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(a) Please see Attachment 3 of Carrier Letter 2013-22 for the process and information required for OPM review of CAPs.
(b) We are encouraged by the improvement in HEDIS results and look forward to additional performance gains in the coming year. Please note that progress toward HEDIS goals will be reflected in OPM's overall health plan evaluation. Contract specialists will pay particular attention to any health plan that declines in overall evaluation score, and any health plan remaining below OPM's minimum performance threshold despite two or more Corrective Action Plans for the same metric(s).
OPM permits the use of either hybrid or administrative data collection, where applicable per measure specifications, for metrics reported to NCQA. For HEDIS 2013, we asked carriers to refrain from switching data collection methodologies while we implemented a new OPM scoring system. For HEDIS 2014, all carriers are encouraged to utilize hybrid data collection for all measures where NCQA provides this option and it is applicable to the reported product.
While we will continue to accept the use of only administrative data collection, we believe the hybrid data collection method will allow more complete data capture. If expenses associated with hybrid data collection cannot be accommodated within a plan’s projected expense limit for HEDIS 2015, an explanation and cost justification should be submitted along with the administrative expense limit proposal.
Metrics collected via the administrative methodology only include: Breast Cancer Screening (BCS), Follow-up After Hospitalization for Mental Illness (FUH), Plan-All Cause Readmissions (PCR), Ambulatory Care Emergency Department Visits (AMB-B), Medication Management for People with Asthma (MMA), Use of Imaging Studies for Low Back Pain (LBP), Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB), and Well-Child Visits in the First 15 Months of Life (W15).
Metrics collected via the administrative or hybrid methodologies include: Cholesterol Management for Patients with Cardiovascular Conditions LDL-C Screening (CMC), Comprehensive Diabetes Care Hemoglobin A1c Testing (CDC), Comprehensive Diabetes Care LDL-C Screening (CDC), Prenatal and Postpartum Care - Timeliness of Prenatal Care (PPC), and Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC).
Metrics collected via the hybrid methodology only include: Controlling High Blood Pressure (CBP).
Plans can begin the accreditation process directly, or may wish to make an inquiry or seek formal consultation from their intended accreditor to help match their unique organizational structure to available accreditation pathways/products. Such a consultation would also assess accreditation readiness. OPM has received information from both URAC and AAAHC indicating they are able to scope a consultation upon request.
Plans attaining a comprehensive health plan accreditation from AAAHC, NCQA, or URAC will have their provider and network oversight assessed as part of that process. No further action is needed.
FEHB carriers satisfying OPM’s accreditation through a modular approach must provide evidence that all networks are accredited. This is best accomplished by means of a separate network accreditation. As an alternative, plans able to demonstrate that their entire network is part of a fully accredited health plan that serves as a subcontractor to the FEHB carrier may provide OPM with detailed documentation for consideration.
To our knowledge, NCQA Credentialing and Recredentialing is offered with the Utilization Management Certification, and as such does not address full scope of the "accreditation of provider network(s), including review of the credentialing process" listed in Carrier Letter 2014-10.
OPM requires that each FEHB carrier has appropriate and verifiable oversight, but takes no position on whether Medical Direction should be an in-house or contracted function. The accreditation survey will examine how the Medical Director function is fulfilled and will also evaluate how the carrier ensures that continuity of care/services is provided to members, how quality is assessed and progress is monitored, how handoffs are facilitated, and how the carrier assures that any delegated function is competently performed.
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