NUR 621 What is the difference between the National Committee for Quality Assurance (NCQA) and the Utilization Review Accreditation Commission (URAC)?

Accountable Care Organization (ACO) consists of networks of providers that are rewarded financially if they can slow the growth in their patients’ healthcare spending while maintaining or improving the quality of care they deliver. For ACOs to be a success, there must be a collaboration of care. The goal of the ACOs is to provide well-coordinated, cost-effective care when clients need it. Under the Shared Savings Program, ACOs must meet several eligibility requirements, including providing certification to the Centers for Medicare and Medicaid Services (CMS) and their ACO application to be considered for and participate in this saving program (Strategic Management Services, 2022).

The National Committee for Quality Assurance (NCQA) is a private non-profit organization dedicated to improving healthcare quality (NCQA, 2022). The NCQA’s mission is to improve health care quality with the vision of better healthcare, better choices, and better health (NCQA, 2022). The NCQA developed quality standards and performance measures for a broad range of healthcare entities, and these tools helped organizations and individuals to identify opportunities for improvement (NCQA, 2022). The NCQA Health Plan Accreditation help to meet the goal of a plan that supports care that keeps members at an optimum level of health while controlling costs and meeting government and purchaser requirements (NCQA, 2021). Another accrediting body that helps to improve the quality of care is the Utilization Review Accreditation Commission (URAC). The URAC is one of America’s most prestigious accrediting organizations and non-profit accreditation entities that helps to improve the quality of care (URAC, 2022). The URAC’s renowned accreditation and certification programs set the highest standards in quality and safety (URAC, 2022).

Accreditation is essential in healthcare for accountability and to meet standards. Accreditation helps to improve healthcare quality and adherence (URAC, 2022). Health plans may choose one accrediting organization over another because of costs, accreditation process, recognition, and the different requirements needed to be accredited. Despite the choice of the accrediting body, the aim is to ensure high-quality care.

References

National Committee for Quality Assurance. (2021). Health plan accreditation. https://www.ncqa.org/programs/healthplans/health-plan-accreditation-hpa/

National Committee for Quality Assurance. (2022). About the NCQA. https://www.ncqa.org/about-ncqa/

Strategic Management Services. (2022). Accountable care organizations: ACO final rule summary.

Accountable Care Organizations Requirements: ACO Final Rule Summary

Utilization Review Accreditation Commission. (2022). About the URAC. https://www.urac.org/about/

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Accreditation agencies are impartial organizations that oversee and evaluate the functioning of healthcare organizations to ensure they meet the pre-established performance standards. The accreditation agencies set quality standards and benchmarks to strengthen the organizations’ goals to deliver high-quality patient care. In addition, they oversee the functioning of organizations and physicians to evaluate their performance against the pre-established quality standards. With the paradigm shift from treatment and cure to prevention, health care organizations focus more on continuous quality improvement to promote positive patient outcomes. National Committee for Quality Assurance (NCQA) plays an accreditation role to organizations that incorporate medical groups, physician networks, and health plans such as PPOs and HMOs (Richter & Beauvais, 2018). It utilizes accountability, measurements, and transparency to identify the top healthcare performers and compel improvement. The private sector and the government clients seek the services of NCQA through grants and contracts to measure quality and provide the necessary improvements. NCQA focuses on HEDIS (Healthcare Effectiveness Data and Information Set) in addition to recognition and certification programs.

References

Richter, J. P., & Beauvais, B. (2018). Quality indicators associated with the level of NCQA accreditation. American Journal of Medical Quality, 33(1), 43–49. https://doi.org/10.1177/1062860617702963.

Denver, R. C. (2011). Accreditation to approve health plans and providers. National Conference of State Legislatures. https://www.ncsl.org/documents/health/HRHealthPlans.pdf.

Payne, J. (2018). A commitment to quality care: URAC accreditation for CA SB1160 and beyond. Mitchell. https://www.mitchell.com/insights/workers-comp/articles/commitment-quality-care-urac-accreditation-ca-sb1160-and-beyond.

NCQA (National Committee for Quality Assurance) uses measurement, transparency, and accountability to highlight top performers and drive improvement. It began early in 1990 by measuring and then accrediting health plans. NCQA’s mission has grown to measure the quality of medical providers and practices. Most NCQA employees work on (Healthcare Effectiveness Data and Information Set) HEDIS and accreditation, certification, and recognition programs. Government and private sector clients hire it through contracts and grants to help measure and improve quality. Accreditation is awarded for three years, and certification is awarded for two years. NCQA accredits organizations ranging from health plans including HMOs and PPOs to physician networks and medical groups (National Committee for Quality Assurance, 2022). The (National Committee for Quality Assurance) NCQA requires MCOs (Managed Care Organizations) to report quality indicators and to address concerns about under-care as part of their accreditation requirements. The NCQA uses the (Healthcare Effectiveness Data and Information Set) HEDIS for quality reporting by HMOs and other health plans. Despite the expansion of MCOs in early 1990, increased resistance to managed care by physicians limited the negotiation of HMO contracts in many communities. Consumers and some employers also became resistant to taking part in managed care plans (Penner, 2016).

URAC (Utilization Review Accreditation Commission) is an independent, nonprofit accreditation agency based in Washington, D.C. whose mission is to advance healthcare quality through leadership, accreditation, measurement, and innovation. URAC was founded in 1990 as a third-party healthcare quality validator. URAC uses evidence-based measures and develops standards through inclusive engagement with a broad range of stakeholders committed to improving healthcare quality. Most accreditations are awarded for three years. However, there are two programs with a two-year cycle (Health Content Provider and Health Website). URAC accredits health plan programs including dental plans, healthcare management programs, pharmacy quality management programs, and provider integration and coordination programs (Utilization Review Accreditation Commission, 2022).

References

National Committee for Quality Assurance (2022). https://www.ncqa.org

Utilization Review Accreditation Commission (2022). https://www.urac.org

Penner, S. J. (2017). Economics and financial management for nurses and nurse leaders (3rd ed.). Springer Publishing Company.

Accreditation is important as it helps determine if an institution meets or exceeds minimum quality standards. The National Committee for Quality Assurance (NCQA) accredits organizations that range from health plans that include HMOs and PPOs to physician networks and medical groups (U.S. Centers for Medicare & Medicaid Services, 2021). The NCQA is an independent 501 nonprofit organization in the United States that works to improve health care quality through the administration of evidence-based standards, measures, programs and accreditation. Independent organizations are also known as nonprofit or nongovernment organizations (NGOs). NGOs pursue a charitable goal at either a local, national or global level and can achieve it by petitioning governments or fundraising. Nonprofit organizations are also called a not-for-profit organization as they do not earn any profit but instead donate it in order to hep the organization reach its objectives and goals (Penner, 2017).

Utilization Review Accreditation Commission (URAC) was founded in 1990 and is a Washington DC based healthcare accrediting organization that establishes quality standards for the healthcare industry. URAC accredits health plan programs that include dental plans, healthcare management programs, pharmacy quality management programs, and provider integration and coordination programs. The NCQA and URAC have their own unique entities but both share in the goal of making improving healthcare and delivering high quality care. Patients may choose one over the other based on cost, performance, and alignment with one’s personal goals. There are currently only eleven Centers for Medicare & Medicaid (CMS) approved accrediting organizations, therefore those 11 accrediting bodies may hold an increased level of rank (U.S. Centers for Medicare & Medicaid Services, 2021). The URAC is the only CMS accrediting organization. Accreditation improves the overall quality of care in healthcare facilities and in certain specialty areas can also improve patient outcomes and stimulate continuous improvement.

Penner, S. J. (2017). Economics and financial management for nurses and nurse leaders (3rd ed.). Springer Publishing Company.

U.S. Centers for Medicare & Medicaid Services. (2021). CMS-approved accrediting organizations. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Accrediting-Organization-Contacts-for-Prospective-Clients-.pdf

Accreditation is important as it helps determine if an institution meets or exceeds minimum quality standards.docx

The National Committee for Quality Assurance (NCQA) was founded in 1990. They began their mission by assessing and accrediting health plans. The organization is an independent non-profit organization located in the United States. The organization’s goal is to improve patients’ quality of healthcare through evidenced-based practice, quality measures, quality programs, and accreditation. Since 1990 the organization has evolved and are able to measure the medical healthcare quality that is offered and provided to the community by healthcare providers (NCQA, n.d.). NCQA are hired by the government and private sector to assist them evaluate, measure, and improve patient quality healthcare. There are more than 173 million individuals that are enrolled in NCQA accredited health plans. Some of the accreditation programs under the NCQA include, Accountable Care Organizations, Health Plan Accreditation, Case Management Accreditation, and PCMH CAHPS Distinction to name a few.

The Utilization Review Accreditation Commission (URAC) is a non-profit organization located in Washington, DC. The role of the organization is to review policies and procedures. They conduct onsite visits to healthcare organizations to evaluate if the organization is following, complying, and operating in accordance with state polices. The URAC provides a rigorous accreditation process to ensure that healthcare organizations are meeting industry best practices. The organization’s goal is to provide a model for creating organizational structure and management. Obtaining accreditation from URAC shows or proves commitment to quality and accountability (URAC, n.d.).

The difference between The National Committee for Quality Assurance (NCQA) and the Utilization Review Accreditation Commission (URAC) is where NCQA offers a grading system to healthcare organizations such as HMOs and PPOs. They also accredit physician networks and medical groups that are willing to obtain accreditation. The Utilization Review Accreditation Commission provides accreditation to healthcare programs that include dental plans, healthcare management programs, pharmacy quality management programs, provider integration, and coordination programs. Healthcare organizations are not required to go through accreditation, but it is a choice that healthcare organization are willing to be taken seriously in the healthcare industry.

References

National Committee for Quality Assurance (NCQA). (n.d.). About NCQA. https://www.ncqa.org/about-ncqa/

URAC. (n.d.). Health utilization management accreditation. https://www.urac.org/accreditation-cert/health-utilization-management-accreditation/

The National Committee for Quality Assurance (NCQA) and the Utilization Review Accreditation Commission (URAC) are the two main accrediting bodies in the health insurance world (Familiarize yourself with the major health plan accreditors, 2017). Minimum standards are established by accreditation for managed care. This is so health plans can identify facilities and individual professionals that are qualified appropriately. They also are identified in order to participate in their networks and help to achieve quality care to members (Familiarize yourself with the major health plan accreditors, 2017).

The NCQA was established in 1990. They provide credentialing standards for managed behavioral healthcare organizations, physician organizations, health plans, and credentials verification organizations. The CVO certification program helps to improve services provided to managed care clients through credentials verification operations. Certification surveys are completed both onsite and offsite through evaluations conducted by a survey team. The survey team consists of at least one credentialing and one recredentialing surveyor and an administrative surveyor. The survey team’s findings are then analyzed by the Review Oversight Committee (ROC) to assign a certification status. The status is based on the performance during the survey against the core standards and requirements (Familiarize yourself with the major health plan accreditors, 2017).

The URAC was also established in 1990. It offers more than thirty certification and accreditation programs. Healthcare organizations are accredited based on functions. URAC provide many different services including organizational review of health plan standards and improving quality. Hospitals, health maintenance organizations, third-party administrators, provider groups, and preferred provider organizations can apply for accreditation. The accrediting process is conducted in four stages and include application, desktop review, onsite review, and committee review (Familiarize yourself with the major health plan accreditors, 2017).

There are many reasons health plans may choose one accrediting body over the other. Depending on what kind of healthcare organization can determine which body is selected since they each provide for different organizations. The need for different plan coverage could determine what body to go with as well. The different processes for accreditation may help make a decision or which one has a better reputation for quality. Regulatory requirements may also be a determining factor.

Familiarize yourself with the major health plan accreditors. Familiarize yourself with the major health plan accreditors | Credentialing Resource Center. (2017, March 30). Retrieved January 16, 2022, from https://credentialingresourcecenter.com/articles/familiarize-yourself-major-health-plan-accreditors

The National Committee for Quality Assurance (NCQA) is a free, not-revenue driven relationship in the United States that fosters clinical benefits quality through the association of verification-based standards, measures, activities, and approval. The National Committee for Quality Assurance chips away at a formula of measure, assessment, and improvement and it means to create understanding across the business by working with policymakers, supervisors, subject matter experts, and patients, similarly as prosperity plans. The National Committee for Quality Assurance regulates purposeful approval programs for individual specialists, prosperity plans, and clinical social affairs. It offers dedicated tasks zeroing in on shipper testaments, programming confirmation, and consistency looking into various areas (National Committee for Quality Assurance, 2018). A public oversight board reviews the gathering’s disclosures, and an approval level is consigned reliant upon how an MCO has the stuff contrary to these rules, which fall into five classes: access and organizations, qualified providers, staying sound, improving, and living with affliction. NCQA’s obligation to the clinical benefits system is assessed through estimations that track the idea of care passed on by the country’s prosperity plans. Reliably, these numbers have improved for the past five years; clinical consideration shows have been refined, experts have learned better ways to deal with training, and patients have become busier with their thoughts. Those overhauls in quality thought convert into lives saved, sicknesses avoided, and cost diminished.

As shown by the Utilization Review Accreditation Commission URAC, affirmation is described as an evaluative, intensive, direct, and comprehensive communication in which a clinical consideration affiliation goes through an appraisal of its systems, cycles, and execution by an impartial, external relationship to ensure that it is driving business such that meets destined measures and is dependable with general rules (URAC, 2019). URAC approves many kinds of clinical benefits substances subject to their ability; two or three models are pharmacies, crisis centers, and provider social occasions. The restrictive assumptions set by URAC keep awake with the quick changes in the clinical benefits structure and give a trait of separation to clinical consideration relationships to show their commitment to quality and obligation. URAC endeavors to ensure that the destiny of clinical benefits controls costs, raises rates, and further creates expected prosperity results.

National Committee for Quality Assurance. (2018). Health Care Accreditation, Health Plan Accreditation Organization – NCQA – NCQA. NCQA. https://www.ncqa.org/

URAC. (2019). URAC. URAC. https://www.urac.org/

NUR 621 What is the difference between the National Committee for Quality Assurance (NCQA) and the Utilization Review Accreditation Commission (URAC)?