FAQ Directory

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.

NCQA performs surveys on the PHQ standards, but may develop standards for auditing physician measurement and a program for certifying auditors. With such standards, NCQA will consider making external audit a requirement.

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.

The cost of a PHQ Survey is based on survey and evaluation type. The current pricing table for NCQA PHQ Certification is available from the NCQA Web site at www.ncqa.org/tabid/753/Default.aspx.

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.

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.

No. NCQA does not evaluate an organizations code; it reviews the organizations measure specifications and compares them to the original source specification (if applicable).

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.

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)

For Element A, the denominator is all quality measures on which the action is based and the numerator is measures that meet the definition of standardized in the Explanation.

No. HEDIS RRU measures are specified for assessment at the plan level, not for measurement of individual physician performance.

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.