Accreditation

Beacon Health Strategies has been granted full Accreditation as an NCQA Accredited Managed Behavioral Health Organization (MBHO). Full Accreditation is granted for a period of three years to those plans that have excellent programs for continuous quality improvement and meet NCQA’s rigorous standards.

What is NCQA?
NCQA’s mission is to improve the quality of healthcare. NCQA is an independent, not-for-profit organization dedicated to measuring the quality of America’s health care.

How does the Accreditation process work?
NCQA Accreditation is a nationally recognized evaluation that purchasers, regulators and consumers can use to assess MBHOs. NCQA Accreditation evaluates how well a health plan manages all parts of its delivery system – physicians, hospitals, other providers and administrative services – in order to continuously improve health care for its members. The Accreditation process is an evaluation of how an MBHO ensures that its members are receiving high quality care. The Accreditation process is completely voluntary and includes rigorous on-site and off-site evaluations conducted by a team of physicians and managed care experts. A national oversight committee of physicians and behavioral health providers analyzes the team’s findings and assigns an Accreditation Level based on an MBHO’s performance compared to NCQA standards.

What is reviewed as part of the organization’s Accreditation process?
There are approximately 60 standards for quality included in the following seven categories:

• Quality Management and Improvement
• Utilization Management
• Credentialing and Recredentialing
• Member’s Rights and Responsibilities
• Preventive Behavioral Health Care Services

These standards are purposely set high to encourage MBHOs to continuously enhance their quality. Developed with input from employers, managed care organizations, state and federal regulators, these standards are intended to help organizations achieve the highest level of performance possible, reduce patient risk for untoward outcomes, and create an environment of continuous improvement.

According to Margaret E. O’Kane, NCQA President, “Beacon Health Strategies’ MBHO Accreditation is proof that it’s an organization which works hard to coordinate care, ensure access and provide good customer support for members. It’s a sign that Beacon Health Strategies is focused on improving the behavioral health of its members.”

Beacon Health Strategies has been granted a Full two year accreditation status by URAC for Case Management and Health Utilization Management at its Woburn, Massachusetts Site located at 500 Unicorn Park Drive, Woburn MA. 01801. Beacon Health Strategies is currently in the process of applying for accreditation for Case Management and Health Utilization Management accreditation at its Providence, RI site located at 235 Promenade Street, Suite 400, Providence, Rhode Island, 02908.

What is URAC?
URAC’s mission is to promote continuous improvement in the quality and efficiency of health care management through processes of accreditation and education.

How does the accreditation process work?
URAC has a modular approach to accreditation which allows for a diverse range of health care organizations to apply for URAC accreditation with the flexibility to achieve accreditation for a wide spectrum of managed care services. The URAC accreditation process demonstrates a commitment to quality services and serves as a framework to improve business processes through benchmarking organizations against nationally recognized standards. Organizations participate in an accreditation process that entails a rigorous review occurring in four phases. The process covers a period of approximately three to six months. Applicants who successfully meet all requirements are awarded a Full two-year accreditation, and an accreditation certificate is issued to each company site that participated in the accreditation review. Accredited organizations must continue to remain in compliance with the applicable standards throughout the accreditation cycle.

What services are Beacon Health Strategies accredited for by URAC?
Case Management
Case management services are one of the fastest-growing practice areas in health care today. Health care organizations use case management to better meet patients’ needs and improve their treatment outcomes by coordinating the full continuum of care. URAC is the only accreditation organization offering standards that specifically address the rapidly evolving field of case management. The URAC standards cover several critical operational categories for any quality case management program including:

• Staff Structure and Organization
• Staff Management and Development
• Information Management
• Quality Improvement
• Oversight of Delegated Functions
• Organizational Ethics
• Complaints

The URAC Case Management Standards enable organizations to successfully:

• Train case managers
• Identify individuals for case management
• Manage and conduct case management activities in an efficient and professional manner
• Promote the autonomy of consumer and family decision making
• Maintain confidentiality
• Delegate responsibility

Health Utilization Management Accreditation
Most medical care paid for by private or public health insurance undergoes some form of administrative review to determine the appropriateness of proposed medical care. That means almost every American enrolled in a private or government funded health benefit plan is affected by how this type of review is administered. In 1990, URAC developed the first Health Utilization Management (UM) Review Standards to ensure that organizations conducting utilization review followed a process that was clinically sound and respected patients’ and providers’ rights while giving payors reasonable guidelines to follow. URAC’s current Health Utilization Management and Workers Compensation Utilization Management standards build on the Core Accreditation Standards, and:

• Establish consistency and maintain the highest confidentiality in UM processes
• Serve as the basis for many states’ laws and regulations and are the most widely recognized UM standards at the state and federal level
• Are applicable to stand-alone UM organizations and UM functions within health benefits programs such as indemnity insurance, health maintenance organizations (HMOs), preferred provider organizations (PPOs), and the newer Consumer-Directed Health Care plans.
• Can be adopted by specialty UM companies, such as behavioral health and CAM
• Are compatible with the 2002 U.S. Department of Labor claims regulations

URAC Health UM Accreditation requires each organization to establish and implement a three-step process to determine if a proposed medical treatment or service is medically necessary:

• Initial Clinical Review – A licensed health professional, such as a nurse, conducts this first, critical step
• Peer Clinical Review – A physician qualified to render a clinical opinion about the proposed treatment or service must perform peer clinical review
• Appeals Consideration – Patient or provider initiates the appeal, which is considered by a qualified, board-certified physician in the same specialty not involved in the initial review decision. The process must be expedited, if requested.