Note: Effective January 1, 2006, The Joint Commission discontinued its Network Accreditation Program for Preferred Provider Organizations. However, The Joint Commission will continue to provide a full array of support services and oversight to organizations accredited under this program through the end of each organization’s respective accreditation award period.
In March 2002, the Department of Health and Human Services’ Centers for Medicare and Medicaid Services announced that Medicare+Choice (now Medicare Advantage) organizations licensed as health maintenance organizations and PPOs accredited by The Joint Commission will be “deemed” for meeting Medicare certification requirements. This authority allows Joint Commission-accredited HMOs and PPOs to be deemed in six categories:
- Antidiscrimination
- Access to services
- Quality assurance programs
- Confidentiality and accuracy of enrollee records
- Information on advance directives
- Rules regarding provider participation
CMS found that Joint Commission standards for managed care organizations contained in the 2005-2006 Comprehensive Accreditation Manual for Managed Care Organizations meet or exceed those established by the Medicare program. The Balanced Budget Act of 1997 directed CMS to establish and oversee a program that allows private, national accreditation organizations to “deem” that a Medicare Advantage organization meets certain Medicare requirements. PPOs seeking deemed status through Joint Commission accreditation as a Medicare Advantage plan must undergo survey under the current CAMMCO.
Standards and survey process
Standards for PPOs not seeking deemed status for Medicare Advantage plans are contained in the Accreditation Manual for Preferred Provider Organizations. The Joint Commission develops its state-of-the art standards in consultation with health care experts, providers, measurement experts, purchasers and consumers. These standards focus on common issues thought to contribute to quality health care services provided or contracted for by PPOs. The standards provide a basis for assessing the extent to which the PPO is a well-managed organization. The standards cover the following areas:
- Management of Human Resources
- Education and Communication
- Management of Information
- Leadership
- Improving Performance
- Utilization Management
The standards were updated in 2004 following a series of focus groups with PPO representatives, state regulators and CMS officials. The Joint Commission also sought input from professional associations, consumer groups and employers-purchasers. In addition, The Joint Commission’s Health Care Network Professional and Technical Advisory Committee reviewed and recommended approval of the revised standards, which were also approved by the Standards and Survey Procedures Committee of the Board of Commissioners.
The on-site survey assesses the PPO’s compliance with standards and helps the PPO identify and correct potential problems that will enable it to ensure ongoing compliance with the standards.
For more information, call the Network Accreditation Program at (630) 792-5291.
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