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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3.15.2009 Use of patient experience data collected from external organizations Is the use of patient experience data within the scope of NCQA review in the following circumstances:

1. The organization incorporates third-party performance information data with its own and then takes action on it (i.e., integrates the third-party data with its own to develop a composite that it reports or uses as the basis of action, such as payment or network or benefit design)

2. The organization provides a link for members on a third-party site so the member can review that information?

For scenario 1, the data is within the scope of review for PHQ because the organization has incorporated the data with its own or tailored the data and then used the data as a basis for its own action (e.g., reporting, payment or network or benefit design).

For scenario 2, if the organization simply provides a link to an external source of performance information on physicians without altering that data and represents it as such, and the organization does not take any action based on the data (e.g., pay any incentive or use data for network or benefit design) then it is outside the scope of review for PHQ.

2.15.2009 Working with Physicians What actions must an organization take to meet Element F factor 1?

The organization must provide, at the time of initial contracting, new physicians with specific performance measurements applicable to them. The organization may provide the information:

In writing

In person at meetings

On the Web, if it notifies physicians, practices or medical groups that the information is available

1.15.2009 Use of HEDIS measures in PQ certification May organizations use NQF-endorsed health plan HEDIS specifications for physician-level measurement?

Organizations are expected to follow the NQF-endorsed HEDIS Physician Measurement specifications. These are generally the same as the HEDIS Health Plan specifications, but may have some modifications. If a measure in the desired area has not been endorsed by NQF, the organization may use an alternate measure from the HEDIS set and still qualify as a standardized measure, as discussed in the explanation in PHQ 1 Element A.

1.15.2009 Using quality and cost, resource use or utilization measures together If an organization uses quality measures for a particular specialty, may it measure episode cost for any condition treated by that specialty, or is it limited to measuring cost only for conditions where quality has been measured?

Organizations are not limited to measuring cost only for conditions where quality has been measured. An organization that measures quality for a physician specialty may measure and take action on cost, resource use and utilization for the specialty.

12.12.2008 Principles for use of results Does Element H, factors 1 and 2, apply to all patient experience surveys?

Yes. Factor 1 applies because patient experience results are considered measures of quality.

12.12.2008 Composite measures How does NCQA review Element A if a measure used to take action is a combination of a quality measure and a measure that is not in scope, where the quality measure is standardized?

For PHQ 1, Element A, NCQA determines whether individual quality measures (used on their own or in a composite with other criteria) meet the element as defined by the hierarchy of standardized measures. The organization may use additional criteria (e.g., board certification status) to determine performance designation, in combination with quality measures, but the additional criteria remain out of the scope for this element. The organization receives credit for the standardized quality measure.

12.12.2008 Organization accountability Are organizations responsible for confirming the factors in Element D, or is this the responsibility of an external vendor?

For Element D, the organization must demonstrate that it has a process to verify that it has followed the specifications outlined in Element C (e.g., sample sizes, attribution, statistical validity).

If the organization uses a vendor to administer the survey, this process may be performed by the vendor, but documentation demonstrating how the element is met must be included for the PHQ Survey.

12.12.2008 Survey measures How is Element A scored for non-NQF endorsed surveys? Is each question a measure or, if measures roll up to a composite, is the composite considered one measure?

Non-NQF endorsed patient experience surveys are counted as one measure for the entire survey. CAHPS-CG questions or composites count as separate measures.

12.12.2008 Patient experience measures Are all questions related to patient perception considered quality measures?

Yes. NCQA considers all patient experience results to be measures of quality.

12.12.2008 Taking action on collaborative and organization results How does the survey process work if an organization takes action on measure results from a collaborative and from its own measurement?

All measures on which the organization bases action are included in the scope of a PHQ Survey, including those developed and whose results are calculated as part of a collaborative and those calculated directly by the organization.

NCQA evaluates the organizations activities in one of two ways.

1.Evaluate the collaborative onceif the collaborative opts to undergo a PHQ surveyand apply the survey results to all participants

2.Evaluate the measures, methods and processes of the collaborative when each participant organization is surveyed

The organizations scores on any element are based on the performance of both the collaborative and the organization. The organization must meet the element for all measures, including the collaborative measures it uses. For example, for Element C: Methodology, NCQA evaluates the organizations methodology for each measure directly. It may evaluate the collaboratives methodology either once during a survey of the collaborative or for each organization during the organizations survey. Regardless of the process, all measures must meet the requirements of Element C in order to meet the element.

When a collaborative undergoes a survey directly, the process is streamlined for all involved (the collaborative, the organization and NCQA). In addition, the process may be more cost-effective, since NCQAs pricing is designed to reflect economies of scale.

12.12.2008 Notice for providing results Does a 45-day notice period apply when measurement is more frequent than annual (e.g., quarterly)?

The 45-calendar-day notice period for providing results and an opportunity for a physician to request a correction or change applies to each cycle of measurement and action an organization takes, regardless of frequency (e.g., biannual, annual, semiannual, quarterly); however, if an organization recalculates results without changing its methodology or measures, it does not need to provide the methodology again as long as it supplies information on how to obtain that methodology.

The exception to the minimum 45-calendar-day notice period for action is if the action involves only pay-for-performance activities that are not publicly reported (e.g., an action that is only between the organization and the physician). In this instance, the organization may provide the results and methodology concurrent with additional or bonus payment. The organization must still provide a process for the physician to request corrections or changes.

12.12.2008 Requests for corrections or changes For Elements F and G, how can patient experience of care data corrected, when this information is not disclosed to physicians?

The plan is not required to disclose member-specific results, nor is it expected that a physician can correct member responses. At a minimum, the physician must be given the methodology (e.g., sampling, attribution) and survey questions and, upon request, be allowed to confirm that the patients in the universe from which the sample was drawn are his or her patients, given the methodology.