Did you know there are special accrediting bodies that dictate the way remote nursing work is done? The National Committee for Quality Assurance (NCQA), the Utilization Review Accreditation Commission, and the Centers for Medicare and Medicaid (CMS) Star Ratings are a few key organizations to know.
The acronyms themselves couldn’t be any more boring, but don’t click away just yet.
These accreditation bodies are important to understand before you apply for a remote nursing job. If you don’t want to get tripped up in an interview, here’s everything you need to know so you can sound polished and in-the-know with the remote healthcare world.
The National Committee for Quality Assurance (NCQA)
NCQA was founded in the 90’s as a nonprofit. The organization says, “Before NCQA, health care was operating data-free and ‘in the dark.’” What do they mean by that?
NCQA measures and accredits health plans to determine if they get their stamp of approval. Basically, it’s like a report card for insurance companies and health practice compliance. The overall rating is between 1 and 5.
Overall, NCQA requirements cover specific areas of insurance plan operations, like:
- Member satisfaction, rights, and responsibilities
- Credentialing, like verifying licensure
- Utilization management and review
- Population health
- Medicaid benefits
NCQA is especially important to understand if you’re considering becoming a Healthcare Effectiveness Data Information Set (HEDIS) nurse. HEDIS nurses are responsible for locating this information in patient charts to help collect data.
Examples of HEDIS data include information like:
- Are pregnant members receiving timely prenatal care?
- Do diabetic patients get regular eye and diabetic retinopathy screenings?
- Are providers offering eligible members the appropriate vaccines at every visit?
The NCQA creates and updates all HEDIS measures, and health plans have to report their HEDIS data to keep their accreditation. NCQA reports that over 200 million Americans are enrolled in HEDIS-reporting health plans. NCQA also has an accreditation for Patient-Centered Medical Homes (PCMH).
The Utilization Review Accreditation Commission (URAC)
URAC was also created in the 1990s, like NCQA. URAC designed standards for United States utilization review. Why is this important? According to URAC, “It’s critical for everyone involved to meet national standards for quality, accountability, consumer protection and other key areas. The best way to do that is through accreditation by an independent third-party organization.”
URAC creates standards and measures to ensure that utilization management is done correctly.
Some of these standards and measures include:
- Timely determination
- Quality improvement program in place
- Use of established clinical guidelines when in the review process, like MCG or InterQual.
- Appeals processes are established for members
Your remote nursing job leadership, like the compliance team, will ensure that your company meets its URAC requirements. You may notice new procedures that trickle down and influence your daily workflows. Turnaround time metrics, review policies, or member determination letters are a few that may affect your work. Though the compliance team oversees how URAC requirements are implemented, the nursing team still carries out these orders and plays a role in the URAC requirements.
Centers for Medicare and Medicaid Star Ratings
The Centers for Medicare & Medicaid Services (CMS) Star Ratings program assesses and compares Medicare Advantage and Prescription Drug Plans. The mission for these ratings is to help consumers be “empowered to make the best health care decisions for them,” according to CMS.
Traditional Medicare and Medicare Part D, which covers drugs, are offered by the federal government. Private health plans sometimes bundle these plans into Medicare Advantage plans and Prescription Drug plans, and alter the pricing, network, and benefits to make them appealing to Medicare beneficiaries. However, elderly individuals may find themselves vulnerable to exploitation with Medicare Advantage plans that offer limited benefits, potentially favoring the pockets of insurance companies, rather than providing excellent care to members.
The CMS Star Ratings are a way to grade these plans and keep them accountable.
Some elements that CMS star ratings grade include:
- Appointment availability and wait times
- Customer service
- Accurate drug pricing
These reviews are publicly available on an annual basis so consumers can use them when comparing plans. Low ratings can prevent a plan from recruiting more members, so health plans are invested in maintaining their five-star ratings. CMS Star Ratings are relevant to nurses who work with federal plans, Medicare Advantage, and Prescription Drug Plans.
This is not an exhaustive list of every accrediting and licensing body, so you might hear others come up from time to time. Here are a few key players:
- National Association of Insurance Commissioners (NAIC). This is another organization that sets standards for insurance companies to ensure consumer protection.
- Accreditation Association for Ambulatory Health Care (AAAHC). This is an accrediting body that evaluates and accredits health plans to ensure they meet quality and safety standards for ambulatory care services.
- Health Information Trust Alliance (HITRUST). This is an organization that provides a framework for managing and securing sensitive healthcare information.
Pro tip: Curious if your remote nursing job offer from a small company is a scam? Looking for any of these seals on their website is one of many helpful indicators you can use to verify if the health plan or organization is legitimate.
Now you know more about the healthcare accreditation bodies that make the remote nursing world go round. But you don’t have to stop there! Someday, maybe you’ll end up working in healthcare compliance, or even for one of these accrediting organizations themselves.
Interested in learning more about the remote nursing world? Check out the Nurse Fern blog for more information that can help you land a remote nursing job.