Accreditation status Featured

9:57am EDT July 22, 2002
On June 1, 1994, The National Committee for Quality Assurance (NCQA) began regular and full disclosure of health plans’ accreditation status to the public. The Accreditation Status List, updated as of the end of each month, catalogs all plans that have an accreditation status with NCQA, all plans with pending accreditation decisions, and all plans scheduled to be surveyed.

What is NCQA Accreditation?

NCQA accreditation is a nationally recognized evaluation that consumers, employers and policy makers can use to assess managed care plans. NCQA accreditation evaluates how well a health plan manages its clinical and administrative systems in order to continuously improve health care for its members.

NCQA surveys are rigorous on- and off-site evaluations conducted by a team of physicians and managed care experts. A national oversight committee of physicians analyzes the team’s findings and assigns an accreditation level based on the plan’s performance compared to NCQA standards.

These standards (developed by a broad coalition representing consumers, employers, unions and health plans) are demanding. NCQA has purposely set high standards to encourage health plans to continuously enhance their quality. No comparable evaluation exists for fee-for-service health care.

What are NCQA’s standards?

NCQA’s standards for quality health plans fall into six categories:

  • Quality improvement Does the plan fully examine the quality of care given to its members? How well does the plan coordinate all parts of its delivery system? What steps does it take to make sure members have access to care in a reasonable amount of time? What improvements in care and service can the plan demonstrate?

  • Physician credentials Does the plan meet specific NCQA requirements for investigating the training and experience of all physicians in its network? Does it look for any history of malpractice or fraud? Does it keep track of all physicians’ performance and use that information for their periodic evaluations?

  • Members’ rights and responsibilities How clearly does the plan inform members about how to access health services, choose a physician or change physicians, and make a complaint? How responsive is the plan to members’ satisfaction ratings and complaints?

  • Preventive health services Does the plan encourage members to have preventive tests and immunizations? Does it encourage its physicians to deliver preventive services?

  • Utilization management Does the plan use a reasonable and consistent process when deciding what health services are appropriate for individuals’ needs? When it denies payment for services, does it respond to member and physician appeals?

  • Medical records How consistently do providers’ medical records meet NCQA standards for quality care? Do the records show that providers follow up on abnormal test findings?

What is the accreditation status list?

The list is in three parts, each organized alphabetically. Plans not on the list have not scheduled an NCQA accreditation survey.

The levels of accreditation decisions include:

  • Full accreditation is granted for a period of three years to those plans that have excellent programs for continuous quality improvement and meet NCQA’s rigorous standards.

  • One-year accreditation is granted to plans that have well-established quality improvement programs and meet most NCQA standards. NCQA provides the plans with a specific list of recommendations, and reviews the plans again after a year to determine if they have progressed enough to move up to full accreditation.

  • Provisional accreditation is granted for one year to plans that have adequate quality improvement programs and meet some NCQA standards. These plans need to demonstrate progress before they can qualify for higher levels of accreditation.

  • Denial is given to plans that do not qualify for any of the categories above.

  • Under review denotes plans for which an initial accreditation determination has been made but is under review at the plan’s request. The initial accreditation determination precedes the term under review.

  • Expired denotes a health plan that has allowed its provisional, one-year or full accreditation status to lapse without scheduling another accreditation survey. Plans receiving a denial do not revert to “expired.”

  • NCQA discretionary review denotes plans which NCQA has chosen to review to assess the appropriateness of an existing accreditation decision.

  • Acquisition review pending denotes that NCQA is resurveying the plan following a major acquisition, to ensure the earlier decision is still valid.

  • Merger/consolidation/acquisition review pending denotes that NCQA is resurveying the plan following a merger or consolidation, to ensure that the earlier decision is still valid.

  • Initial decision pending listsplans that have been reviewed for the first time but have not yet received a decision.

  • Future review scheduled shows the date of all initial reviews scheduled within the next 18 months.

How should consumers and purchasers use the list?

Accreditation status is not a guarantee of the quality of care that any individual patient will receive or that any individual physician or other provider delivers. However, plans that are accredited have demonstrated that they provide the consumer protections required by NCQA standards and that they closely monitor, and are continuously improving, the quality of care they deliver.

The National Committee for Quality Assurance, an independent non-profit organization in Washington, D.C., is the nation’s leader in assessing and reporting on the quality of the nation’s managed care plans. NCQA makes health plans accountable for the quality of care and service they deliver in two complementary ways: by evaluating health plans’ internal quality processes through accreditation reviews, and by developing measures to gauge health plan performance.