NCQAs PHQ product was released in April 2006 as part of its Quality Plus Program, a voluntary suite of areas where NCQA-Accredited plans could earn distinction. NCQA Health Plan (formerly MCO) Accreditation standards do not include PHQ requirements.
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 Differences between health plan (MCO/PPO) and PHQ standards We went through MCO accreditation in 2007. PHQ standards were required in our standards. How is this different? How is this the same?
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.
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?
11.17.2008 Measure specifications Since NQF does not publish the actual code sets for all its measures, how does NCQA determine that an organization is following the measure specifications as written?
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.
11.17.2008 Quality measures What criteria does NCQA use to determine what constitutes a quality measure vs. another kind of measure?
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.
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.
11.17.2008 Measure reliability If a plan demonstrates a different methodology for statistical validity, would the methodology be considered?
Element C, Measurement Methodology requires the organization to have a method for determining measurement error and measure reliability. Element H, Principles for Use of Results sets requirements for minimum observations or levels of measure reliability or confidence intervalsas applicable for quality and cost, resource use or utilization measures.
For calculating measure reliability for PHQ, the organization must use the method described in the Explanation in Element C under the subhead Measurement error and measure reliability. Measure reliability is defined as the ratio of the variance between physicians to the variance within one physician, plus the variance between physicians.
NCQA does not prescribe the method used to calculate confidence intervals because the appropriate method may vary based on the parameter (e.g., mean or proportion).
11.17.2008 Approved measures What percentage of an organization's measures must be approved by NQF, AQA or AMA/PCPI?
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)
11.17.2008 Small physician sample size If only a small percentage of available physicians in any specialty within a market have sufficient NQF measures available, may there be an assumption of appropriate quality, thus allowing members access to higher benefits with a larger number of physicians?
11.17.2008 Requests for corrections or changes What does NCQA look for in file review with regard to requests for corrections or changes?
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.
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.