URAC Accreditation Update: Getting Prepared

Specialty Pharmacy Times, Jan/Feb 2013, Volume 4, Issue 1

Vital information on the URAC accreditation process is presented that will help specialty pharmacies prepare. Watch for subsequent articles on the 5 main URAC specialty pharmacy modules of standards.

Vital information on the URAC accreditation process is presented that will help specialty pharmacies prepare. Watch for subsequent articles on the 5 main URAC specialty pharmacy modules of standards.

Although you may have not heard of URAC accreditation yet, it may just be a matter of time before it will either directly or indirectly affect you and your organization. URAC accreditation is growing in importance in the health care industry. It was recently announced that URAC was one of the 2 approved accreditations for health plans as part of the Patient Protection and Affordable Care Act (PPACA).

PPACA Section 1311 (c)(1)(D)(i) requires that all health plans offered through state insurance exchanges be accredited with respect to local performance:

  • Clinical quality measures such as HEDIS
  • Patient experience ratings on a standardized CAHPS survey
  • Consumer access
  • Utilization management
  • Quality assurance
  • Provider credentialing
  • Complaints and appeals
  • Network adequacy and access
  • Patient information programs by an entity recognized by the secretary for the accreditation of health insurance issuers or plans (so long as any such entity has transparent and rigorous methodological and scoring criteria)

So, how does this affect a specialty pharmacy? There are several managed care health plans that have recently mandated in RFPs that specialty pharmacies have URAC specialty pharmacy accreditation. This trend is growing throughout the United States, and if you don’t get prepared you could get locked out of some large managed care health plans—if you have not already been affected.

Managed care health plans are mandating URAC Specialty Pharmacy Accreditation for a couple of different reasons. One is due to the mandate for health plans to have URAC Health Plan Accreditation as part of the PPACA, as mentioned above. There are accreditation standards that are specific to contractors. If you are providing specialty pharmacy services, you will need to adhere to URAC standards as part of your contract agreement. It also helps align their standards for accreditation with the organizations that they partner with and aligns both quality goals and clinical oversight. Another reason health plans mandate URAC accreditation is that it helps to narrow their network of pharmacies. The accreditation helps them ensure that the partnerships they have with specialty pharmacies have solid third party validation of their operations. It also fosters continual improvement and regular updating of current best practices that help enhance operations and services.

Overview Of the URAC Accreditation Process

Step 1: Business signs agreement and pays accreditation fees.

Step 2: Business works on accreditation responses and provides documentation in relation to the standards.

Step 3: Accreditation body responds to documentation and entity has a determined time frame to respond to Requests for Information (RFIs).

Step 4: Accreditation body does an onsite audit of policies and procedures.

Step 5: Once an accreditation is granted, there will be a periodic review of policies and procedures.

As mentioned, you will start by working with URAC and its business development team to determine the fees. The fees are based on your volume of specialty pharmacy claims. There are tiered pricing levels to help newer pharmacies get started. They even have a provisional accreditation category that will help assist brand-new start-up specialty pharmacies. It gives them a little more time to prepare for full accreditation than an existing pharmacy. If you are an existing specialty pharmacy, then you will undergo the normal URAC accreditation process. URAC will prepare an agreement that will need appropriate sign off and to be sent back with payment of the fees.

The next step is to do a GAP analysis and figure out what enhancements need to be implemented into your operations. All URAC accreditations are prescriptive in nature and not instructive. Basically this means that they won’t tell an organization how to manage a standard. They will verify that your P&P is being followed and that your staff is familiar with the P&P. You will need to compare your operational processes and policies with the URAC standards. As part of the accreditation fees, you will get a specialty pharmacy training session.

This training session is offered as either a live or an online WebEx-type training. You also get a quality summit meeting admission with your accreditation fees. One important note is that you want to take advantage of these training sessions early in the process or they could expire. You usually have approximately 6 months to get your documents and policies and procedures loaded into the Accreditnet tool. Another very important note is to make sure you provide clear citation information. This can help the desktop reviewer identify where the standards are met in your documents that are submitted. Being as specific as possible and highlighting the information is also helpful.

After everything is loaded into Accreditnet, URAC will perform a desktop review of what you have loaded. Basically, they are comparing your submissions with the standards for the accreditation. This process can take between 4 and 6 weeks, depending on how well you did providing information and documentation. After they get finished with the initial desktop review, they will come back with an RFI. This will be a process that will help you prepare for your upcoming on-site audit.

You will be asked to enhance your policies, submit more documentation, and correct any mistakes that were made during the initial submission. The process of responding to RFIs may take several times to complete. The first RFI submission time to respond is 30 days. Any subsequent RFI submissions will need to be responded to within 10 days. After you get this completed you will need to prep for the next step—the on-site audit.

The on-site audit will be scheduled with your organization. This will not be a surprise, because URAC wants to make sure your key people are available to be interviewed. URAC will provide you with an agenda for the on-site visit. The agenda will give you approximate time-frames on what will be taking place. Inspections are typically 1 day, but I have seen 2-day inspections. The agenda also has items that you will want to have prepared and available for the on-site audit. Basically, the inspectors will be verifying that you are operationally performing the standards and information in your policy and procedures. After the on-site audit, the inspectors will take the information back to a committee to review the findings and they will make a ruling on your accreditation.

Helpful URAC Accreditation Information

Information and Education

  • If you have not received a copy of the Specialty Pharmacy Accreditation manual/guide, it can be accessed online by signing onto your URAC account at www.URAC.org. If you have any trouble you can also contact URAC at (202) 216- 9010.
  • The Accreditnet online application tool will help you facilitate submission of your documentation. It is recommended that you either attend a free live webinar or watch a recorded webinar at www.urac .org/healthcare/accreditation/accreditnet .aspx. There is also an instruction booklet that can be downloaded to assist you.
  • There are also several educational tools. They range from live seminars, webinars, and podcasts to manuals. Some of these educational materials are complimentary and some have fees. Here is the link to the URAC educational information: www .urac.org/accreditationEducation/. You will find a calendar of events and access to all the tools mentioned above.

Scoring

  • No longer have “primary” and “secondary” standard elements
  • Distinct standard element weight categories 1 to 4
  • Mandatory standard elements Not weighted All elements must be fully met at 100% Same as current policy
  • Lowest site score determines application score
  • All module scores roll up into 1 total score Core = 30% of total score Other modules combined contribute to 70% of total 100 points possible
  • Must meet all mandatory elements in order to achieve a FULL accreditation, regardless of total score (no change from previous policy)
  • Must achieve a FULL accreditation in order to receive recognition in the Accreditation Summary Report (ASR)
  • A “Leading Indicator” is a non-weighted, optional element—and acts as “extra credit”

Monitoring Program

Once accreditation is received, you will be monitored by URAC for compliance. There are 2 ways they monitor your compliance:

  • Annual Attestation Pharmacy will have to fill out an annual report to submit to URAC Any changes to key contacts and organizational structure need to be done ASAP and can be done in the Accreditnet application

  • On-Site Monitoring This is typically sparked by a complaint The event is announced (3- to 7-day notice) No staff interviews No additional fees Will occur regardless of a reply from point of contact. This is one reason why any changes to staff or organization need to be updated in Accreditnet ASAP Will have a different reviewer from original survey/on-site inspection Mainly focused on documentation Scoring of the monitoring could change the accreditation status for the organization

Now that you have some good information on the overall URAC accreditation process, we will go a little deeper into the standards. There are 5 main URAC specialty pharmacy modules of standards. In subsequent editions of Specialty Pharmacy Times, we will dive a little deeper into each of these standards and modules to help explain what things you need to do in order to properly prepare for accreditation.

About the Author

Quintin Jessee, PharmD, is director of specialty pharmacy consulting for D2 Pharma Consulting LLC and has more than 10 years of senior management experience in specialty pharmacy operations.