What is NCQA Health Plan Accreditation

Are you a health plan looking into NCQA accreditation? We know that the process can be daunting and often stressful, so we’ve compiled a list of NCQA basics to help those who are pondering an NCQA accreditation. If you are a health plan who has already chosen to pursue NCQA accreditation, take a look at our blog post “NCQA Health Plan Accreditation : The Difference Between Failure and Success.” For those of you just getting started let’s dive into the NCQA basics, from who the NCQA is to an overview of their Health Plan accreditation levels. Hopefully this list helps jump-start your journey towards successful healthcare accreditation.

What is the NCQA?

The National Committee for Quality Assurance is an independent, non-profit in the United States that is concerned with establishing quality standards for healthcare organizations that aim to identify key areas of improvement within the organizations themselves. NCQA was established in the early ‘90s, a time in United States healthcare where there was a discernible shift in healthcare reform throughout The Clinton Administration.

What does the NCQA do?

The NCQA’s programs are voluntary for organizations, physician practices and individual physicians – though, their stamp of approval is widely regarded as a longstanding measure of quality improvement and speaks to an organization’s ongoing quality initiatives. They also review health plans, and in a competitive healthcare marketplace, it certainly doesn’t hurt to have accreditation if you want to do business. NCQA review is a rigorous process, one that requires planning, dedication and even a bit of elbow grease. Knowing that it is both an economic investment and an investment of time and energy for staff, how can your organization decide if you should undertake NCQA accreditation?

NCQA Health Plan Accreditation

For health plans the NCQA Health Plan accreditation is the gold standard. The NCQA Health Plan accreditation “has helped improve the managed care experience for health plans, patients, physicians and employers. Recognizing hundreds of plans that cover more than 136 million people (43 percent of the U.S. population).” The NCQA reviews the plan’s ability to meet employer demands, industry demands and, arguably most important, consumer demands. Especially now that consumers are ‘shopping around’ for health insurance coverage, it’s never been a more competitive market for insurers to try to survive in. Federal plans, like Medicare, insist upon the accreditation and forty states in the union recognize the accreditation; several dozen mandate it.

NCQA manages several key areas of performance, whether they are evaluating an organization, a group of physicians or a health plan:

  • Health promotion. Do the activities of the health plan or organization promote preventative care, work hard to ensure the return to health of its beneficiaries and is the goal to help patients avoid illness?
  • Recovery. Even the best preventative care is unlikely to keep everyone healthy at all times; so, when patients are sick, does the organization or plan work hard to get patients back on their feet? How do they evaluate and support new treatments and technologies? Are patients being offered the most up-to-date care – or are they getting left behind?
  • Chronic Illness. For patients with chronic illnesses, does the organization or plan develop proven, long-term strategies for management of these conditions? Do patients have access to resources in their communities?
  • Access. Are there enough doctors to meet demands of the community? If patients report not having access to the care they need, how are these reports handled? What is done to remedy this situation?
  • Qualification. Are the doctors serving the institution the highest qualified and working “to the top of their licensure?” Are physicians and other medical staff routinely evaluated and their credentials checked? Are they required to complete continuing education to further their expertise and experience to assimilate new information and technologies in the rapidly evolving field of medicine?

NCQA Health Plan Accreditation Levels

Excellent: NCQA awards its highest accreditation status of Excellent to organizations with programs for service and clinical quality that meet or exceed rigorous requirements for consumer protection and quality improvement. HEDIS results are in the highest range of national performance.

Commendable: NCQA awards a status of Commendable to organizations with well-established programs for service and clinical quality that meet rigorous requirements for consumer protection and quality improvement.

Accredited: NCQA awards an accreditation status of Accredited to organizations with programs for service and clinical quality that meet basic requirements for consumer protection and quality improvement. Organizations with this status may not have had their HEDIS/CAHPS results evaluated. If HEDIS/CAHPS results were evaluated, organizations must take further action to achieve higher accreditation status.

Provisional: NCQA awards a status of Provisional to organizations with programs for service and clinical quality that meet some, but not all, basic requirements for consumer protection and quality improvement. Organizations awarded this status need to improve their processes as well as clinical and service quality to achieve a higher accreditation status.

Interim: NCQA awards a status of Interim to organizations with basic structure and processes in place to meet expectations for consumer protection and quality improvement. Organizations awarded this status will need to undergo a new review within 18 months to demonstrate they have executed those processes effectively.

Denied: NCQA denies Accreditation to organizations whose programs for service and clinical quality did not meet NCQA requirements during the Accreditation survey.

*Levels taken from NCQA website