenses were always up to date in the facility. CEU stands for Continuing educational “unit of credit equal to 10 hours of participation in an accredited program designed for professionals with certificates or licenses to practice various professions (Peterson)”.

    There are many places they can find these classes for their CEU’s and Physicians and Nurses must go through their normal college credits and graduate from a verified school. They have to pass their own individual boards, which are rigorous tests that will show that they can “practice what they preach” (so to speak). Physicians and Nurses must submit a Licensure Application as new graduates. They must meet all the requirements for the licensure in their specific locations. Each state will have its own statutes and rules that may be the same or completely different. Renewing those licenses, typically annually will depend upon the amount of CEU’s and practice hours they have throughout the year, as well as other activities that may be state specific. In a managed care like NCQA, to become part of their system you organization would have to meet 12 Quality Management and Improvements, 15 Utilization Management requirements, 9 Credentialing and Re-credentialing, and the list goes on. This is not a process in which one will wake up one day and say I want to join that group and have it done by dinner time. It is a rigorous task to meet the guidelines given by the group. Once your organization has gathered and completed the required tasks, the organization you are applying to will come out during the process and after to audit your systems.

    This is another arduous task, but one that must be looked at as a learning experience. They will test and analyze your systems to make sure they meet not only state standards but any others they feel is important. Being in charge of this area in the facility there has to be very open and courteous communication between you and your license holders. The physicians have their own separate offices at times and have their own staff that will remind the physician about their own CME’s. In this instance you are lucky and only have to remind your nurses that they need to make sure they are completing courses that will count towards their CME’s. Having poor or bad communication between offices can cause you to get licenses that are past due or result in you getting them from another office the physician associates with. The key is to remember that they have busy schedules and you cannot seem as if you are pestering them for the information.

    Being able to help out if asked is another skill that is good to have. Being able to help find classes that they can go to for the CEU’s (Continuing Education Units), is a big help that not all facilities think about. If a charge nurse is close to renewing her license and has not had time to do classes to gain enough CEU’s, being able to help him/her look for classes in their related fields is a major help. It may take some extra time on your part, but look at the local colleges and online, your nurses will know which classes are approved areas for them to take. I believe that a great solution to help offices keep up with their managed care’s regulations and stipulations an access program that will connect only with that company and can be updated on both ends.

    If you had a program that is only between the Managed Care and their affiliates (physicians and their offices) it can use system updates to let the physicians know when a new rule has been implemented. This spreadsheet can also let the physician know when the Managed Care might need a copy of their updated licenses, CEU’s or liability insurance. One could also put in an area in the access program that will have a place to upload a picture/copy of these items that way there will never be a need to keep checking and calling offices for the items. This system will also show the physician(s) where they stand in the managed care, if they are in good standing or if they have areas they need to work on. This system will also save on paper, being that no reminder letters will be sent out to each physician or their offices. Having a system like this also will come with a price to make sure information is protected.

    Some of the licensure information has the physician’s date of birth or other information that does not need to be shared with anyone who should not have access to it. In this way, a great firewall would need to be established that works only with logins given by the managed care. An ongoing virus scan would need to implement as well, making sure that no virus is uploaded and information leaked out. This can be done by investing a good amount in your internet protection and safety. A system administrator will have their hands full setting this system up but it can be done with the right expertise. With this system in place and running smoothly each party (the managed care and the physicians) can pass information quicker between each other and not loose time waiting for responses to letters or emails. This system would be in real time and show what each has in the time it is looked at.

    A physician would be kept up to date on what changes are coming and what may have already passed and make their changed accordingly to maintain in good standing with the managed care. The managed care can be sure to know that each physician under them will know of new changes without having to send letters or emails. In conclusion managed care and physicians can save time and money by adapting a system that will update each other in what is needed will save time and eventually money. This system will cut costs down on postage used to send letters and faxes (as you will not have to worry about making a copy of smaller pieces of paper to fax). This day in age everyone is leaning more on electronic communication and this database would allow more communication between the 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

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    Achieving and Maintaining Accreditation in Managed Care. (2016, May 05). Retrieved from https://graduateway.com/achieving-and-maintaining-accreditation-in-managed-care/

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