FAQ Directory

Here are some of the most frequently asked questions about NCQA’s various programs. If you don’t see what you are looking for in one of the entries below, you can  ask a question through My NCQA.

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11.17.2008 Small physician sample size If only a small percentage of available physicians in any specialty within a market have sufficient NQF measures available, may there be an assumption of appropriate quality, thus allowing members access to higher benefits with a larger number of physicians?

Yes. Assumption of appropriate quality in this context is permitted.

11.17.2008 Taking action on cost measures Is an organization prohibited from using cost efficiency if quality results are not available?

Yes. The organization may not take action based on cost, resource use or utilization results alone. This is a must pass requirement for certification and is consistent with the Consumer-Purchaser Disclosure Project Patient Charter.

The organization is required to consider quality in conjunction with cost, resource use or utilization when it takes action. To the extent that the organization develops and presents a composite score or rating using cost, resource use or utilization and quality measures, it must disclose the specific measures for each category and their relative weight when it determines the composite or rating.

11.17.2008 HEDIS measures If we use HEDIS measures, will NCQA still look at code?

No. NCQA does not evaluate an organizations code; it reviews the organizations measure specifications and compares them to the original source specification (if applicable).

11.17.2008 Surveyors for PHQ certification What organizations will conduct surveys now or in the future? Only NCQA or, for example, would Licensed HEDIS Audit Organizations conduct them?

NCQA performs surveys on the PHQ standards, but may develop standards for auditing physician measurement and a program for certifying auditors. With such standards, NCQA will consider making external audit a requirement.

11.17.2008 Standardized measures What counts in the denominator for standardized measuresall measures on which action is taken, or all quality measures on which action is taken?

For Element A, the denominator is all quality measures on which the action is based and the numerator is measures that meet the definition of standardized in the Explanation.

11.17.2008 Acceptance of HIP 6 for Autocredit of PHQ 2 Will NCQA accept HIP 6 for autocredit for PHQ 2008?

Yes. The substance of the standards did not change and the purpose of HIP is to give autocredit.

11.17.2008 Differences between health plan (MCO/PPO) and PHQ standards We went through MCO accreditation in 2007. PHQ standards were required in our standards. How is this different? How is this the same?

NCQAs PHQ product was released in April 2006 as part of its Quality Plus Program, a voluntary suite of areas where NCQA-Accredited plans could earn distinction. NCQA Health Plan (formerly MCO) Accreditation standards do not include PHQ requirements.

11.17.2008 Credit for Physician Recognition Programs Define how NCQA Physician Recognition programs can be used for autocredit.

NCQAs Recognition Program measures meet many of the elements in PHQ.

If an organization takes action based on measures in NCQAs Recognition Programs, the measures meet the elements where specified in the standards. The organization does not need to provide additional documentation about how the measures meet these elements.

NCQAs Recognition Programs are the Diabetes Physician Recognition Program (DPRP); Heart-Stroke Recognition Program (HSRP); Back Pain Recognition Program (BPRP); Physician Practice Connections (PPC); and the Physician Practice ConnectionsPatient-Centered Medical Home (PPC-PCMH).

11.17.2008 Working with hospitals on reporting For PHQ 2, Element E, are plans required to share results, explain how they are used and get feedback from hospitals ONLY if they report the results in a format different from the primary data source. Is this NA if we only provide links to the data?

Factors 1 and 2 are NA if the organization does not change the format of its results from the primary data source. Factors 3 and 4 always apply and are scored irrespective of factors 1 and 2.

11.17.2008 Board certification and physician quality Will NCQA accept board certification, maintenance of certification and NCQA Recognition as markers of physician quality, or must there also be measurement of NQF markers?

The organization may take action based on physician completion of an ABMS or AOA board performance-based improvement module (generally, in conjunction with maintenance of certification) at least every two years. These activities may be used as a quality measurement activity to meet PHQ 1. Under certain circumstances, the organization may use measures from other national or regional performance-based designation programs to satisfy some or all requirements for PHQ 1, Element A. The organization must discuss this in advance with NCQA to determine if the designation program meets the criteria.

11.17.2008 Relative Resource Use (RRU) Measures Are HEDIS RRU measures appropriate for PHQ 1 Element B?

No. HEDIS RRU measures are specified for assessment at the plan level, not for measurement of individual physician performance.

11.17.2008 Productivity measures Are productivity measures within scope? For example, number of visits per half day: does NCQA classify this as a utilization measure or as something else?

No. Productivity measures are out of scope for the 2008 PHQ standards. Quality, cost, resource use and utilization measures are in scope if the organization takes action based on them.