How To Prepare For An NCQA Audit
Achieving the industry’s gold standard
The healthcare system has many moving parts, and one of the most important ones is provider credentialing. This tedious administrative task not only protects patients from medical harm but also helps organizations avoid negligence claims, reimbursement delays and financial loss.
By adhering to NCQA standards, healthcare companies can better protect their patients, pocketbooks and clinicians. Those wanting to stand out in the healthcare marketplace and demonstrate their commitment to quality should and can apply to become NCQA accredited or certified. We’ll explore the difference between the two and how to prepare for an NCQA audit.
What is NCQA?
NCQA stands for The National Committee for Quality Assurance. Founded in 1990, this non-profit organization aims to improve healthcare quality through its programs, measures and evidence-based standards. They offer numerous voluntary certification and accreditation programs, such as:
Patient-Centered Medical Home (PCMH)
Health Equity Accreditation
Population Health Program Accreditation
Health Plan Accreditation
Diabetes Recognition Program.
And more!
NCQA accreditation vs certification
Accreditation
One question that occasionally pops up is, “What’s the difference between NCQA accreditation and certification?” NCQA accreditation is considered the gold standard in the healthcare industry. It requires that healthcare companies follow certain specifications, which they are then surveyed on. For instance, health plans that submit HEDIS (Healthcare Effectiveness Data and Information Set) data to NCQA must complete audits annually.
Certification
NCQA states that its certification products are a subgroup of the guidelines and standards for accreditation products. Certifications are ideal for organizations that provide specific services, like credential verification organizations, but not comprehensive programs. The certification review process is meticulous and may require onsite and offsite evaluations.
NCQA accreditation can streamline credentialing
Anytime you hire a Licensed Independent Practitioner (LIP), you should complete a thorough verification process.
However, the credentialing process has become more complicated due to third-party payer requirements, accrediting bodies and expanded provider scope of practice. Plus, it could take three to six months to complete credentialing for one potential hire, and then re-credentialing is often required every two to three years.
In short, credentialing is a lot of work, which leads many healthcare facilities to outsource credentialing services to Credentials Verification Organizations (CVOs) like OpenLoop. CVO’s streamline the credentialing process so you can benefit from improved efficiency, fewer errors and reduced administrative burdens.
Provider credentialing and NCQA audits
NCQA has developed a set of standards that act as a framework for credentialing healthcare providers. Organizations with accreditation may boost their reputation, provide more efficient services, fulfill state requirements and even increase revenue streams. However, first, they have to complete a rigorous audit process.
The NCQA audit assesses whether organizations follow those standards and meet specific performance measures. To do so, they review a sampling of reports and credentialing packets. The audit is split into multiple parts, including:
A facility self-assessment: Healthcare facilities should evaluate their policies and procedures to identify potential areas for improvement.
Site visit: NCQA surveyors complete a virtual or onsite visit to assess policies, procedures, and documentation. They may also interview your staff. Once they’ve completed their review, they’ll report their findings and grant accreditation or certification if your organization meets their standards. If it doesn’t, they’ll tell you what issues must be addressed.
Credentialing packet review: Surveyors review provider applications, verification forms and more to ensure they comply with regulations.
Ongoing report monitoring: Various reports, such as Medicare and Medicaid sanctions reports, are reviewed for compliance.
How to prepare for an NCQA audit?
Alright let’s get into it. Achieving NCQA accreditation is a goal for many healthcare facilities, but it can also be intimidating. Fortunately, there are steps you can take to prepare, which we’ll explain below:
1. Review the standards
This may seem obvious, but healthcare leaders shouldn’t try to “wing” the NCQA audit process. Instead, familiarize your organization with the NCQA standards and guidelines.
2. Complete a self-assessment
Once you’ve reviewed the NCQA standards, you should identify where your organization needs to improve. For instance, are there outlines for creating a credentialing committee or procedures in place for what’s considered an acceptable verification and monitoring process? If not, you’ll want to get those procedures developed and ensure they align with NCQA standards.
3. Utilize modern technology
Technology can help simplify the credentialing process in numerous ways. Tools like electronic applications, automated source verification and AI for reviewing trends and abnormalities offer many benefits. Not only does this lead to faster credentialing, but also fewer errors, better patient care and cost savings.
Delegating provider staffing to an NCQA-accredited CVO helps ensure your credential packets are up-to-date and your patients get access to certified expert clinicians.
4. Complete internal monitoring and training
You want to ensure your staff is on the same page, so internal training on NCQA standards is necessary. Continue to monitor reports and ensure you’re meeting payer requirements so your facility isn’t exposed to additional credentialing lapses and mishaps.
Meet patient demands while prioritizing quality and safety
As you’ve learned, provider credentialing is a necessary and critical process for upholding patient safety. However, it’s also a time-consuming task, especially for healthcare organizations that are trying to scale while maintaining excellent quality of care.
This is where OpenLoop comes in. As a NCQA-certified CVO, we help organizations, like yours, streamline provider operations by offering our licensing and credentialing services. By partnering with us, you gain access to our streamline credentialing, extensive nationwide provider and payer networks and HIPAA-compliant white-label technology built to scale with your organization.
Want to learn more? Contact us today!
Our full suite of white-labeled virtual care services includes: