Quality Check

The most important test of the quality-of-care provided by a plan is whether patients get well and stay that way. Most managed-care plans keep an eye on their members' use of services such as the number of office visits, lab tests and the length of hospital stays. But the best plans also examine the effect care has on patients. For example, they may identify which tests and procedures work best and which are wasteful or risky. However, it is important to allow variation from those standards based on a patient's individual history and needs.

In traditional fee-for-service medicine, a doctor's poor performance may only be known to the patient since the insurance plans don't track patient care. Under managed care, a physician is partly accountable to the plan administrators, which makes it easier to track a pattern of questionable physician performance over time.

A good plan will make performance information public. Some plans also conduct periodic patient surveys, so before joining one, ask to see a copy of the most recent survey.

Who's Minding the Managed Care Plan?

  • The National Committee for Quality Assurance (NCQA), a voluntary, nonprofit agency that accredits managed care plans (HMOs and POSs) based on fairly stringent quality criteria. Since its inception in 1990, NCQA has reviewed over half of all plans nationwide--review is completely voluntary. NCQA awards the following types of accreditation status:
    1. Excellent. This new rating is now NCQA's highest accreditation status. It is granted only to those plans that demonstrate levels of service and clinical quality that meet or exceed NCQA's rigorous requirements for consumer protection and quality improvement. Plans earning this accreditation level must also achieve HEDIS results that are int he highest range of national or regional performance.
    2. Commendable. Indicates the plan has excellent quality improvement programs, meets rigorous standards and is accredited for three years (formerly called Full Accreditation). 50 percent of all plans reviewed have received a Commendable accreditation.
    3. Accredited. Indicates the plan has well-established quality improvement programs, meets most NCQA standards, and will be reviewed again in a year to determine if it can move up to full accreditation (formerly called One-Year Accreditation). 36 percent of reviewed plans have received Accredited status.
    4. Provisional. Granted for one year to plans that have adequate quality improvement programs and meet some NCQA standards, but need to demonstrate progress before they can qualify for higher levels of accreditation. Six percent of reviewed plans have received provisional accreditation.
    5. Denied. A denial is given to plans that do not qualify for any of the other possible categories. Six percent of reviewed plans have received a denial.
  • The American Accreditation Healthcare Commission (Formerly the Utilization Review Accreditation Commission or URAC) a nonprofit organization founded in 1990 to establish standards for the managed care industry. URAC surveys plans who request it and awards them accreditation if they meet URAC's standards. URAC accredits PPO's (which NCQA does not). Since 1991, URAC has issued over 1,200 accreditation certificates to over 300 organizations doing business in all fifty states. URAC-accredited organizations provide managed care services to over 120 million Americans. URAC awards the following types of accreditation status:
    1. Fully Accredited. This two-year accreditation indicates the plan meets 100% of URAC's "Shall" standards and meets 60% or more of its "Should" standards. In addition, policies and procedures have been implemented and operations are compliant with those policies as verified by the onsite review.
    2. Conditionally Accredited. May be granted to an organization that has not fully implemented policies and procedures determined to be complaint with URAC Standards. Typically under these circumstances, a company has met URAC standards during the desktop review, but verification of some operating procedures has not occurred for 100% of the "Shall" standards and 60% of the "Should" standards upon completion of the first onsite review.
    3. Denied Accreditation. A denial is given to plans that meet less than 100% of URAC's "Shall" standards and less than 60% of its "Should" standards and will not be able to come into compliance within six months.
  • Every managed care plan is required to have a grievance process clearly delineated and to make it known to its members how to use it. This process allows a patient to appeal the plan's decision on whether or not medical care is needed or on the amount of reimbursement you are entitled to. The agency that regulates this process and takes complaints of enrollees disatisfied with the process, vary by state.
  • In many states both the Department of Health and the Department of Insurance jointly oversee HMOs in the state. The Insurance Department oversees the business and financial aspects of HMOs and investigates consumer complaints concerning contract issues. The Department of Health oversees the quality-of-care delivered to residents, conducts on-site surveys and investigates consumer complaints with respect to the quality of health care. Our listing of State Quality Controls will tell you who's minding the managed care plan in your area.

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