Each year, NAIRO and its members stage an annual Symposium discussing the latest developments and trends in independent medical review. The Symposium delivers in-depth educational content, along with networking opportunities to meet and exchange ideas. The theme for the three-day event is "Trust in Healthcare," highlighting security, regulatory, and legal topics as IROs work in a changing healthcare environment.
NAIRO Q&A Feature with URAC Program Enhancement Principal, Donna Merrick:
- How did you come to be involved with URAC?
Donna: When I moved back to the Washington, DC area in 1996, I responded to an ad in the Washington Post. As a registered nurse, I had been working as a “review nurse” for the VNA (Visiting Nurse Association), ensuring that clinical documentation met CMS standards for Medicare, appealing denials for payment, and preparing for CHAP (Community Health Accreditation Partner) accreditation onsite visits, as well as conducting clinical home care visits. I was looking to build on that experience when I came across URAC, which turned out to be a good fit given my clinical experience, review background, and training in education. Conducting the accreditation reviews provided me with the understanding and knowledge to write the first program guides, and provide workshops to applicants. I have been fortunate to experience and learn to do many things during my tenure here at URAC.
- How long have you been working with URAC?
Donna: For over 19 years; 8 ½ as a Reviewer, and 9 ½ focusing on program revisions.
- Describe your current role with URAC?
Donna: I am responsible for revising existing accreditation and certification programs. I also handle some of the standards interpretation questions, which in some cases are reviewed by the Health Standards Committee. In addition, I’m responsible for publications and developing support materials for new and revised programs.
By the way, my job title changed just last week. It is now “Program Enhancement Principal.”
- What is your favorite aspect about working for URAC?
Donna: URAC hires great people – professional and supportive staff at all levels. Leadership is strong, and ensures that staff has the resources needed to meet the company’s goals and objectives. Also, the IT support is among the best I’ve experienced in a work setting.
- What would you say the best professional advice you have ever received?
Donna: “Look up” and understand the basics of the business and industry you work in. Though it is important to be an expert in your field, it helps to understand the broader picture as well.
- What are some challenges you see our industry facing in the next few years?
Donna: Across the industry, healthcare needs to demonstrate quality by achieving positive health outcomes while reigning in cost – value-based reimbursement in some form will eventually become the norm, and this is having an impact on all types of companies.
- State governments are recognizing the importance of regulating and requiring entities to uphold an accreditation to ensure these programs adhere to quality standards and best practices. Tennessee passed SB0105/HB0094 last year and most recently, California Governor Jerry Brown signed SB 1160 into effect last September.What are some of the next states you foresee going in this direction?
Donna: The short answer is that states, as well as the federal government, have long been moving to require accreditation to ensure quality in programs for many years. Where accreditation requirements for IROs and utilization management organizations have long been in place in most states, there is increased interest in accreditation to support quality efforts in other areas. Pennsylvania General Assembly is considering accreditation requirements for workers compensation utilization review organizations. Federal and state government are also relying on accreditation to support the transition to value based payment. Under MACRA, physicians can support their performance, and ultimately their level of reimbursement, by achieving PCMH Certification from URAC.
- What is the most significant impact you feel holding an accreditation ensures for Utilization Review agents?
Donna: Holding a URAC accreditation signals to the marketplace and key stakeholders that your organization has made a commitment to quality by having an independent accrediting body evaluate your utilization review program.
- How often are accreditation and or core standards reviewed?
Donna: All programs are evaluated annually for the need for a major revision the following year. On average, standards undergo a major revision approximately every 4‑5 years. A minor revision can occur at any time, as the need arises.
- What does this review process look like?
Donna: First, research is conducted to determine the issues and areas that need to be addressed in a major revision. Research includes analyzing reports to identify the issues applicants experienced when responding to the standards. We also meet with industry experts and thought leaders to find out their areas of concern, and conduct a review of the literature. An initial draft is then shared with an advisory group convened to revise the standards. After several meetings, a draft revision goes out for at least 30 days of public comment, and subsequent changes are made and presented to the advisory group. Ultimately, the standards are approved by the URAC Board of Directors.
- What are some key points you hope the attendees will take away from your presentation?
- Become familiar with the major changes to the Core standards and why they were made.
- Identify the standards that are included and excluded for URAC’s IRO accreditation.
- Learn when Core v4.0 will be incorporated into the IRO accreditation and how this impacts first time applicants as well as reaccreditation applicants.
The National Association of Independent Review Organizations will hold the annual event in Nashville, Tennessee October 16‑18th at the Renaissance Hotel. Donna will be presenting on URAC Core Standards and the URAC 2018 Agenda
For more information on NAIRO’s 3rd Annual Symposium visit http://www.nairo.org/symposium.