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NCQA Adds Narrow Networks to 2016 Accreditation Standards

August 12, 2015

New rules include provisions to ensure the accuracy of provider directories, and lists of participating doctors and hospitals. The inaccuracy of some directories has generated concern among patients, and prompted new state regulations.

The accreditation standards for 2016 released by the National Committee for Quality Assurance (NCQA) reflect a broader push to ensure the adequacy of the growing number of so-narrow network insurance plans.

With that in mind, NCQA has added a "Network Management" section to its evaluation standards. The section gathers together several existing measures and asks payers to take a more "holistic" approach to ensuring the quality of networks, says Raena Akin-Deko, the NCQA assistant vice president of product development.

Raena Akin-Deko

The new rules also include provisions to ensure the accuracy of provider directories, lists of participating doctors, and hospitals that consumers use to decide whether to enroll in a plan or choose a provider. The inaccuracy of some directories has generated concern among patients, as well as new state regulations.

The creation of the network management category "now elevates those requirements to say, 'hey, listen, this is a very, very important part of what you are doing,'" Akin-Deko says.

The NCQA is considered a top accreditation program for health plans. In order to pass NCQA muster, insurers have to comply with a list standards and must supply the non-profit group with data on performance. The NCQA reports that it has accredited plans in 50 states that cover 70.5% of all insured Americans.

Narrow Provider Networks Set to Spread

In terms of network adequacy, Akin-Deko says that the group already looks at measures such as how far and how long patients have to travel as measures of access to care. Based on NCQA's experience, time and distance are good measures, but are not sufficient, she says. The group now wants plans to consider patients satisfaction, for example, how long it takes to schedule an appointment.

Member experience has to be a factor, she says: "When you do your analysis of can somebody get to an appointment… how long it takes them to get there… [what are the] complaints and member experience… we want you to consider that as a whole, because that will paint a picture for you for what opportunities there are to improve."

Even prior to passage of the Patient Protection and Affordable Care Act, payers were using networks as a variable to control costs, says Gerald Kominski, director of the Health Economics and Evaluation Research Program at the UCLA Center for Health Policy Research.

No Existing Guidelines to Measure Network Adequacy

NCQA is recognizing that there are other dimensions of plan performance that should be included in their measurements. However, even though the issue of network adequacy is gaining attention because of the PPACA, there are no acceptable guidelines on how to measure it, he says.

"We don't have a deep body of good scientific research on how to identify network adequacy or how to identify whether or not there are quality problems," Kominski says. "We still have some way to go before we have good measures of this dimension of quality in the same way we've developed good measures of clinical quality of care."

He says he is pleased to see that a key national organization like the NCQA is incorporating network adequacy into its set of performance measures.

Gerald Kominski

Another component of the new standards is the requirement that insurers assess and maintain the accuracy of both print and online provider directories. In California, where the adequacy of narrow networks has been a flash point, the subject of lawsuits and state regulation, the state Senate approved a bill this summer that would require plans to make sure directories are accurate and up-to-date. The National Association of Insurance Commissioners (NAIC) also working on a model law addressing the issue.

Maintaining current lists of providers in health plan networks is essential, says Jan Emerson-Shea, vice president for external affairs of the California Hospital Association, who responded to questions by email.

In some situations, the relationships or affiliations between physicians and hospitals may not be thoroughly understood or considered by the health plans. As a result, although the hospital is "in network," the affiliated medical group or physicians on the medical staff may not be contracted providers. When these situations occur, there is no in-network physician who can admit the patient to the in-network hospital, rendering the benefit meaningless, she says.

The updated NCQA standards require organizations to assess the accuracy of four key pieces of information in their directories: location, phone number, whether they are participating in the plan, and whether they are accepting new patients. The standards also call on plans to act on opportunities to improve directory accuracy.

"We had conversations with a number of stakeholder who are trying to address this issue and we know that that it is really, really complex," says Akin-Deko.

Plans have to keep on top of hundreds, sometime thousands, of providers. Under the rules, the plans will need to assess the accuracy of their plans at least once a year.

"We recognize that this is a first step and there are other things we're going to be looking at for provider directory accuracy," she says. "There are a lot of moving pieces."

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