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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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 supplementation does not alter the intended numerator, denominator and exclusion criteria for the measure.
If the organization seeks certification, NCQA evaluates all measures on which it bases action against all elements. If the organization has a physician pay-for-performance program that meets the definition of taking action, then it must meet the elementsincluding all transparency requirements, including, but not limited to, requirements for making available to customers methodology and information about how the measures are used, providing opportunities for input, seeking feedback and having a process for complaints.
If the organizations pay-for-performance program was not designed to include public reporting of physicians measure results, then the organization is not required to make the individual measure results available to customers.
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.
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.
In measuring physician performance and distinguishing among peers, the organization is required to specify minimum observations or denominators for each measure on which the action is based. Denominators are patient observations, which may include multiple observations for an individual.
Criteria must be defined at the level on which action will be taken.
Note: This applies if the organization uses minimum observations rather than confidence intervals or measure reliability.
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.
Element G, Request for Corrections or Changes has four factors. 1. Documentation of the substance of the request 2. Investigation of the request 3. Notification of the specific reasons for the final decision 4. Notification of the outcome prior to taking action on measure results NCQA reviews an organizations documentation to determine if it follows its process for handling physician requests for corrections or changes related to the four factors. In response to inquiries from many organizations, NCQA issued a clarification on the expectations of the process (which is scored in Element F) and the file review against that process. See the Corrections, Clarifications and Policy Changes Web page at www.ncqa.org/tabid/120/Default.aspx.
There is no minimum requirement. If the total number of files is fewer than the requested 40 files, NCQA reviews the entire file universe. For file review elements, NCQA follows its 8/30 methodology. Refer to An Explanation of the 8 and 30 File Sampling Procedure on the NCQA Web site at www.ncqa.org/tabid/125/Default.aspx.
