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 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.

This applies to the following Programs and Years:

11.17.2008 Pay for Performance Is consumer transparency required for certification? Our program is pay for performance targeted at physicians and hospitals only.

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.

This applies to the following Programs and Years:

11.17.2008 Collaborative data Must organizations include collaborative data for certification?

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.

This applies to the following Programs and Years:

11.17.2008 Delegating PHQ 2 to an NCQA-Certified HIP PHQ has no delegation oversight standard, but information distributed by NCQA in response to HIP Certification indicates that a delegation agreement with an NCQA-Certified HIP is required to receive automatic credit in PHQ 2. Must a health plan show an agreement that meets the six factors typically required by other NCQA delegation standards?

No. Delegation oversight was not included and is not required.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

11.17.2008 PHQ and HP Accreditation When will the PHQ standards be folded in to the health plan accreditation standards?

NCQA has not made a decision about incorporating the PHQ standards into health plan accreditation. Should NCQA decide to do so, it will put such a proposal out for Public Comment.

This applies to the following Programs and Years:

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).

This applies to the following Programs and Years:

11.17.2008 Pay for Performance The draft program did not pertain to pay-for-performance programs, whose goal is QI at the practice, not public disclosure. Why was this added to "taking action?"

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.

This applies to the following Programs and Years:

11.17.2008 Survey Pricing If we go through provisional certification and are then required to go through full certification within 12 months, does our organization get a reduced price?

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years: