Health Plan Accreditation 2024: Utilization Management (UM)

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About this Webinar Training

Explaining Health Plan Accreditation 2024: Utilization Management (UM)

NCQA Health Plan Accreditation (HPA) is the only program in the industry that bases results on clinical performance and consumer experience (HEDIS® and CAHPS®).

This live, multi-day course leads learners through an end-to-end deep dive into the HPA standards for Utilization Management (UM). Through this course, presenters will provide you with insight to interpret the requirements, navigate the standards, and avoid misconceptions. In addition to answering live questions, the presenters address scenarios and examples based on performance improvement opportunities from prior NCQA surveys.

Please note, this course presents information based on HPA 2024 standard requirements that are released in July 2023. The scope of this course applies directly to NCQA Accreditation Surveys conducted between July 1, 2024, and June 30, 2025.

Group Training?

To inquire about group training rates, complete our online form.

Key Topics

– Controlling UM systems.

– Handling member appeals.

– Determining coverage and medical necessity.

– Administering denial notices.

– Improving survey readiness and performance.

Benefits and Resources

• Presentation slides.

• Recording of live session.

• Live Q&A.

• Pre-work activity and group breakout session for engagement.

• Scenarios for applied learning.

• NCQA surveyor’s perspective of the standards.

• IPCE Credits for physicians, nurses, and pharmacists.

What You Will Learn

– Interpret the intent of HPA requirements for UM Standards.

– Describe relationships and themes across UM Standards.

– Recognize requirement implications and considerations for stakeholders.

– Define performance improvement opportunities.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

Who Should Attend

Clinicians, executives, managers, specialists, consultants, delegates, and vendors who are employed or contracted by health plans with responsibilities pertaining to the scope of work listed below:

– Case Management.

– Compliance or Risk Management

– Population Health Management or Public Health.

– Quality Assurance/Improvement or Performance Management.

– Contracts Management.

– Health Information Systems.

Faculty

Irv Koehler, RN, MBA, CPHQ, CPC

Irv Koehler is a health care quality consultant for the Koehler Quality Group, LLC. In this position, he is an NCQA administrative surveyor and provides consulting services to organizations evaluating and preparing for NCQA Accreditation/ Certification projects, risk adjustment validation for managed care organizations, education on quality improvement practices and outcome measure development and tracking.  

Mr. Koehler is also a registered nurse with active licensure in Florida and Tennessee, and certification in quality and medical coding. Previously, he was a quality improvement professional at AmeriHealth Caritas and BlueCross BlueShield of Tennessee.

Mr. Koehler has an MBA from the Florida Institute of Technology, a BS in Nursing from Florida Southern College, a BA in Psychology and an ADN from Purdue University.

Clint Koenig, MD, MSPH, MA

Clint Koenig, MD, MA, MSPH is the Senior Medical Director at OhioHealthy, a new system-based health plan in Columbus, Ohio. He has served as State Medical Director in New Hampshire and Ohio. Other leadership roles include the Health Plan Regional Chief Medical Officer at Universal American, a government programs health management organization in Syracuse, New York, as well as, the Director for Utilization Management at Monroe Plan for Medical Care, a healthcare management organization in Rochester, New York. In addition, Clint held Chief Medical Officer roles in Federally Qualified Health Centers and integrated delivery systems.

He has been an NCQA surveyor for 10 years and surveys health plans, Patient Centered Medical Home, Special Needs Plans and Long Term Services and Supports organizations.

Dr. Koenig received his MD from Albany Medical College in Albany, New York. He completed his residency in Family Medicine, from the University of Missouri. He also completed a fellowship at the University of Missouri, where he received a master’s degree in Public Health and Journalism.

Continuing Education

 In support of improving patient care, the National Committee for Quality Assurance is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), the American Nurses Credentialing Center (ANCC) to provide Interprofessional Continuing Education for the healthcare team.

This activity was planned by and for the healthcare team, and learners will receive 4 Interprofessional Continuing Education (IPCE) credit for learning and change.

This educational activity is approved for a maximum of 4 AMA PRA Category 1 CreditTM, ANA CNE and ACPE

The assigned universal program number: JA0004597-0000-23-038-H04-P . Upon successful completion of this program (attending the full session and completing a program evaluation), participants will access CPE Monitor on the ACPE website to locate and track their CPE statement of credit.

This live course grants 2.0 Continuing Education Unit (CEU) points for PCMH Certified Content Experts.
* Please note – You must attend the entire program to be eligible for total number of contact hours. 

NABP CREDIT REPORTING:

If you are a pharmacist completing a course offering CPE credits, please notify NCQA through ncqa.org within 14 calendar days that you have completed a CPE course. You must provide the title of the course, your NABP identification number and your DOB (month/date) within the notification to NCQA. We also recommend you update your education.ncqa.org profile with your NABP identification number.

DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS

The National Committee for Quality Assurance (NCQA) endorses the Standards of the Accreditation Council for Continuing Medical Education which specify that sponsors of continuing medical education activities and presenters at and planners for these activities disclose any relevant financial relationships either party might have with commercial companies whose products or services are discussed in educational presentations.

For sponsors, relevant financial relationships include large research grants, institutional agreements for joint initiatives, substantial gifts, or other relationships that benefit the institution.  For presenters or planning committee members, relevant financial relationships include the receipt of research grants from a commercial company, consultancies, honoraria, travel, or other benefits, or having a self-managed equity interest in a company; or having an immediate family member or partner with such a relationship.

Disclosure of a relationship is not intended to suggest or condone bias in any presentation but is made to provide participants with information that might be of potential importance to their evaluation of a presentation.

Relevant financial relationships exist with the following companies/organizations:

Faculty:
Irv Koehler: None
Clint Koenig: None

Additional Planning Committee Member:
Felicia Khaalid: None

This program was developed in part by NCQA staff.

This program received no commercial support.

Event Type

1. Self Paced