Here are some of the most frequently asked questions about NCQA’s various programs. If you don’t see what you are looking for in one of the entries below, you can ask a question through My NCQA.
Neither NQF nor HEDIS provider-level measures specifications require a specific attribution method, although HEDIS measures provide options for an organization to consider. While this might result in variation from one organization to another, there is currently no single industry standard method for attribution.
PHQ 2013
Though an organization may not have members in the way a health plan does, Web sites have users or consumers who might want to submit complaints (e.g., user complaints). Therefore, to meet the intent of Elements C and D, an organization must have policies and procedures to process, register and respond to consumer complaints; and must provide a documented process and evidence for how it handled those complaints.
PHQ 2013
For scenario 1, the data must be considered as part of the program being reviewed for PHQ because the organization has incorporated the data with its own or tailored the data and then used the data as a basis for its own action (e.g., reporting, payment or network or benefit design). For scenario 2, if _ as part of its program _ the organization simply provides a link to an external source of performance information on physicians without altering that data and represents it as such, and the organization does not take any action based on the data (e.g., pay any incentive or use data for network or benefit design) then it is not considered part of the program.
PHQ 2013
The definition of a program is clearly defined in Section 1 of the Policies and Procedures. A physician measurement program includes: 1) A defined group of physicians– the definition must include both physician type (e.g. specialty) and geographic area covered; 2) A defined set of clinical quality, service or patient experience measures– the program may also include a defined set of cost, resource use or utilization measures; 3) A defined methodology for producing measure results; 4) A specific action taken at a specific point in time based on the measure results.
A hospital transparency program includes: 1) A defined group of hospitals– the definition must include both hospital type and location; 2) A defined set of all-payer quality or cost measures whose results are publicly reported at a specific point in time.
Distinct programs are reviewed separately and a certification decision is issued for each. Physician measurement programs and hospital transparency programs are always distinct programs, even when operated by the same legal entity. NCQA reserves the right to determine that programs that are managed in a decentralized manner constitute distinct programs for review.
To the extent that one program is a derivative of another and share common aspects (e.g., an organization uses the same measures and methodology for a single defined physician group but takes two actions [reporting and network tiering]) and the organization seeks verification for both at the same time, NCQA can review common aspects once to streamline the survey process, although these are distinct programs.
PHQ 2013
It depends on the relationship between the organization and the practitioners, and what the state licensing agency allows. If the organization contracts with the IHS and directs its members to Indian Health Clinics, there is no need to credential individual practitioners for NCQA purposes, and consequently, no need to verify practitioner licenses. The clinics would fall under CR 8 in the 2013 HP Standards and Guidelines.
However, if the organization has an independent relationship with practitioners in a clinic and directs its members to these practitioners for care, the organization must credential the practitioners. The organization must verify practitioner licenses if the state licensing agency does not recognize the IHS license as a proxy for state license. Conversely, if the state licensing agency recognizes the IHS license as a proxy for the state license, there is no need to verify practitioner licenses. The organization must provide documentation showing state acceptance of the IHS license, during its survey.
NCQA does not prescribe the cost measures an organization selects, though it requires an organization to specify all aspects of its methodology (Element C). In addition, the organization must risk-adjust its measures (Element C, factor 8) and must meet the minimum statistical requirements for measurement error and measure reliability (PQ1 Element D, factor 2).
PHQ 2013
Element C, Define Methodology requires the organization to have a method for determining measurement error and measure reliability. Element D, Adhere to Key Principles sets requirements for minimum observations or levels of measure reliability or confidence intervalsas applicable for quality and cost, resource use or utilization measures. For calculating measure reliability for PHQ, the organization must use the method described in the Explanation in Element C under the subhead Measurement Error. Measure reliability is defined as the ratio of the variance between physicians to the variance within one physician, plus the variance between physicians. NCQA does not prescribe the method used to calculate confidence intervals because the appropriate method may vary based on the parameter (e.g., mean or proportion).
PHQ 2013
Yes. In prior versions of PHQ, NCQA required organizations to include all programs that met the definition of taking action in the survey, NCQA had a narrower definition. Because under PHQ 2013 organization chooses which programs to include or exclude in a PHQ survey, NCQA has broadened the definition so that if it chooses, an organization may opt to have programs certified that may not have been required under the prior PHQ.
For PHQ 2013, NCQA has defined taking action as: 1) Publicly reporting performance on quality or cost, resource use or utilization; 2) Using performance on quality or cost, resource-use or utilization measures as a basis for network design (such as tiering) or benefit design; 3) Using performance on quality or cost, resource-use or utilization measures to allocate rewards under a systematic, pay-for-performance program; 4) Reporting performance on quality, cost, resource use or utilization to physicians to support referral decisions.
If an organization is interested in certification for a program that includes actions not include an action defined above, it should contact NCQA to determine eligibility.
PHQ 2013
NCQA considers entities that perform relevant functions to be eligible for NCQA CM Accreditation, including, but not limited to: CM organizations, population health management organizations, health plans (HP), managed behavioral healthcare organizations (MBHO), provider-based organizations– including medical groups, hospitals, integrated delivery systems, patient-centered medical homes (PCMH) and accountable care organizations (ACO), community care teams.
CM 2014
