November 4, 2004
CMS GRANTS NCQA DEEMING AUTHORITY FOR MEDICARE PPOs; MOVE PRECEDES EXPECTED JUMP IN PPO PARTICIPATION
NCQA Accreditation will satisfy most Medicare Advantage quality requirements, streamline oversight process
WASHINGTON—The Centers for Medicare and Medicaid Services (CMS) recently granted NCQA deeming authority for preferred provider organizations (PPOs) following a review of its PPO accreditation standards. CMS found that NCQA’s standards “meet or exceed” Medicare’s own quality requirements. As a result, PPOs participating in Medicare Advantage will be able to cite their NCQA Accreditation to satisfy federal regulatory oversight requirements. CMS’s deeming program allows organizations that participate in the Medicare Advantage program to satisfy many of these requirements by earning accreditation from an approved third party rather than through a full CMS audit.
In 2002, NCQA became the first private organization to gain deeming status for HMOs under Medicare Advantage (then Medicare+Choice). Since that time, NCQA has become the industry leader in accrediting Medicare Advantage plans. Currently 50 of the approximately 150 plans participating in the Medicare Advantage program have opted to pursue NCQA Accreditation.
“This is our second big vote of confidence from CMS and our second opportunity to relieve some of the oversight burden for plans that serve Medicare beneficiaries,” said NCQA President Margaret E. O’Kane. “We look forward to serving the needs of a growing Medicare Advantage PPO market and to ensuring that beneficiaries get the best possible care no matter which type of plan they choose.”
The Medicare Modernization Act of 2003 increases reimbursement rates and expands the choice of Medicare Advantage plans to include regional PPOs. The regional PPOs will be available to beneficiaries in 2006. By 2010, CMS has predicted nearly 30% of beneficiaries will have joined a Medicare Advantage plan, either an HMO or a PPO.
NCQA’s Medicare Advantage PPO standards will expand on NCQA’s existing PPO Accreditation standards, adding requirements in areas such as: advance directives, antidiscrimination, provider participation, and other areas specified by CMS.
NCQA’s Medicare Advantage PPO Accreditation program is administered on a sophisticated, on-line platform that allows participating organizations to conduct a pre-survey assessment to determine their readiness for an actual review.Feedback from that review can be used to focus on improvements before surveyors ever arrive on site.
Reaction to the announcement among organizations that expect to participate in the Medicare Advantage program has been positive. “The value of earning NCQA Accreditation is that it makes your organization better,” said Charles Fazio, M.D., Medical Director for Quality for Medica, a large, Minnesota-based PPO. “Deeming authority will reduce the regulatory compliance burden as well. That's a real win-win situation; health plans get credit for doing the right thing and beneficiaries get better care.”
More information about NCQA’s Medicare Advantage PPO standards will be available in Spring 2005.
NCQA is a private, non-profit organization dedicated to improving health care quality. NCQA accredits and certifies a wide range of health care organizations.NCQA provides health care quality information free of charge through the Web and media in order to help consumers, employers and others make more informed health care choices.
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