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Case Study
Midwest Midsize Payer Achieves National Committee for Quality Assurance Health Plan Accreditation
Summary
Learn how Change Healthcare Consulting helped a Midwest midsize health plan achieve NCQA HPA for all three lines of business and stay on track for its next accreditation.
Customer
Midwest Midsize Payer
Challenge
National Committee for Quality Assurance (NCQA) Health Plan Accreditation (HPA) standards had significantly changed, and new components required the plan to create new positions and roles. In addition to the new personnel, the client was also facing staffing transitions in key positions.
Achieving the Gold Standard
The NCQA HPA is considered the gold standard of health plans, as it is the only program in the industry that bases results on clinical performance and consumer experience (HEDIS® and CAHPS®), and both individuals and employers use this publicly reported accreditation to identify high-quality health plans
Twenty-seven states require that health plans serving their Medicaid population be accredited by NCQA—with seven others accepting NCQA HPA as meeting broad accreditation requirements. Beyond simply requireing HPA, 12 states use the results of the accreditation process to satisfy federal oversight requirements. Invoking Medicaid’s “nonduplication” provisions (known as “deeming”) allows states to:
- Simplify administrative review efforts.
- Reallocate resources to other priority projects.
- Demonstrate a commitment to maximizing limited oversight resources.
- Acknowledge health plans that have gone through the rigorous NCQA accreditation process.
One midsize payer in the Midwest was unexpectedly in need of assistance for NCQA reaccreditation. With only a few months to go before the survey, the health plan needed assistance with three lines of business and had minimal resources to complete its mission. Although the HPA preparation process is perpetual, the 12 months leading up to the accreditation determination is critical. During this period, the health plan must ensure that the proper documentation is completed, cited, and presented in a manner that highlights the organization’s capabilities to meet the rigorous requirements.
Overcoming Challenges With Personnel Changes
The Change Healthcare Consulting team engaged with the client to advise and help the plan attain reaccreditation during an especially challenging time. First, a few of the NCQA HPA standards had significantly changed over the previous two years, and new components required the plan to create new positions and roles. In addition to the new personnel, several of the client’s primary resources had moved on to other opportunities in the six months preceding the survey, resulting in ongoing transitions in key positions. On top of these internal challenges, the COVID-19 pandemic had a significant impact on typical business processes.
Mining Through Years’ Worth of Documentation
The Change Healthcare Consulting team assessed and prioritized the current state of the health plan’s documentation against NCQA regulations. Once gaps were identified, the team began working through two and a half years’ worth of documentation, citing proof points to show that all regulations were properly followed. The team was able to quickly mobilize resources and locate existing projects that met NCQA standards but which hadn’t been recognized by the organization as valid evidence. The team educated the health plan’s new team members on how to speed the process along. The Change Healthcare Consulting team also provided subject matter experts for extra support and assistance.
Achieving Accreditation and Staying on Track
Despite the odds, Change Healthcare Consulting helped the health plan achieve NCQA HPA for all three lines of business. This big win also positioned the organization to stay on track for its next accreditation. Recent U.S. regulatory changes have shifted the administrative burden of auditing health plans from CMS to NCQA. Medicaid plans in 31 states will soon be required to obtain NCQA accreditation, and many believe this requirement will eventually extend to all 50 states.
