THE CLIENT
A managed care health system serving the comprehensive needs of communities and offering care delivery sites across the Midwest.
THE CHALLENGE
The client wanted to expand its reach by offering its Marketplace product in in a nearby state. T he state requires either National Committee for Quality Assurance (NCQA) accreditation or Centers for Medicare and Medicaid Services (CMS) approval to determine network adequacy and allow plans to operate in the state. The client, already established with HMA in other states, reached out to secure our services to help them with the accreditation process.
While NCQA accreditation is never easy, this process was complicated by several factors including a six-month timeline in order to start processing requests during the open enrollment period, as well as a complex company structure.
APPROACH
Working on-site, HMA鈥檚 experts assembled a team from the client鈥檚 staff to assist with the accreditation process and completed a second-level review of every document as they readied the accreditation submission. After submission, HMA consultants helped the team answer two rounds of complex questions in response to requests from NCQA.
The biggest challenges were questions regarding the company鈥檚 organizational structure because the plan operates under different names in different states. Multiple-state accreditation is a challenge to explain to NCQA, but HMA鈥檚 seasoned experts were able to create a very clear document and explanation that showed the organizational structure and sole ownership of the health plan. This was crucial because it was a non-typical issue and questions needed to be answered in a satisfactory manner in order to ensure accreditation and the ability to sell the plan鈥檚 product during open enrollment for 2020.
In addition, in order to ensure the accreditation was secured in time, our team was able to obtain an expedited decision from NCQA. Preparing for accreditation is usually a year-long process, but the team was able to complete the process and secure accreditation in less than six months.
RESULTS
The client was granted interim accreditation status on November 15, 2019, in time for the plan to enter the marketplace for open enrollment. Coming up just two points short of a perfect score, the plan reached its goal of opening services in the state.
In addition to helping the client reach its goal, HMA experts continue to work with the company to tailor and implement a Survey Ready Model to ensure they are prepared for the next accreditation cycle. HMA also is providing accreditation services to the client in two additional states.
The company president and chief executive officer said accreditation would not have been possible without HMA鈥檚 expertise and guidance.
