Seal of Approval

June 1, 2005

The accreditation process influences quality business improvement and has value beyond an organization seal of approval. Experts say the cost of low quality far exceeds the cost of the accreditation process.

AS MCOs SEEK to increase their market share in a highly competitive marketplace, accreditation can be a plus that helps them stand out from the crowd. In fact, for MCOs seeking contracts from major national employers, accreditation is more than a plus: it is a business necessity.

NCQA accredits about 230 HMOs and point-of-service plans, with a total of 60 million members. It has additional programs in place to accredit preferred provider organizations as well as other, more narrowly focused MCOs.

The substantial task of gathering and reporting this data was eased recently when NCQA introduced its Interactive Survey System (ISS), which allows organizations to submit their survey data via the Internet. "Scoring tools are built into the software," says Brian Schilling, NCQA director of communications. "Plans can use ISS to fine-tune themselves and evaluate whether they're ready to go through the survey process."

An NCQA onsite survey team usually includes four people, two physician surveyors plus two administrative surveyors who visit for two or more days. NCQA has a pool of 180 surveyors, including about a dozen who do surveys full-time. Survey fees are based on the number of plan members, and are usually about $40,000, with large plans paying up to $100,000.

Through NCQA, plans may receive "excellent," "commendable," "accredited" or "provisional" status, with less than 1% earning the "provisional" category. Accreditation generally stands for three years, although the lower levels stand for one year. In 2000, about 60% of plans were achieving the top level, but they've gotten better each time they go through the process. Now, about 90% achieve "excellent" status, Schilling says.

"That's good news and bad news," he says. "It's wonderful that plans are doing such admirable work, but when everyone receives our top ranking, that makes it harder to distinguish among plans. That's one reason we recently launched additional voluntary quality standards on topics such as member connections and case management, so that cutting-edge plans will have another way to distinguish themselves."

The Accreditation Association for Ambulatory Health Care (AAAHC) was formed in 1979 to help ambulatory healthcare organizations improve their quality of care, and over the years it has accredited more than 2,000 organizations. "In early 2000, we evaluated the marketplace and decided to expand our presence in the managed care market," says Joan Riebock, senior director of program operations. "Since many states require MCO accreditation, we're building recognition in those states."

The average fee for an AAAHC survey is $30,000, Riebock says. MCOs may achieve accreditation for three years, one year or six months, depending on their degree of compliance with AAAHC standards. The MCOs that select AAAHC as their accrediting body often are Medicare and Medicaid plans, Riebock says.

"AAAHC standards aren't prescriptive," she says. "We describe the characteristics of an accreditable organization, but MCOs may find many different ways to be in compliance. For example, while plans may use HEDIS measures to demonstrate compliance with the AAAHC standards for benchmarking, there are also other ways they can meet these requirements."

All AAAHC surveyors are "volunteers" who do accreditation surveys in addition to their related professional work. "We try to match the background and experience of the surveyor with the sort of care offered by the organization being surveyed," Riebock says. "That means our surveyors are able to offer educational, consultative assistance to the plan during the survey process."