FAQ Directory: Physician and Hospital Quality Certification

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8.29.2013 NCQA Complaint Review Process Are complaints sent to a specific person at an organization?

Yes. Complaints are forwarded to the organizations Accreditation contact.

PHQ 2013

8.29.2013 NCQA Complaint Review Process Is the NCQA Complaint Review Process dated March 25, 2013 new?

No, this is not a new process or policy. NCQA has followed this process for handling complaints for more than a decade. In the interest of transparency, NCQA is sharing its policy with organizations.

PHQ 2013

8.29.2013 NCQA Complaint Review Process Does the Authorization NCQA receives from the complainant permit the organization to release information to NCQA and NCQA to the organization?

Yes. Release of information to the organization by NCQA and the organizations release of information to NCQA is covered. The organization is not required to seek subsequent release from the member/complainant because the authorization form covers both entities. However, the organization is free to seek their own authorization should they choose to do so.

PHQ 2013

8.29.2013 NCQA Complaint Review Process When does the "30 calendar-day" response period begin?

The time period for response begins when the health plan receives the complaint from NCQA.

PHQ 2013

8.29.2013 NCQA Complaint Review Process Does NCQA expect the organization to release peer-related information?

This is up to the organization, in conjunction with their legal counsel, if disclosure is permitted. The organization is expected to provide a copy of the response given to the complainant to NCQA.

PHQ 2013

5.15.2013 Pay-for-performance Program If our organization displays information about our pay-for-performance program but does not display physician performance information for this program, how does NCQA score PQ 3A, 3B, 3C, 3D and 4B?

PQ 3A factors 3-5 and PQ 3B are scored NA if the organization does not display physician performance information for the pay-for-performance program.

PQ 3 C and D are scored against the pay-for-performance requirements if the organization has one complaint process for all programs. If the organizations complaint process is program-specific, PQ 3C and D are scored NA for the pay-for-performance program. NCQA scores PQ 4B factor 1 and the customer portion of factor 4 NA for the pay-for-performance program.

Because there is no NA scoring option in PQ 3B, 3C and 4B, these requirements are scored yes for pay-for-performance programs described above until the NA scoring option is added during the 7/29 release of the ISS tool.

PHQ 2013

11.15.2012 Relative Resource Use (RRU) Measures Are HEDIS RRU measures appropriate for PQ 1 Element B?

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

PHQ 2013

11.15.2012 Must-Pass: PQ 1 Element A Is PHQ 1, Element A a must-pass element? If so, is the change permanent?

PHQ 1, Element A is a must-pass element at the 50 percent scoring level; this is a permanent change.

PHQ 2013

11.15.2012 Noncompliant patients and physician ratings Has NCQA made recommendations or looked at the effect of noncompliant patients on physician ratings?

Although patient factors such as noncompliance may affect measure performance rates, an integral role of the physician is to work continuously with patients to educate them on the importance of a specific process or meeting a specific target/goal.

PHQ 2013

11.15.2012 Applications for PHQ surveys How long after NCQA receives an application for survey does the survey begin?

NCQA suggests that organizations submit an application for survey at least 180 calendar days in advance of the date requested for their Initial Survey, but preferably applications will be submitted further in advance. Organizations should indicate their preferred survey date and NCQA will accommodate them if possible.

PHQ 2013

11.15.2012 Credit for Performance-Based Designation Programs as Quality measures Does use of Performance-Based Designation programs _ such as NCQA, BTE Recognition programs and Meaningful Use count as quality measures?

Yes, refer to Appendix 4: Performance-Based Designation Programs for the level of credit received for each program.

PHQ 2013

11.15.2012 Cost, resource use or utilization measures Are there standardized measures for cost, resource use or utilization? If there are none, what measures are plans using?

At this time, there are no standardized (i.e., endorsed) measures of cost, resource use or utilization at the physician level.

PHQ 2013