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 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 Handling complaints For the file review component in PHQ 1 (re: member complaints), is there review of a minimum number of files? In other words, we do not anticipate a large number of this type of complaint.

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.

This applies to the following Programs and Years:

11.17.2008 Measure specifications Expand on the minimum denominator criteria for quality measures. Do you mean minimum observations per measure? Or minimum observations per provider? Or is that already in the requirements?

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.

This applies to the following Programs and Years:

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.

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 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:

11.17.2008 Credit for Physician Recognition Programs Define how NCQA Physician Recognition programs can be used for autocredit.

NCQAs Recognition Program measures meet many of the elements in PHQ.

If an organization takes action based on measures in NCQAs Recognition Programs, the measures meet the elements where specified in the standards. The organization does not need to provide additional documentation about how the measures meet these elements.

NCQAs Recognition Programs are the Diabetes Physician Recognition Program (DPRP); Heart-Stroke Recognition Program (HSRP); Back Pain Recognition Program (BPRP); Physician Practice Connections (PPC); and the Physician Practice ConnectionsPatient-Centered Medical Home (PPC-PCMH).

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 Use of rental networks and hospital quality For PHQ 2, Element E, if we "rent" our national hospital network and do not contract directly, may we share hospital results with the entity we rent from, rather than the individual hospitals?

Each hospital must receive results. Either the organization must provide results to each hospital or it may have a written agreement with the national network stating that it will provide results to hospitals. If the national network provides results to each hospital, it must provide documentation (e.g., reports, materials) to the organization that it has met the requirements.

This applies to the following Programs and Years:

11.17.2008 Exemption process for surveys Can you confirm the process for exemption for PHQ 1?

During the application process, the organization lists and briefly explains instances where it feels exemptions apply.

This applies to the following Programs and Years:

11.17.2008 PHQ and Physician Practice Connection Recognition Do you have a crosswalk for PHQ as it relates to Physician Practice Connection (PPC) Recognitionstandard 8 in particular?

No. The PHQ standards evaluate organizations that measure physician performance; PPC recognizes physician practices that use systematic processes and information technology to enhance quality of patient care. The two programs serve different purposes. In particular, PPC 8: Performance Reporting and Improvement focuses on the practices internal measurement and quality improvement process. It does not address the methodology required in PHQ, but focuses on the QI process.

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: