What is NCQA and JCAHO?

The National Committee for Quality Assurance (NCQA) and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) are two nonprofit review organizations you should be aware of, as they provide the lion share of accreditations within the healthcare industry and provide valuable information about PPO's, HMO's, hospitals and other healthcare providers.

Within the United States, the Department of Health and Human Resources Center for Medicare and Medicaid Services (CMS) receives thousands of requests from healthcare providers to be considered as preferred providers to individuals with Medicare and/or Medicaid. The CMS relies on surveys completed by one of its approved Accreditation Organizations (AO) to determine if the requesting agencies have met the health and safety standards of the CMS.

Healthcare providers select the Accreditation agency based on the size of the business seeking accreditation, the specialty of the provider and the fee which the Accreditation Organization will charge based on the business’ size. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) provides the lion share of accreditations for hospitals, and out-patient providers which include physicians, therapists, supply companies, laboratories and surgery centers.

The Joint Commission on Accreditation of Healthcare Organizations www.jointcommission.org (pronounced "Jay-co") was established in 1951 under the name "Joint Commission on Accreditation of Hospitals" (JCAH) for the purpose of setting safety standards within hospitals. By 1981, the organization's reviews included other health care organizations such as home care and hospice agencies. The name was changed to include the other "healthcare organizations".

Once again, healthcare organizations do not have to seek JCAHO accreditation. However, if a healthcare organization hopes to be considered a Medicare provider, they must be accredited by JCAHO or one of other Centers for Medicare and Medicaid (CMS) approved organizations. Medicare's selection of providers has great influence over other medical insurance providers. If a healthcare organization/provider meets Medicare's standards, then other insurance companies will accept the healthcare organization/provider as one of their preferred providers. In this way, JCAHO and other AO’s are very influential.

You may recall a hospital in the Los Angeles area which was in the news several years ago. The facility found itself in the headlines because it failed JCAHO's inspection. While there were those who believed the closure of this hospital (which failed not one, but three inspections by JCAHO) would result in a health risk to the community it served, quite the opposite is true!

You do not want to use a healthcare organization which did not pass JCAHO or other AO’s inspection with flying colors!!!!!

The standards that JCAHO sets are basic safety standards!!!! If the healthcare organization in your area cannot meet these very basic standards, your safety can be at risk!

JCAHO surveys occur about every three years. The facility is informed of when the survey will take place. This gives the facility plenty of time to be prepared! If a facility does not pass or passes with low marks, JCAHO will return to insure the areas of non-compliance have been corrected. If the facility continues to "fail" inspection, the facility will lose its accreditation, which translates out to the loss of Medicare funds and the funds of private insurance carriers.

With so much advanced notice and the opportunity to correct any errors if a facility fails its initial inspection, you can imagine that it is very hard for an organization/facility to lose its accreditation. If JCAHO does pull an organization's accreditation, we all need to be concerned for the safety of individuals seeking care at this facility!

The National Committee for Quality Assurance www.NCQA.org was formed in 1979 by the managed care industry to review PPO plans, and HMO organizations at both the insurance company level and the healthcare provider level. The NCQA provides a grading system of organizations "brave enough" to seek their accreditation. NCQA and URAC accreditations are not required; however providers who wish to be taken seriously as quality care providers seek to be accredited by one or both of these organizations.

Some small offices or providers may not be able to afford the cost or wish to go through the rigorous review process. Not being certified by JCAHO, URAC, NCQA or similar accreditation organizations does not mean the organization or provider's doors will be closed or that they are not good providers. It just means you should be aware that the of the care provided has not been evaluated for safety and quality.

Personally, I would not want my friends or family members to be treated by a hospital if it was not able to pass a well-announced safety inspection. Would you?

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