What is accreditation? Accreditation is the process by which health insurance plans and managed care organizations are evaluated. It determines whether they meet the national standards of quality proposed by an accrediting agency. Accreditation is important within the health care delivery system because it helps to ensure that the managed care organizations meet high quality of standards and accountability when providing a variety of health care services to their clients.
Organizations such as the National Committee for Quality Assurance (NCQA), the American Accreditation HealthCare Commission (AAHCC), the Medical Quality Commission (MQC)., and the Utilization Review Accreditation Commission (URAC) offer accreditation programs to managed care organizations within the United States. These organizations accredit a variety of managed care organizations such as Health Maintenance Organizations (HMO), nursing homes, hospitals, mental health care facilities, and Preferred Provider Organizations (PPO). According to Margaret E. O’Kane, President of the National Committee for Quality Assurance, the accreditation process involves assisting the health plan, typically against numerous standards in areas such as quality assurance, credentialing, medical records, utilization management, preventive services, and members’ rights.
In order to complete the process of accreditation several actions occur. Health care providers’ health information is reviewed and verified. According to Jerry S. Sobelman, CPA, review and verification includes: current professional license(s), current Drug Enforcement Administration and Controlled Drug Substance Certificates, verification of education, post-graduate training, hospital staff privileges and levels of liability insurance. However, the individual health care providers are not the only ones that must go through this process. Site evaluations or audits are conducted also. “Each office is rated on individual items such as...