FAQ Directory: Physician and Hospital Quality Certification

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11.15.2012 Survey Tool With PQ 2013 evaluating at the program level, are we required to purchase a tool for every certifiable entity, as in PHQ 2008?

No. An organization is required to purchase a separate survey tool for every program it brings forward. One program operated by an organization such as a corporate parent without variation from region to region may be surveyed using a single tool. An organization that brings forward more than one program must purchase and submit a separate tool for each discrete program it brings forward.

There is a pricing option for derivative programs a derivative program is defined as a program that shares common aspects (e.g. an organization uses the same measures and methodology for a single defined group of physicians but takes a different action (reporting vs. network tiering) as another program its organization brings forward for certification. NCQA can review common aspects once to streamline the survey process (thus the discounted price), although these are distinct programs. To receive a discount, the programs must be brought forward at the same time. Please see the pricing exhibit in the survey agreement. If you need additional information, please contact NCQA Customer Support at (888) 275-7585.

PHQ 2013

11.15.2012 Taking action on cost measures Is an organization prohibited from using cost efficiency if quality results are not available?

No. The organizations program must consider quality in conjunction with cost, resource use or utilization when taking action. However, if the organization is unable to identify standardized measures of quality for a particular specialty or if there is insufficient data on an individual physician, practice or group the organization can act on cost performance when quality performance is not known. This is allowed in order to maximize the availability of performance information but must be handled in a fully transparent manner so that it is very clear when a physician is designated as high value and when they are purely designated as low cost. Refer to the standards _ specifically the explanation in PQ1 D (on page 51) _ for further explanation.

PHQ 2013

11.15.2012 Organizational accountability Are organizations responsible for confirming the factors in Element F, or is this the responsibility of an external vendor?

For Element F, the organization must demonstrate that it has a process to verify that it has followed the specifications outlined in Element C (e.g., sample sizes, attribution,statistical validity). If the organization uses a vendor to administer the survey, this process may be performed by the vendor, but documentation demonstrating how the element is met must be included for the PHQ Survey.

PHQ 2013

11.15.2012 Board Certification Does Board Certification status count as a quality measure?

No, Board Certification status alone does not count as a quality measure.

PHQ 2013

11.15.2012 Physician requests For PQ 2 Element C, could a collaborative manage the process?

Yes. PHQ requirements do not prohibit a collaborative from managing a request for corrections or changes made by physicians, but the organization remains accountable and responsible for responding to complaints from consumers and to requests for changes from physicians or hospitals based on actions taken by the organization.

PHQ 2013

11.15.2012 Use of patient experience data collected from external organizations Is the use of patient experience data considered part of the program in the following circumstances: 1. The organization incorporates third-party performance information data with its own and then takes action on it (i.e., integrates the third-party data with its own to develop a composite that it reports or uses as the basis of action, such as payment or network or benefit design) 2. The organization provides a link for members on a third-party site so the member can review that information?

For scenario 1, the data must be considered as part of the program being reviewed for PHQ because the organization has incorporated the data with its own or tailored the data and then used the data as a basis for its own action (e.g., reporting, payment or network or benefit design). For scenario 2, if _ as part of its program _ the organization simply provides a link to an external source of performance information on physicians without altering that data and represents it as such, and the organization does not take any action based on the data (e.g., pay any incentive or use data for network or benefit design) then it is not considered part of the program.

PHQ 2013

11.15.2012 Certification for information providers May an information provider earn certification for the pieces it provides (e.g., standards, methodology, underlying data), while its customer (i.e., health plan that publishes the information) pursues other pieces (e.g., member communication and complaints, physician communication)?

No. PHQ consists of the specified certification options: Physician Quality (PQ), Hospital Quality (HQ), or both. Contact phq@ncqa.org to discuss your situation so we can consider additional survey options to meet market needs.

PHQ 2013

11.15.2012 Defining "Taking Action" Is there a new definition of taking action in the 2013 PHQ Standards?

Yes. In prior versions of PHQ, NCQA required organizations to include all programs that met the definition of taking action in the survey, NCQA had a narrower definition. Because under PHQ 2013 organization chooses which programs to include or exclude in a PHQ survey, NCQA has broadened the definition so that if it chooses, an organization may opt to have programs certified that may not have been required under the prior PHQ.

For PHQ 2013, NCQA has defined taking action as: 1) Publicly reporting performance on quality or cost, resource use or utilization; 2) Using performance on quality or cost, resource-use or utilization measures as a basis for network design (such as tiering) or benefit design; 3) Using performance on quality or cost, resource-use or utilization measures to allocate rewards under a systematic, pay-for-performance program; 4) Reporting performance on quality, cost, resource use or utilization to physicians to support referral decisions.

If an organization is interested in certification for a program that includes actions not include an action defined above, it should contact NCQA to determine eligibility.

PHQ 2013

11.15.2012 Requests for corrections or changes Are organizations responsible for confirming the factors in Element F, or is this the responsibility of an external vendor?

For Element F, the organization must demonstrate that it has a process to verify that it has followed the specifications outlined in Element C (e.g., sample sizes, attribution, statistical validity). If the organization uses a vendor to administer the survey, this process may be performed by the vendor, but documentation demonstrating how the element is met must be included for the PHQ Survey.

PHQ 2013

11.15.2012 Complaints The concept of "member complaints" pertains to health plans only, but not necessarily to Web sites or collaboratives. How does NCQA evaluate for those entities?

Though an organization may not have members in the way a health plan does, Web sites have users or consumers who might want to submit complaints (e.g., user complaints). Therefore, to meet the intent of Elements C and D, an organization must have policies and procedures to process, register and respond to consumer complaints; and must provide a documented process and evidence for how it handled those complaints.

PHQ 2013

11.15.2012 Methodology for evaluation of cost measures What constitutes an acceptable methodological approach to evaluation of cost?

NCQA does not prescribe the cost measures an organization selects, though it requires an organization to specify all aspects of its methodology (Element C). In addition, the organization must risk-adjust its measures (Element C, factor 8) and must meet the minimum statistical requirements for measurement error and measure reliability (PQ1 Element D, factor 2).

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