Quality Improvement
What is NCQA Accreditation? 
MercyCare Health Plans is pleased to report that the National Committee of Quality Assurance (NCQA) awarded us an "Excellent" accreditation following their June 2004 site visit. An "Excellent" is the highest achievable status an organization can earn from NCQA.
NCQA is the only nationally standardized and accepted seal of approval that effectively demonstrates to current and prospective purchasers a HMO's quality level of programming and functioning.
To briefly summarize what encompasses NCQA accreditation, the basic requirements are in the following areas:
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Quality Improvement & Management: Quality improvement activities and results. Disease Management, Medical Record Documentation, Appropriate Access to Care, Appropriate Availability of Care, Clinical Practice Guidelines
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Utilization Management: Establishing appropriate Clinical Criteria and application of in medical necessity decision making, developing and implementing Grievances processes, Pharmacy Management procedures, and oversight of appropriate utilization.
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Member Rights & Responsibilities: Providing adequate member education, member service, access to information, and establishment and adherence to published member rights & resonsibilities.
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Credentialing: Assuring that appropriately educated, trained, and regulated providers comprise the network (primary source verification)
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Preventive Health: The process of adopting Clinical Practice Guidelines (CPG's) and educating members and providers relative to encouraging preventable illnesses.
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HEDIS®: Participating in the Health Employer Data Information Set (HEDIS®) annual reporting. Measures that are specifically scored for NCQA and compared to comparable plans. Examples include: Childhood / Adolescent immunizations, Asking Smokers to Quit, Beta Blocker treatment After Heart Attack, Comprehensive Diabetes Care, Cholesterol Management After Acute Event.
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CAHPS®: Consumer Assessment of Health Plan Satisfaction survey participation. Examples include: Getting Needed Care, Claims Processing, Customer Service, Rating of Health Plan, and Rating of Personal Doctor.
MercyCare Health Plans 2004 CAHPS® / HEDIS® :
In order for an HMO to earn an "Excellent" accreditation status, as MercyCare has, an organization needs to be in the 90th percentile following NCQA's review of the six core areas (highlighted above) and the additional sixty elements which comprise the measurement of the core areas.
Additional Quality Improvement items:
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