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Frequently Asked Questions (FAQs) About NCQA's Accreditation, Certification and HEDIS®.

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Product: PHQ 2008

 
MISC   Use of the term "days" within the standards and guidelines
    Question: Do all references to “days” in the standards and guidelines mean “calendar days”?
    Resolution: Yes. Unless otherwise specified, all references to “days” in the standards and guidelines mean calendar days.
 
MISC   Pay for Performance
    Question: The draft program did not pertain to pay-for-performance programs, whose goal is QI at the practice, not public disclosure. Why was this added to "taking action?"
    Resolution: In the draft standards released for Public Comment in March 2008, NCQA included pay-for-performance but did not use that specific term; instead, we referred to “payment” strategies. Specifically, NCQA defined the Scope of Review for the majority of elements in PHQ 1 as: NCQA evaluates all measures the organization uses for measuring physician performance for the purpose of taking action. In the Explanation, NCQA defined “taking action” as follows. •Publicly reporting physician performance on quality or cost or resource use •Using physician performance on quality or cost or resource use measures as a basis for network design (such as tiering), benefit design or payment strategies NCQA defined “payment strategies” in Element M, Using Measure Results as follows. The organization uses reimbursement to provide incentives for improvement among its physicians, practice sites or medical groups, or uses payment to reward performance. In the final standards, NCQA used the term “pay-for-performance” and specifically narrowed the scope of programs included.
 
MISC   Tools for readiness evaluations
    Question: Is there a non-Web based tool available for our organization to use for self-assessment?
    Resolution: An organization can use the PDF version of the standards to assess readiness to undergo a survey, but in order to undergo a survey it must purchase and use the Web-based Interactive Survey System (ISS) Tool. To purchase the PDF version of the standards or the Survey Tool, visit the NCQA Web site (www.ncqa.org) or contact Customer Service at 888-275-7585.
 
MISC   PHQ and HP Accreditation
    Question: When will the PHQ standards be folded in to the health plan accreditation standards?
    Resolution: NCQA has not made a decision about incorporating the PHQ standards into health plan accreditation. Should NCQA decide to do so, it will put such a proposal out for Public Comment.
 
P&Ps   Survey Pricing
    Question: If we go through provisional certification and are then required to go through full certification within 12 months, does our organization get a reduced price?
    Resolution: No. Survey prices apply to each discrete survey; NCQA does not apply credit forward to a future survey. Survey pricing reflects the amount and level of resources NCQA dedicates to evaluating an organization and at the time of the Full Certification Survey, NCQA must re-evaluate the organization on all requirements.
 
P&Ps   Certification for information providers
    Question: May an information provider earn certification for the pieces it provides (e.g., standards, methodology, underlying data), while its customer (i.e., health plan that publishes the information) pursues other pieces (e.g., member communication and complaints, physician communication)?
    Resolution: No. PHQ consists of the specified certification options: Physician Quality (PQ), Hospital Quality (HQ), or both. Contact phq@ncqa.org to discuss your situation so we can consider additional survey options to meet market needs.
 
P&Ps   Reapplying for certification
    Question: When may an organization that fails to be certified reapply?
    Resolution: NCQA does not specify a minimum period after a denial during which an organization may undergo a new review, but the organization must have completed a new cycle of measurement and action in order for NCQA to review it against the standards.
 
P&Ps   Survey pricing
    Question: How much does the PHQ Survey cost?
    Resolution: The cost of a PHQ Survey is based on survey and evaluation type. The current pricing table for NCQA PHQ Certification is available from the NCQA Web site at www.ncqa.org/tabid/753/Default.aspx.
 
P&Ps   Adding new products/product lines to existing PHQ Distinction
    Question: If a plan was initially PHQ Certified in HMO only and now wants to add PPO, is the certification process separate?
    Resolution: NCQA no longer conducts surveys under the 2006 PHQ standards. If an organization had distinction for its HMO under the 2006 standards and seeks certification for its PPO, the PPO must be reviewed against the 2008 standards. Under the 2008 PHQ standards, if a plan manages both products (e.g., HMO and PPO) the same, NCQA can survey both products together. The organization should contact NCQA to discuss its options, including a possible option to upgrade (i.e., apply some results from its 2006 survey to a 2008 survey). Note: An Upgrade does not extend the expiration date of the Distinction; that date transfers to the new certification status.
 
P&Ps   Differences between health plan (MCO/PPO) and PHQ standards
    Question: We went through MCO accreditation in 2007. PHQ standards were required in our standards. How is this different? How is this the same?
    Resolution: NCQA’s PHQ product was released in April 2006 as part of its Quality Plus Program, a voluntary suite of areas where NCQA-Accredited plans could earn distinction. NCQA Health Plan (formerly MCO) Accreditation standards do not include PHQ requirements.
 
P&Ps   Certification time limits
    Question: How long does certification last?
    Resolution: Certification in PHQ, PQ or HQ is valid for two years. Organizations must undergo a survey against the standards at least every two years to maintain their certification status. Provisional Certification is valid for 12 months; it is a temporary option and will not be offered after June 30, 2009.
 
PHQ   Use of Performance-based Improvement Module (PIM)
    Question: Element A states that “If an organization takes action based on physician completion of an ABMS or AOA board performance-based improvement module generally in conjunction with maintenance of certification) at least every two years, those activities may be used as a quality measure for the purposes of meeting this standard.” When counting the quality measures for Element A, for how many measures does NCQA award credit (e.g. for each measure in the PIM or for each PIM)?
    Resolution: Regardless of the number of measures within a PIM, each PIM counts as one standardized measure for PHQ 1, Element A. This is consistent with the current language in the PHQ standards and guidelines (i.e., activities may be used as “a measure”). To receive credit for using PIMs and for the survey team to verify that the Board requires a PIM as part of certification maintenance, the organization must list in the Survey Tool's Element A Measure Worksheet: (1) the PIMs on which it bases the action; (2) list the source of the measures as Specialty Medical Boards; and (3) provide a direct link to the Board where the PIM and its measures can be found.
 
PHQ   Measure Specifications
    Question: NCQA requires that an organization’s measure specifications exactly match the specification of the standardized measure in order to receive credit for PHQ 1 A. In some cases, National Quality Forum (NQF)) or Ambulatory Quality Alliance (AQA) may have endorsed or accepted a measure specification which has subsequently been updated by the measure developer based on changes to underlying clinical evidence, coding, etc. If NQF or AQA have not yet updated the endorsement/acceptance, does the organization still receive credit if it is using the most recent specification from the measure developer?
    Resolution: Yes. An organization that uses the most current specifications from the measure developer meets the intent of PHQ 1, Element A for that measure, even if the NQF or AQA acceptance/endorsement has not been updated.
 
PHQ1   PHQ and Physician Practice Connection Recognition
    Question: Do you have a crosswalk for PHQ as it relates to Physician Practice Connection® (PPC) Recognition—standard 8 in particular?
    Resolution: No. The PHQ standards evaluate organizations that measure physician performance; PPC recognizes physician practices that use systematic processes and information technology to enhance quality of patient care. The two programs serve different purposes. In particular, PPC 8: Performance Reporting and Improvement focuses on the practice’s internal measurement and quality improvement process. It does not address the methodology required in PHQ, but focuses on the QI process.
 
PHQ1   Changing measure specifications
    Question: With regard to patient experience measures, may we use items from CAHPS-CG but change the referent time period? For example, not rating the last 12 months, but rating the last visit and changing the response categories accordingly?
    Resolution: No. Changing the referent time period materially alters the measure and would therefore not qualify as a standard measure for Element A. Patient experience measures endorsed, developed or accepted by the NQF, AQA, AMA PCPI, national accreditors or government agencies may be used, but the organization must follow the measure or instrument specifications as written.
 
PHQ1   Quality measures
    Question: Does Board Certification status count as a quality measure?
    Resolution: No, Board Certification status alone does not count as a quality measure.
 
PHQ1   Pay for Performance
    Question: Is consumer transparency required for certification? Our program is “pay for performance” targeted at physicians and hospitals only.
    Resolution: If the organization seeks certification, NCQA evaluates all measures on which it bases action against all elements. If the organization has a physician pay-for-performance program that meets the definition of “taking action,” then it must meet the elements—including all transparency requirements, including, but not limited to, requirements for making available to customers methodology and information about how the measures are used, providing opportunities for input, seeking feedback and having a process for complaints. If the organization’s pay-for-performance program was not designed to include public reporting of physicians’ measure results, then the organization is not required to make the individual measure results available to customers.
 
PHQ1   Patient experience measures
    Question: Do the results of Patient Experience of Care surveys, using questions derived from CAHPS-CG, have a role in the evaluation of physician quality?
    Resolution: Yes. Patient experience measures are considered measures of quality. The organization may use items or composites from the CAHPS-CG survey.
 
PHQ1   Board certification and physician quality
    Question: Will NCQA accept board certification, maintenance of certification and NCQA Recognition as markers of physician quality, or must there also be measurement of NQF markers?
    Resolution: The organization may take action based on physician completion of an ABMS or AOA board performance-based improvement module (generally, in conjunction with maintenance of certification) at least every two years. These activities may be used as a quality measurement activity to meet PHQ 1. Under certain circumstances, the organization may use measures from other national or regional performance-based designation programs to satisfy some or all requirements for PHQ 1, Element A. The organization must discuss this in advance with NCQA to determine if the designation program meets the criteria.
 
PHQ1   Noncompliant patients and physician ratings
    Question: Has NCQA made recommendations or looked at the effect of noncompliant patients on physician ratings?
    Resolution: Although patient factors such as noncompliance may affect measure performance rates, an integral role of the physician is to work continuously with patients to educate them on the importance of a specific process or meeting a specific target/goal.
 
PHQ1   Coding accuracy
    Question: Is evaluation of coding accuracy and quality considered to be in scope for these measures?
    Resolution: NCQA does not evaluate coding accuracy and quality. Element D, Verifying Accuracy requires an organization to have a process to evaluate the accuracy of its measure results. The organization may use external auditors to verify its methodology, but is not required to do so. In the future, NCQA may develop standards for auditing physician measurement and a program for certifying auditors. With such standards, NCQA will consider making external audit a requirement.
 
PHQ1   Working with Physicians
    Question: Our organization posts the results of our physician measurement program on our directory on January 1 and any tiered networks or differential benefits are effective that same date. We make the results available to members by request (e.g. the member can call an 800 number to ask about a physician’s status in the tiered network) on December 1. Which date – January 1 or December 1 – does NCQA consider the action date for the purposes of calculating whether we notify physicians 45 days ahead of action and resolve requests for corrections or changes before taking action?
    Resolution: If information is available to the public--even if it is only available by request--NCQA considers this to be public reporting. Therefore, in this scenario the “taking action” date is December 1.
 
PHQ1   Requests for corrections or changes
    Question: For Elements F and G, how can patient experience of care data corrected, when this information is not disclosed to physicians?
    Resolution: The plan is not required to disclose member-specific results, nor is it expected that a physician can correct member responses. At a minimum, the physician must be given the methodology (e.g., sampling, attribution) and survey questions and, upon request, be allowed to confirm that the patients in the universe from which the sample was drawn are his or her patients, given the methodology.
 
PHQ1   Exemption process for surveys
    Question: Can you confirm the process for exemption for PHQ 1?
    Resolution: During the application process, the organization lists and briefly explains instances where it feels exemptions apply.
 
PHQ1   Productivity measures
    Question: Are productivity measures within scope? For example, number of visits per half day: does NCQA classify this as a utilization measure or as something else?
    Resolution: No. Productivity measures are out of scope for the 2008 PHQ standards. Quality, cost, resource use and utilization measures are in scope if the organization takes action based on them.
 
PHQ1   Physician requests
    Question: For PHQ 1 Element G, could a collaborative manage the process?
    Resolution: Yes. PHQ requirements do not prohibit a collaborative from managing a request for corrections or changes made by physicians, but the organization remains accountable and responsible for responding to complaints from consumers and to requests for changes from physicians or hospitals based on actions taken by the organization.
 
PHQ1   Measure specifications
    Question: Since NQF does not publish the actual code sets for all its measures, how does NCQA determine that an organization is following the measure specifications as written?
    Resolution: NCQA recognizes that some NQF-endorsed or AQA-approved specifications may require additional specifications to implement in specific contexts. Organizations may supplement endorsed specifications as long as they follow all endorsed specifications and if such supplementation does not alter the intended numerator, denominator and exclusion criteria for the measure.
 
PHQ1   Taking action on collaborative and organization results
    Question: How does the survey process work if an organization takes action on measure results from a collaborative and from its own measurement?
    Resolution: All measures on which the organization bases action are included in the scope of a PHQ Survey, including those developed and whose results are calculated as part of a collaborative and those calculated directly by the organization. NCQA evaluates the organization’s activities in one of two ways. 1.Evaluate the collaborative once—if the collaborative opts to undergo a PHQ survey—and apply the survey results to all participants 2.Evaluate the measures, methods and processes of the collaborative when each participant organization is surveyed The organization’s scores on any element are based on the performance of both the collaborative and the organization. The organization must meet the element for all measures, including the collaborative measures it uses. For example, for Element C: Methodology, NCQA evaluates the organization’s methodology for each measure directly. It may evaluate the collaborative’s methodology either once during a survey of the collaborative or for each organization during the organization’s survey. Regardless of the process, all measures must meet the requirements of Element C in order to meet the element. When a collaborative undergoes a survey directly, the process is streamlined for all involved (the collaborative, the organization and NCQA). In addition, the process may be more cost-effective, since NCQA’s pricing is designed to reflect economies of scale.
 
PHQ1   Notice for providing results
    Question: Does a 45-day notice period apply when measurement is more frequent than annual (e.g., quarterly)?
    Resolution: The 45-calendar-day notice period for providing results and an opportunity for a physician to request a correction or change applies to each cycle of measurement and action an organization takes, regardless of frequency (e.g., biannual, annual, semiannual, quarterly); however, if an organization recalculates results without changing its methodology or measures, it does not need to provide the methodology again as long as it supplies information on how to obtain that methodology. The exception to the minimum 45-calendar-day notice period for action is if the action involves only pay-for-performance activities that are not publicly reported (e.g., an action that is only between the organization and the physician). In this instance, the organization may provide the results and methodology concurrent with additional or bonus payment. The organization must still provide a process for the physician to request corrections or changes.
 
PHQ1   Handling complaints
    Question: For the file review component in PHQ 1 (re: member complaints), is there review of a minimum number of files? In other words, we do not anticipate a large number of this type of complaint.
    Resolution: There is no minimum requirement. If the total number of files is fewer than the requested 40 files, NCQA reviews the entire file universe. For file review elements, NCQA follows its 8/30 methodology. Refer to An Explanation of the ‘8 and 30’ File Sampling Procedure on the NCQA Web site at www.ncqa.org/tabid/125/Default.aspx.
 
PHQ1   Standardized measures
    Question: What counts in the denominator for standardized measures—all measures on which action is taken, or all quality measures on which action is taken?
    Resolution: For Element A, the denominator is all quality measures on which the action is based and the numerator is measures that meet the definition of “standardized” in the Explanation.
 
PHQ1   Measure requirements
    Question: Regarding standardized measures, will the requirement of 70% of measures being standardized increase over time or will it be held constant?
    Resolution: NCQA has not decided. All products are periodically evaluated and proposed changes are published for Public Comment before updates are released.
 
PHQ1   Approved measures
    Question: What percentage of an organization's measures must be approved by NQF, AQA or AMA/PCPI?
    Resolution: To achieve certification, the organization must score at least 50% on Element A, Measuring Physician Performance. The 50% score threshold requires that at least 50% but fewer than 60% of the measures used by the organization to measure physician quality for taking action meet the element (i.e., are standardized). To achieve full points (100%), at least 70% of the measures used by the organization to measure physician quality for taking action must meet the element (i.e., must be standardized)
 
PHQ1   Small physician sample size
    Question: If only a small percentage of available physicians in any specialty within a market have sufficient NQF measures available, may there be an assumption of appropriate quality, thus allowing members access to higher benefits with a larger number of physicians?
    Resolution: Yes. Assumption of appropriate quality in this context is permitted.
 
PHQ1   Credit for Physician Recognition Programs
    Question: Define how NCQA Physician Recognition programs can be used for autocredit.
    Resolution: NCQA’s Recognition Program measures meet many of the elements in PHQ. If an organization takes action based on measures in NCQA’s Recognition Programs, the measures meet the elements where specified in the standards. The organization does not need to provide additional documentation about how the measures meet these elements. NCQA’s Recognition Programs are the Diabetes Physician Recognition Program (DPRP); Heart-Stroke Recognition Program (HSRP); Back Pain Recognition Program (BPRP); Physician Practice Connections (PPC); and the Physician Practice Connections—Patient-Centered Medical Home (PPC-PCMH™).
 
PHQ1   Standardized Measure Specifications
    Question: For Element A, if physicians may eliminate noncompliant patients as part of the corrections process, are standardized measures still considered to be nationally recognized?
    Resolution: If a patient is removed from a measure for not taking prescribed medication or for not following recommended treatment, the measure is not considered standardized. If the patient meets specific exclusion criteria listed in the specifications and is removed from the measure, the measure is considered standardized.
 
PHQ1   Applications for PHQ surveys
    Question: How long after NCQA receives an application for survey does the survey begin?
    Resolution: NCQA suggests that organizations submit an application for survey at least 90 days in advance of the date requested for their Initial Survey, but applications may be submitted further in advance than 90 days. Organizations should indicate their preferred survey date and NCQA will accommodate them if possible.
 
PHQ1   Organization accountability
    Question: Are organizations responsible for confirming the factors in Element D, or is this the responsibility of an external vendor?
    Resolution: For Element D, the organization must demonstrate that it has a process to verify that it has followed the specifications outlined in Element C (e.g., sample sizes, attribution, statistical validity). If the organization uses a vendor to administer the survey, this process may be performed by the vendor, but documentation demonstrating how the element is met must be included for the PHQ Survey.
 
PHQ1   Providing Results and Estimates of Statistical Reliability
    Question: Element F, factor 3 requires organizations to provide results and estimates of statistical reliability for comparative information to each physician. What evidence must organizations provide to meet factor 3?
    Resolution: To meet the intent of factor 3, the organization must provide physicians with the results of each applicable measure and an estimate of statistical reliability. The organization determines how it expresses the estimate of statistical reliability (e.g., range, standard deviation, confidence interval, coefficient of variation). The organization should also provide descriptive information with the numbers; the estimate of reliability is a numeric value.
 
PHQ1   Taking action on cost measures
    Question: Is an organization prohibited from using cost efficiency if quality results are not available?
    Resolution: Yes. The organization may not take action based on cost, resource use or utilization results alone. This is a “must pass” requirement for certification and is consistent with the Consumer-Purchaser Disclosure Project Patient Charter. The organization is required to consider quality in conjunction with cost, resource use or utilization when it takes action. To the extent that the organization develops and presents a composite score or rating using cost, resource use or utilization and quality measures, it must disclose the specific measures for each category and their relative weight when it determines the composite or rating.
 
PHQ1   Measure reliability
    Question: If a plan demonstrates a different methodology for statistical validity, would the methodology be considered?
    Resolution: Element C, Measurement Methodology requires the organization to have a method for determining measurement error and measure reliability. Element H, Principles for Use of Results sets requirements for minimum observations or levels of measure reliability or confidence intervals—as applicable for quality and cost, resource use or utilization measures. For calculating measure reliability for PHQ, the organization must use the method described in the Explanation in Element C under the subhead Measurement error and measure reliability. ”Measure reliability” is defined as the ratio of the variance between physicians to the variance within one physician, plus the variance between physicians. NCQA does not prescribe the method used to calculate confidence intervals because the appropriate method may vary based on the parameter (e.g., mean or proportion).
 
PHQ1   Methodology for evaluation of cost measures
    Question: What constitutes an acceptable methodological approach to evaluation of cost?
    Resolution: NCQA does not prescribe the cost measures an organization selects, though it requires an organization to specify all aspects of its methodology (Element C). In addition, the organization must risk-adjust its measures (Element C, factor 8) and must meet the minimum statistical requirements for measurement error and measure reliability (Element H, factor 2).
 
PHQ1   Risk adjustment
    Question: How is risk adjustment defined for quality measures?
    Resolution: Case-mix adjustment considers variations in the health of physicians’ populations, often defined by age and gender. Severity is a patient’s degree of illness for a specific mix of conditions (e.g., cancer stages), morbidity or comorbidity. Together, case mix and severity are often called “risk.” Risk can be either the risk for needing a mix of medical services (utilization and associated costs) or the patient’s likelihood of achieving a specific level of quality-related outcome. Risk adjustment may not apply to quality measures, particularly process measures. For quality measures, NCQA requires the organization to demonstrate that it has considered whether to risk-adjust measures—and that it has an explicit methodology if it does and an explicit rationale if it does not. If the organization determines that case-mix and severity adjustment do not apply to a quality measure, it provides documentation that supports the determination. If the organization adjusts measures for case-mix or severity, it provides documentation describing the methodology used.
 
PHQ1   Measures with Multiple Indicators
    Question: Some standardized measures (e.g., Comprehensive Diabetes Care, Chlamydia Screening in Women) have multiple indicators. For PHQ 1, Element A, where scores are based on the percentage of standardized measures , does NCQA count each indicator as a measure, or does it count measures with multiple indicators as one measure?
    Resolution: For PHQ 1 Element A, NCQA counts different indicators as separate measures if they reflect separate care processes; however, NCQA does not count different age stratification rates as separate measures For example, HbA1c testing and LDL-C screening count as two measures even though they are both part of Comprehensive Diabetes Care, but for Chlamydia Screening in Women, the two age stratifications and the total rate can only count as one measure.
 
PHQ1   HEDIS measures
    Question: If we use HEDIS measures, will NCQA still look at code?
    Resolution: No. NCQA does not evaluate an organization’s code; it reviews the organization’s measure specifications and compares them to the original source specification (if applicable).
 
PHQ1   Relative Resource Use (RRU) Measures
    Question: Are HEDIS RRU measures appropriate for PHQ 1 Element B?
    Resolution: No. HEDIS RRU measures are specified for assessment at the plan level, not for measurement of individual physician performance.
 
PHQ1   Cost, resource use or utilization measures
    Question: Are there standardized measures for cost, resource use or utilization? If there are none, what measures are plans using?
    Resolution: At this time, there are no standardized (i.e., endorsed) measures of cost, resource use or utilization at the physician level.
 
PHQ1   Quality measures
    Question: What criteria does NCQA use to determine what constitutes a quality measure vs. another kind of measure?
    Resolution: A quality measure is one of clinical performance or patient experience, where one can generally identify the “direction of good,” with a clear definition of what is “better” performance or “worse” performance.
 
PHQ1   Collaborative data
    Question: Must organizations include collaborative data for certification?
    Resolution: All measures on which an organization bases action are included in the scope of the PHQ Survey, including those that are developed and whose results are calculated as part of a collaborative. The exception is during the first year the standards are in effect (October 1, 2008–September 30, 2009). For surveys that start during that period, the organization may opt to carve out measures from a collaborative. The rationale for this exemption is two-fold. First, organizations will not need to wait until a collaborative undergoes a survey in order to have their own survey. Second, if the collaborative needs to make changes to any measures, methods or processes to meet the standard, it is not within the organization’s control to make the changes—although as a participant, it influences them. This allows time for the collaborative to make changes.
 
PHQ1   Surveyors for PHQ certification
    Question: What organizations will conduct surveys now or in the future? Only NCQA or, for example, would Licensed HEDIS Audit Organizations conduct them?
    Resolution: NCQA performs surveys on the PHQ standards, but may develop standards for auditing physician measurement and a program for certifying auditors. With such standards, NCQA will consider making external audit a requirement.
 
PHQ1   Requests for corrections or changes
    Question: What does NCQA look for in file review with regard to requests for corrections or changes?
    Resolution: Element G, Request for Corrections or Changes has four factors. 1. Documentation of the substance of the request 2. Investigation of the request 3. Notification of the specific reasons for the final decision 4. Notification of the outcome prior to taking action on measure results NCQA reviews an organization’s documentation to determine if it follows its process for handling physician requests for corrections or changes related to the four factors. In response to inquiries from many organizations, NCQA issued a clarification on the expectations of the process (which is scored in Element F) and the file review against that process. See the Corrections, Clarifications and Policy Changes Web page at www.ncqa.org/tabid/120/Default.aspx.
 
PHQ1   Notice for providing results
    Question: Does a 45-day notice period apply when measurement is more frequent than annual (e.g., quarterly)?
    Resolution: Yes. The 45-calendar day notice period for providing results and providing an opportunity for a physician to request a correction or change applies to each cycle of measurement and action an organization takes, regardless of frequency (e.g., biannual, annual, semiannual, quarterly); however, if an organization recalculates results without changing its methodology or measures, it does not need to provide the methodology again as long as it supplies information on how to obtain that methodology. The exception to the minimum 45-calendar-day notice period for action is when the action involves only pay-for-performance activities that are not publicly reported (e.g., an action that is only between the organization and the physician). In this instance, the organization may provide the results and methodology concurrent with additional or bonus payment. It must still provide a process for the physician to request corrections or changes.
 
PHQ1   Attribution
    Question: Do the NQF or HEDIS provider-level measurement specifications define attribution? For example, to whom to attribute performance: the diagnosing MD, prescribing MD, provider with most encounters and so on? If not, does this not result in variation?
    Resolution: Neither NQF nor HEDIS provider-level measures specifications require a specific attribution method, although HEDIS measures provide options for an organization to consider. While this might result in variation from one organization to another, there is currently no single industry standard method for attribution.
 
PHQ1   Measure specifications
    Question: Expand on the “minimum denominator criteria” for quality measures. Do you mean “minimum observations per measure”? Or “minimum observations per provider”? Or is that already in the requirements?
    Resolution: In measuring physician performance and distinguishing among peers, the organization is required to specify minimum observations or denominators for each measure on which the action is based. Denominators are patient observations, which may include multiple observations for an individual. Criteria must be defined at the level on which action will be taken. Note: This applies if the organization uses minimum observations rather than confidence intervals or measure reliability.
 
PHQ1   Use of patient experience data collected from external organizations
    Question: Is the use of patient experience data within the scope of NCQA review in the following circumstances: 1. The organization incorporates third-party performance information data with its own and then takes action on it (i.e., integrates the third-party data with its own to develop a composite that it reports or uses as the basis of action, such as payment or network or benefit design) 2. The organization provides a link for members on a third-party site so the member can review that information?
    Resolution: For scenario 1, the data is within the scope of review for PHQ because the organization has incorporated the data with its own or tailored the data and then used the data as a basis for its own action (e.g., reporting, payment or network or benefit design). For scenario 2, if the organization simply provides a link to an external source of performance information on physicians without altering that data and represents it as such, and the organization does not take any action based on the data (e.g., pay any incentive or use data for network or benefit design) then it is outside the scope of review for PHQ.
 
PHQ1   Use of HEDIS measures in PQ certification
    Question: May organizations use NQF-endorsed health plan HEDIS specifications for physician-level measurement?
    Resolution: Yes. Organizations may use NQF-endorsed health plan HEDIS specifications until July 1, 2010. For programs updated with new results after July 1, 2010, organizations must follow the NQF-endorsed HEDIS Physician Measurement specifications. These are generally the same as the HEDIS Health Plan specifications, but may have some modifications. If a measure in the desired area has not been endorsed by NQF, the organization may use an alternate measure from the HEDIS set and still qualify as a standardized measure, as discussed in the explanation in PHQ 1, Element A.
 
PHQ1   Measure specifications
    Question: Since NQF does not publish the actual code sets for all its measures, how does NCQA determine whether an organization is following the measure specifications as written?
    Resolution: NCQA recognizes that some NQF-endorsed or AQA-approved specifications may require additional specifications to implement in specific contexts. Organizations may supplement endorsed specifications as long as they follow all endorsed specifications, and if supplementation does not alter the intended numerator, denominator and exclusion criteria for the measure.
 
PHQ1   Complaints
    Question: The concept of "member complaints" pertains to health plans only, but not necessarily to Web sites or collaboratives. How does NCQA evaluate for those entities?
    Resolution: Though an organization may not have “members” in the way a health plan does, Web sites have users or consumers who might want to submit complaints (e.g., user complaints). Therefore, to meet the intent of Elements L and M, an organization must have policies and procedures to process, register and respond to consumer complaints; and must provide a documented process and evidence for how it handled those complaints.
 
PHQ1   Composite measures
    Question: How does NCQA review Element A if a measure used to take action is a combination of a quality measure and a measure that is not in scope, where the quality measure is standardized?
    Resolution: For PHQ 1, Element A, NCQA determines whether individual quality measures (used on their own or in a composite with other criteria) meet the element as defined by the hierarchy of standardized measures. The organization may use additional criteria (e.g., board certification status) to determine performance designation, in combination with quality measures, but the additional criteria remain out of the scope for this element. The organization receives credit for the standardized quality measure.
 
PHQ1   Working with Physicians
    Question: What actions must an organization take to meet Element F factor 1?
    Resolution: The organization must provide, at the time of initial contracting, new physicians with specific performance measurements applicable to them. The organization may provide the information: •In writing •In person at meetings •On the Web, if it notifies physicians, practices or medical groups that the information is available
 
PHQ1   Automatic credit for NQF endorsed surveys
    Question: Does an organization that uses the NQF-endorsed CAHPS-CG survey receive automatic credit? If not, what is the organization’s accountability for confirming factors in the measurement methodology?
    Resolution: An organization does not receive automatic credit for using CAHPS-CG for an NCQA Survey. For Element C, the organization must follow the aspects of the survey methodology outlined in the endorsed specification, and must specify how it will address all other aspects of methodology required by the element.
 
PHQ1   Frequency of re-measurement
    Question: For plans using patient experience measures, must re-measurement occur every two years to meet Element E?
    Resolution: Yes. Plans that use patient experience measures must measure at least every two years to receive credit for this element.
 
PHQ1   Patient experience measures
    Question: Are all questions related to patient perception considered “quality” measures?
    Resolution: Yes. NCQA considers all patient experience results to be measures of quality.
 
PHQ1   Principles for use of results
    Question: Does Element H, factors 1 and 2, apply to all patient experience surveys?
    Resolution: Yes. Factor 1 applies because patient experience results are considered measures of quality.
 
PHQ1   Using quality and cost, resource use or utilization measures together
    Question: If an organization uses quality measures for a particular specialty, may it measure episode cost for any condition treated by that specialty, or is it limited to measuring cost only for conditions where quality has been measured?
    Resolution: Organizations are not limited to measuring cost only for conditions where quality has been measured. An organization that measures quality for a physician specialty may measure and take action on cost, resource use and utilization for the specialty.
 
PHQ1   Survey measures
    Question: How is Element A scored for non-NQF endorsed surveys? Is each question a measure or, if measures roll up to a composite, is the composite considered one measure?
    Resolution: Non-NQF endorsed patient experience surveys are counted as one measure for the entire survey. CAHPS-CG questions or composites count as separate measures.
 
PHQ1   ABMS or AOA board performance-based improvement module
    Question: Are physicians required to update their performance improvement module (PIM) data every two years, or must the organization check every two years to find out who has completed a PIM?
    Resolution: The organization must verify that a physician has completed a PIM within two years of the organization taking an action, or within the period specified for the corrective action process, which must be within a two-year period to qualify as a quality measurement activity.
 
PHQ1   Acceptable threshold for percentage of physicians in a practice necessary to designate a practice
    Question: If our organization designates at the practice level, is an individual measure (e.g. meeting an e-prescribing measure or practicing in a designated center of excellence) acceptable for designating the group based on a percentage of physicians in the group who meet the measure?
    Resolution: Yes, with a caveat: your organization’s methodology must specify a threshold for the percentage of physicians meeting the measure, which must not be less than 50%. If the percentage of physicians meets or exceeds this threshold, then your organization may use an individual measure to designate the practice.
 
PHQ1   Removal of Must-Pass from PHQ 1 Element A
    Question: Is PHQ 1, Element A no longer a must-pass element? If so, is the change permanent?
    Resolution: PHQ 1, Element A is no longer a must-pass element; this is a permanent change. The designation has been removed in ISS. If in the future, NCQA recommends must-pass status for this element, it will go out for Public Comment and Board approval before it is changed.
 
PHQ2   Working with hospitals on reporting
    Question: For PHQ 2, Element E, are plans required to share results, explain how they are used and get feedback from hospitals ONLY if they report the results in a format different from the primary data source. Is this NA if we only provide links to the data?
    Resolution: Factors 1 and 2 are NA if the organization does not change the format of its results from the primary data source. Factors 3 and 4 always apply and are scored irrespective of factors 1 and 2.
 
PHQ2   Acceptance of HIP 6 for Autocredit of PHQ 2
    Question: Will NCQA accept HIP 6 for autocredit for PHQ 2008?
    Resolution: Yes. The substance of the standards did not change and the purpose of HIP is to give autocredit.
 
PHQ2   Delegating PHQ 2 to an NCQA-Certified HIP
    Question: PHQ has no delegation oversight standard, but information distributed by NCQA in response to HIP Certification indicates that a delegation agreement with an NCQA-Certified HIP is required to receive automatic credit in PHQ 2. Must a health plan show an agreement that meets the six factors typically required by other NCQA delegation standards?
    Resolution: No. Delegation oversight was not included and is not required.
 
PHQ2   Use of rental networks and hospital quality
    Question: For PHQ 2, Element E, if we "rent" our national hospital network and do not contract directly, may we share hospital results with the entity we rent from, rather than the individual hospitals?
    Resolution: Each hospital must receive results. Either the organization must provide results to each hospital or it may have a written agreement with the national network stating that it will provide results to hospitals. If the national network provides results to each hospital, it must provide documentation (e.g., reports, materials) to the organization that it has met the requirements.

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