Independent Medical Reviews

NCQA accreditation: What does it mean?

July 06, 2020

A stamp saying 'Accredited' in red ink.

Numerous acronyms comprise the healthcare industry. As we discussed in a previous blog, even if you’ve worked in healthcare for years, it can be challenging to remember all of them.

The same is true for healthcare accreditation. TJC, also known as The Joint Commission, bestows accreditation to organizations that demonstrate a commitment to continuous improvement in patient care. URAC, previously known as the Utilization Review Accreditation Commission, about which we’ve written before, provides accreditation for healthcare organizations to demonstrate and highlight their commitment to utilization review (UR) quality and accountability. Accreditation from the Accreditation Association for Ambulatory Health Care, (AAAHC), means an organization participates in on-going self-evaluation, peer review and education to continuously improve its care and services.

The National Committee for Quality Assurance (NCQA) accredits and certifies an array of healthcare organizations, including providers, practices and health plans. The non-profit organization began in the early 1990s by measuring and then accrediting health plans. Until then, no comprehensive method was in place to evaluate a health plan’s quality, and no standards of quality were utilized to evaluate plans against.

The organization’s 12-person leadership team includes its founder, Margaret E. O’Kane. Since 2008, the organization’s mission has grown to measure the quality of medical providers and practices. Today, more than 1,000 health plan products have earned NCQA Health Plan Accreditation and an estimated 173 million people are enrolled in NCQA-accredited health plans. More than 191 million people are enrolled in health plans that report quality results using the organization’s effectiveness data and information set.

Health plan accreditation

One of NCQA’s biggest programs is its Health Plan Accreditation, the standards of which are used to evaluate plans on:

  • Quality Management and Improvement
  • Population Health Management
  • Network Management
  • Utilization Management
  • Credentialing and Recredentialing
  • Members’ Rights and Responsibilities
  • Member Connections
  • Medicaid Benefits and Services

The accreditation process takes an average of 12 months and is the only healthcare industry program that bases results on clinical performance and consumer experience.

For a healthcare organization to earn an NCQA Health Plan Accreditation, it is required to meet standards encompassing more than 100 measured elements. According to NCQA, the accreditation process helps “guarantee that organizations making these decisions are following objective, evidence-based best practices.” Its purpose is to help health plans improve operational efficiencies, satisfy state requirements and employer needs, keep patients happy and healthy, and demonstrate their commitment to quality.

A key component of NCQA’s accreditation process is the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Health Plan Survey 5.0. It’s part of the Experience of Care domain of HEDIS® (the Healthcare Effectiveness Data and Information Set), a set of health plan performance measures used for public reporting and accreditation. Although it would seem as though most health plans have achieved NCQA accreditation, one in four insured Americans receive care from plans that have not demonstrated compliance with the rigorous standards.

Utilization management accreditation

Under the umbrella of its Health Plan Accreditation is NCQA’s program for utilization management (UM). The UM accreditation process uses NCQA’s framework for ensuring healthcare organizations are using appropriate resources and evidence-based criteria, aligned with state requirements, to deliver necessary and quality care to patients. This is achieved by applying industry best practices and evaluating their reputation by demonstrating the quality of their programs to employers, regulatory agencies, health plans and managed behavioral healthcare organizations (MBHOs).

The Utilization Management Accreditation framework specifically addresses implementing industry-wide best practices to ensure fair and timely utilization evaluations using:

  • Objective, evidence-based criteria
  • Collection and use of relevant clinical information to make utilization decisions
  • Qualified health professionals to assess requests and make utilization decisions

AMR and accreditation

AMR is a proven leader in unbiased, accurate and quality independent medical review, as well as physician-level peer review services based on evidence-based medicine. We provide coverage during and after regular business hours, and on weekends and holidays, to supplement or cover health plans’ internal MD staff. AMR is accredited by URAC in health utilization management and comprehensive internal and external independent review, and supports our clients’ utilization management programs by complying with applicable NCQA requirements.

NCQA accreditation: What does it mean?