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.
NCQA does not evaluate coding accuracy and quality. Element D, Verifying Accuracy requires an organization to have a process to evaluate the accuracy of its measure results. The organization may use external auditors to verify its methodology, but is not required to do so. In the future, NCQA may develop standards for auditing physician measurement and a program for certifying auditors. With such standards, NCQA will consider making external audit a requirement.
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)
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.
In the draft standards released for Public Comment in March 2008, NCQA included pay-for-performance but did not use that specific term; instead, we referred to payment strategies. Specifically, NCQA defined the Scope of Review for the majority of elements in PHQ 1 as: NCQA evaluates all measures the organization uses for measuring physician performance for the purpose of taking action.
In the Explanation, NCQA defined taking action as follows.
Publicly reporting physician performance on quality or cost or resource use
Using physician performance on quality or cost or resource use measures as a basis for network design (such as tiering), benefit design or payment strategies
NCQA defined payment strategies in Element M, Using Measure Results as follows.
The organization uses reimbursement to provide incentives for improvement among its physicians, practice sites or medical groups, or uses payment to reward performance.
In the final standards, NCQA used the term pay-for-performance and specifically narrowed the scope of programs included.
Yes. PHQ requirements do not prohibit a collaborative from managing a request for corrections or changes made by physicians, but the organization remains accountable and responsible for responding to complaints from consumers and to requests for changes from physicians or hospitals based on actions taken by the organization.
All measures on which an organization bases action are included in the scope of the PHQ Survey, including those that are developed and whose results are calculated as part of a collaborative. The exception is during the first year the standards are in effect (October 1, 2008_September 30, 2009). For surveys that start during that period, the organization may opt to carve out measures from a collaborative. The rationale for this exemption is two-fold. First, organizations will not need to wait until a collaborative undergoes a survey in order to have their own survey. Second, if the collaborative needs to make changes to any measures, methods or processes to meet the standard, it is not within the organizations control to make the changesalthough as a participant, it influences them. This allows time for the collaborative to make changes.
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.
No. Survey prices apply to each discrete survey; NCQA does not apply credit forward to a future survey. Survey pricing reflects the amount and level of resources NCQA dedicates to evaluating an organization and at the time of the Full Certification Survey, NCQA must re-evaluate the organization on all requirements.
