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New standards designed to streamline health plan oversight processes and operations are part of the 2000 Surveyor Guidelines for the Accreditation of Managed Care Organizations (MCOs), the document used by National Com- mittee for Quality Assurance (NCQA) surveyors and health plan personnel to prepare for and conduct accreditation surveys.
NCQA’s 2000 Accreditation standards introduce a number of important new requirements related to internal and external appeals processes, access to behavioral health care, and continued access to providers who leave or are dropped from a plan’s network.
Based on comments to the draft version of the guidelines, NCQA has made a number of changes to its 2000 Accreditation program, many of which are designed to streamline the oversight process and/or health plan operations. Changes include:
- Allowing health plans to skip the internal appeals process, and instead — with the member’s permission — send appeals directly to a third-party independent review organization. Health plans and consumers alike have expressed concerns that adding an independent third-party appeal on top of existing requirements for two-level internal appeals might make the whole process too long.
- Requiring MCOs to have a strategy to improve the quality of medical record keeping, rather than simply requiring biennial review of medical records.
- Focusing follow-up practitioner site visits on problem offices, rather than on all high-volume primary care physicians every two years.
Meanwhile, NCQA has also released its 2000 Standards and Surveyor Guidelines for the Accreditation of Managed Behavioral Health Care Organizations (MBHOs), a much updated version of the standards that further refines NCQA’s requirements for managed care organizations and MBHOs. Like its MCO accreditation standards, NCQA’s MBHO standards introduce new requirements for internal/external appeals processes and continuity of care. The new standards also cover items such as pharmaceutical management procedures.
The 2000 MBHO Accreditation standards also mark the full implementation of several monitoring standards that were not previously scored in the areas of quality management, utilization management, credentialing, and members’ rights and responsibilities.
NCQA’s Surveyor Guidelines for MCOs and MBHOs are effective for surveys conducted between July 1, 2000, and June 30, 2001. They are now available from the NCQA Publications Center. For more information, contact the center at (800) 839-6487, or visit the NCQA Web site at http://www.ncqa.org.