TABLE 1


Accreditation Status List, Summary Statistics, January 30, 1997
Decision Number Percent
Full 118 47
One-Year 85 34
Provisional 24 9
Denial 25 10
Under Review 1 –1%
Total 253 100
Decisions Pending 18
Initial Reviews Scheduled 59
Grand Total 330


















TABLE 2


Standard Federal HMO Act Medicare1 Medicaid FEHBP NAIC Model HMO Act NCQA Accreditation Standards
Quality Assurance (QA) To be federally qualified, HMOs must have:
•  QA program with emphasis on health outcomes (42 USC 300e(c)(6))
•  Review of health care delivery process by physicians or other health professionals (42 USC 300e(c)(6))
•  Systematic data collection; data interpretation; implementation of changes as needed (42 CFR 417.106)
•  Written procedures for remedial action deemed appropriate by the health plan to address QA issues (42 CFR 417.106) 		To participate in the Medicare program, HMOs must have:
•  Ongoing QA program with emphasis on health outcomes
•  Review of health care delivery process by physicians or other health professionals (42 USC 1395mm(c)(6))
•  External quality review by a peer review organization (PRO) (42 USC 1395 mm(i)(7)A))
•  Systematic data collection; data interpretation; implementation of changes as needed (42 CFR 417.418 and 42 CFR 417.106)
•  Reporting of HEDIS 3.0 performance measures (HCFA Operational Policy Letter #47, issued December 1996)
•  Independent administration of a Medicare beneficiary satisfaction survey (HCFA Operational Policy Letter #47)
•  Establishment of written procedures for remedial action deemed appropriate by the health plan to address QA issues (42 CFR 417.418 and 42 CFR 417.106) 		Federal standards include:
•  Internal QA systems with review by appropriate health professionals, systematic data collection and analysis, and provisions for making changes as needed (42 CFR 434.34)
•  QA systems required under HCFA Terms & Conditions for approving Section 1115 waivers
•  Inspections by independent reviewer to determine that Medicaid health plans meet professionally recognized health care standards (42 USC 1396b(m)(6) (B)(iv))
•  HCFA strongly encourages states to collect HEDIS 3.0 data from Medicaid HMOs.
•  State Medicaid programs may establish additional quality standards, as long as they are not inconsistent with federal standards. 		To participate in the FEHBP program, HMOs must use the following QA strategies:
•  Operation of QA program with specified procedures to address, at least, service quality and responsiveness to member inquiries and requests (§1.9 (a)(1-4) of 1997 Standard Contract)
•  Data collection and development of statistical reports on condition-specific patient outcomes (§1.9 (a)(8) of 1997 Standard Contract)
•  Use of a statistically valid sampling technique to measure claims against QA and fraud & abuse prevention standards (FEHBP Attachment to Carrier Letter 93-19(A) Quality Assurance Standards, FEHB Prepaid Plans)
•  Administration of a uniform patient satisfaction survey; responsiveness to survey results (§1.9(d) of 1997 Standard Contract) 		•  Ongoing QA program to monitor and evaluate health services (§7B of Model Act)
•  Procedures to ensure health care delivery under reasonable quality standards, consistent with recognized medical practice standards (§7A of Model Act)
•  Written goals and objectives for QA program that emphasize improved health status (§7B(1) of Model Act)
•  Ongoing, focused activities to evaluate health care services (§7B(2) (e,f) of Model Act)
•  Written plans for taking corrective action as appropriate (§7B(5) of Model Act) 		•  Organizational arrangements for quality improvement program (QI 1.0 of 1996 NCQA Standards for Accreditation)
•  Committee for quality improvement oversight and implementation, with active participation from providers (QI 1.5, 1.7)
•  Annual quality improvement work plan (QI 1.10)
•  Systematic monitoring and evaluation of health care quality and appropriateness (QI 5.0)
•  Identification of important areas for improvement and establishment of meaningful priorities (QI 6.0)
•  Use of quality improvement information in credentialing, recontracting and/or annual performance evaluations (QI 3.1)
Credentialing and Other Requirements for Affiliated Providers •  No explicit statutory requirements
•  Per HCFA guidance for federally qualified HMOs, the following activities demonstrate an organizational commitment to quality:
—Recruitment of physicians who have demonstrated performance consistent with the HMO's established practice standards;
—HMO evaluation of providers' patient complication rates, morbidity or mortality rates, extent to which providers engage in unproven medical practices;
—Consideration of physician malpractice payments; revocation, surrender, or suspension of state license or DEA/BNDD number; criminal convictions, curtailment or suspension of medical staff privileges; Medicare/Medicaid sanctions; censure by state or county medical associations
—Examination of information from the National Practitioner Data Bank (NPDB)
—Recredentialing that incorporates NPDB information and physician performance data
(HCFA manual for federally qualified HMOs §4202.3(E)(1)(a)) 		•  No explicit statutory provisions
•  Per attachment to HCFA guidance on HMO/provider contracts:
—For services rendered to Medicare HMO members, providers must agree to review by the plan's QA and utilization management committees and/or staff. 		•  Not referenced in federal standards
•  State Medicaid programs may establish their own credentialing standards. 		•  Routine credential checks during initial hiring and re-credentialing process are required.
•  Credentialing procedures must include: verification of medical school graduation records; routine check with local and/or medical societies or boards; routine check of DHHS list of de-barred providers; routine check of the National Practitioner Data Bank (§1.9 (a)(6)) of 1997 Standard Contract) 		•  System for provider credentialing and peer review included in quality assurance program (§7B (2) (g)) •  Verification of: practice license; clinical privileges in good standing at provider's primary admitting facility; valid DEA or CDS certificate as applicable; medical school graduation and completion of residency or board certification; work history; current, adequate malpractice insurance; medical liability history (CR 5.0 of 1996 NCQA Standards for Accreditation)
•  Check of the National Practitioner Data Bank; check with the State Board of Medical Examiners or Department of Professional Regulations; check for sanctions by Medicare or Medicaid (CR 7.0)
•  Credentialing and recredentialing process includes a site visit to offices of potential primary care practitioners, OB/GYNs, and other high-volume specialists (CR 8.0, 13.0, 13.2)
•  Plan must review provider sites and record-keeping practices to ensure conformance with the health plan's standards (CR 8.1)
•  Recredentialing, reappointment, or recertification at least every two years (CR 10.0, 10.1)
Access •  Availability and accessibility of services in a reasonably prompt manner that ensures continuity of care; availability of medically necessary services 24 hours a day/seven days a week (42 USC 300e(b)(4))
•  Required HMO payment for out-of-network emergency services if services were medically necessary and immediately required due to an unforeseen illness, injury, or condition and it was not reasonable under the circumstances to obtain these services through the HMO (42 USC 300e(b)(4)) 		•  Same as Federal HMO Act standards for basic and emergency services (42 USC 1395mm(c)(4)) •  Federal requirements include:
•  Services available to Medicaid HMO members to same extent as available to beneficiaries in FFS Medicaid (42 USC 1396b(m)(1)(A)(i))
•  System established by the state Medicaid agency for periodic (at least once a year) medical audits to ensure that Medicaid health plans provide quality and accessible care (42 CFR 434.53)
•  Provision for payment of medically necessary, out-of-network emergency services either by HMO or state Medicaid program (42 USC 1396b(m)(2)(vii))
•  State Medicaid programs may establish additional access standards, provided that they are not inconsistent with federal standards. 		•  Immediate care for emergency appointments (§1.9(a)(7) of 1997 Standard Contract)
•  Availability of urgent appointments within 24 hours of authorized request (§1.9(a)(7)(i) of 1997 Standard Contract)
•  Availability of routine appointments within one month, on average, of an authorized request (§1.9(a)(7)(ii) of 1997 Standard Contract)
•  Average office waiting times (for members arriving on time for scheduled appointments) of 30 minutes (§1.9(a)(7)(iii) of 1997 Standard Contract)
•  An average of 60% of written member inquiries responded to within 10 working days (§1.9(a)(3)(i)(A) of 1997 Standard Contract) 		•  Procedures to ensure availability, accessibility, and continuity of care (§7A) •  Establishment of organizational standards for availability of primary care providers and patient access to services (QI 7.0 of 1996 NCQA Standards for Accreditation)
•  Action to ensure that services are available and accessible to members (RR 5.2)
•  Identification of “points of access” for members regarding primary care, specialty care, and hospital services (RR 5.2.1)

1This chart highlights the major Medicare standards for quality assurance, provider qualifications, and access to care. For more extensive, detailed information, see the HMO/CMP Manual.
2The Secretary of the U.S. Department of Health and Human Services (HHS) is required to contract with a utilization and quality control PRO for an initial period of three years, renewable triennially, to review services provided through the Medicare program. Organizations eligible to contract as PROs must “show that they are either physician-sponsored or physician access organizations.” A physician-sponsored organization, which has priority, “is both composed of a substantial number of licensed doctors of medicine or osteopathy practicing medicine or surgery in the respective review area and is representative of the physicians practicing in the review area.”A physician access organization is one that “has available to it, by arrangement or otherwise, the services of a sufficient number of licensed doctors of medicine or osteopathy practicing medicine or surgery in the review area to assure adequate peer review of the services furnished by the various medical specialities and subspecialities.” The PRO must have at least one consumer representative on its governing board. Payor organizations such as Medicare fiscal organizations in the contract area can be considered if no other eligible non-payor orgnaization is available for a contract. (42 USC §1320c et. seq.)
3Section 1115 of the Social Security Act provides the HHS Secretary with broad discretion for waiving certain Medicaid laws in order to conduct experimental, pilot, or demonstration projects. This allows state and federal governments to implement Medicaid programs that test new and innovative ideas related to benefits and service, requirements and processes, program payment, and services delivery. Some of these demonstrations have sought to serve more low-income, uninsured individuals while achieving cost savings through new program efficiencies.