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 Quality measures What criteria does NCQA use to determine what constitutes a quality measure vs. another kind of measure?

A quality measure is one of clinical performance or patient experience, where one can generally identify the direction of good, with a clear definition of what is better performance or worse performance.

11.17.2008 Risk adjustment How is risk adjustment defined for quality measures?

Case-mix adjustment considers variations in the health of physicians populations, often defined by age and gender. Severity is a patients degree of illness for a specific mix of conditions (e.g., cancer stages), morbidity or comorbidity. Together, case mix and severity are often called risk. Risk can be either the risk for needing a mix of medical services (utilization and associated costs) or the patients likelihood of achieving a specific level of quality-related outcome.

Risk adjustment may not apply to quality measures, particularly process measures. For quality measures, NCQA requires the organization to demonstrate that it has considered whether to risk-adjust measuresand that it has an explicit methodology if it does and an explicit rationale if it does not. If the organization determines that case-mix and severity adjustment do not apply to a quality measure, it provides documentation that supports the determination. If the organization adjusts measures for case-mix or severity, it provides documentation describing the methodology used.

11.17.2008 Adding new products/product lines to existing PHQ Distinction If a plan was initially PHQ Certified in HMO only and now wants to add PPO, is the certification process separate?

NCQA no longer conducts surveys under the 2006 PHQ standards. If an organization had distinction for its HMO under the 2006 standards and seeks certification for its PPO, the PPO must be reviewed against the 2008 standards. Under the 2008 PHQ standards, if a plan manages both products (e.g., HMO and PPO) the same, NCQA can survey both products together. The organization should contact NCQA to discuss its options, including a possible option to upgrade (i.e., apply some results from its 2006 survey to a 2008 survey). Note: An Upgrade does not extend the expiration date of the Distinction; that date transfers to the new certification status.

11.17.2008 Measure specifications Since NQF does not publish the actual code sets for all its measures, how does NCQA determine that an organization is following the measure specifications as written?

NCQA recognizes that some NQF-endorsed or AQA-approved specifications may require additional specifications to implement in specific contexts. Organizations may supplement endorsed specifications as long as they follow all endorsed specifications and if such supplementation does not alter the intended numerator, denominator and exclusion criteria for the measure.

11.17.2008 Approved measures What percentage of an organization's measures must be approved by NQF, AQA or AMA/PCPI?

To achieve certification, the organization must score at least 50% on Element A, Measuring Physician Performance. The 50% score threshold requires that at least 50% but fewer than 60% of the measures used by the organization to measure physician quality for taking action meet the element (i.e., are standardized). To achieve full points (100%), at least 70% of the measures used by the organization to measure physician quality for taking action must meet the element (i.e., must be standardized)

11.17.2008 Certification time limits How long does certification last?

Certification in PHQ, PQ or HQ is valid for two years. Organizations must undergo a survey against the standards at least every two years to maintain their certification status. Provisional Certification is valid for 12 months; it is a temporary option and will not be offered after June 30, 2009.

11.17.2008 Changing measure specifications With regard to patient experience measures, may we use items from CAHPS-CG but change the referent time period? For example, not rating the last 12 months, but rating the last visit and changing the response categories accordingly?

No. Changing the referent time period materially alters the measure and would therefore not qualify as a standard measure for Element A.

Patient experience measures endorsed, developed or accepted by the NQF, AQA, AMA PCPI, national accreditors or government agencies may be used, but the organization must follow the measure or instrument specifications as written.

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.