URAC Overview: Network Management and Consumer Satisfaction

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1 URAC Overview: Network and Consumer Satisfaction Presenter: Donna Merrick Director, Program Standards and Maintenance Date: December 8, 2015

2 About URAC Mission To promote continuous improvement in the quality and efficiency of health care management through processes of accreditation, education, and measures. Structure Non-profit, independent entity Broad-based governance Providers Employers Consumers Payers Regulators Expert Advisory Panels (Volunteer) Strategic Focus Consumer Protection and Empowerment Improving and Innovating Health Care 2

3 Fast Facts About URAC Non-profit, independent organization founded in 1990; originally chartered to accredit utilization review services URAC offers over 30 distinct accreditation programs across the entire continuum of care URAC currently accredits over 600 organizations operating in all 50 states and internationally URAC s accreditation programs are nationally utilized by state and federal regulators to ensure the highest level of quality is delivered to consumers 3

4 URAC Accreditation and Certification Programs Health Care Health Care Operations Health Plan Accreditation Pharmacy Quality Provider Health Utilization Case Disease Health Call Center Independent Review Organization Workers Compensation Utilization Health Network Health Content Provider/Website Credentials Verification Organization Health Plan Health Plan for Health Insurance Marketplace Medicare Advantage Health Plan Specialty Pharmacy Community Pharmacy Drug Therapy Mail Service Pharmacy Pharmacy Benefit Workers Compensation Pharmacy Benefit Accountable Care Clinical Integration PCMH Practice Certification Telehealth Dental Network Dental Plan Measures Core accreditation is available as a stand-alone program. Certification is available to organizations providing support services to URAC-accredited organizations. 4

5 Consumer Focused Principles Underlying URAC s Standards Health plans must have written policies and procedures for recruiting clinicians to their First network, level credentialing text Arial providers, size 20 and managing their network. Second level text Arial size 18 Health plans Third, are responsible fourth, fifth for level analyzing text Arial and size documenting 16 the geographic and demographic make-up of their enrollees as well as creating provider networks that are both accessible and deliver quality medical care. Consumers are provided an appeal process whenever they have financial responsibilities for out-of-network care. Consumers receive clear communications on how to access care both outside and inside the network including preventive, urgent, and emergency care. Health plans must routinely review information that could indicate problems with quality, access, or adequacy of their provider network. Such information include member complaints and appeals. 5

6 URAC Standards Directly Addressing Network and Patient Rights Scope of Services: Confirms that a plan has a process in place to establish and assess the requirements of the service area, in terms of both population demographics and geographic area, being served by a network. Access and Availability: Establishes that the health plan is actively monitoring the performance of its network on an ongoing basis, comparing the network capacity to current and potential future member needs and sharing these findings with its internal Quality Committee (QMC) for further action, if appropriate. Provider Selection Criteria: Verifies that the organization has a mechanism in place to inform providers regarding network participation requirements. Out of Network and Emergency Services: Validates that an organization has a plan in place to meet its obligation to provide all necessary care, and for the provision of emergency medical services when such services are not readily available within the network. The procedures must be made available to consumers in writing and in plain language. 6

7 URAC Standards Directly Addressing Network and Patient Rights Non-Certification Appeals Process: Validates that a patient can appeal, through a formal process, any denial of covered services based on medical necessity. Appeals Process: Requires the organization to include and review all relevant information before rendering an appeal decision. The health plan implements the appeal decision, certifying the requested service if the appeal overturns the initial non-certification. Compliance Program: Identifies the methods and accountabilities for an organization s compliance program by identifying and ensuring adherence to applicable laws and regulations. 7

8 Role of Consumer Satisfaction in URAC Accreditation CORE 35 Consumer Complaint Process: Requires the health plan to have a formal process to address consumer complaints that includes a process to inform consumers of their options beyond initial complaint process. The health plan reports analysis of complaints to Quality Committee. CORE 39 Consumer Satisfaction: Requires the health plan to have a mechanism implemented to collect or obtain information about consumer satisfaction on services provided to enrolled consumers. MR 3 Consumer Input and Surveys: Requires the health plan to gather information about consumer satisfaction specifically CAHPS, to obtain consumers perspective on the quality of care provided and to collect consumer suggestions and guidance. These standards coupled with URAC network management standards require health plans to constantly and consistently measure the quality and access of services they provide and have a process to remedy identified problems. 8

9 URAC Partnering with States Arkansas Addendum Standards Addressing Network Adequacy AR 1: Time and Distance Targets for Provider Access AR 2: Availability of Emergency Services AR 3: Continuity of Care Plan for Cessation of QHP Services AR 4: Back-up Process for Ensuring Provider Access AR 5: Additional [Department of Insurance] Requirements for QHP Provider Directories 9

10 Contact Information URAC 1220 L Street, NW, Suite 400 Washington, D.C Phone: (202) Fax: (202) For more information info@urac.org Donna Merrick Director, Programs Standards and Maintenance dmerrick@urac.org Aaron Turner-Phifer State Government Relations Officer aturner-phifer@urac.og 10