URAC, the national body that is the self-described “leader in promoting health care quality through its accreditation and certification” of managed care firms, processes, and programs, is getting into the PBM certification business. According to a recent press release, URAC has formed a standards committee to “advise the organization on the creation of requirements for the first-ever accreditation programs addressing pharmacy benefits management in the Medicare, commercial insurance and health plan arenas”.
URAC has gotten into the managed care approval business in a big way of late, and now provides accreditation in 15 areas, including call center operations, consumer directed health, UR, workers comp UR, and claims processing. While the accreditation process can be onerous, some industry sources question the diligence, precision, and rigor of the process itself. According to one highly experienced workers comp clinical manager, the accreditation of one vendor was “shocking; I don’t know what they (URAC) were looking at…my audit clearly showed some major deficencies in (the vendor’s) QA, documentation, timeliness of communications, and feedback to the (clinical) staff.”
This echoes other comments I have heard from entities evaluating vendors; it appears that URAC certification/accreditation, which serves as a seal of approval, demonstrating the vendor has met rigorous standards, may be losing a bit of its “gold seal” status. This would be unfortunate, as many state regulators, employers, public entities, and vendors rely on URAC to be the expert in evaluating potential vendors for quality and consistency of operations.
What does this mean for you?
If URAC develops a PBM evaluation process that is rigorous, appropriate, and sensitive to both vendors’ and purchasers’ needs and requirements, your job should be easier. That doesn’t mean you shouldn’t do your own due diligence, and do it diligently.
Jun
9
When I was working in Quality Improvement for a Managed Care company, URAC was a walk in the park. We had one person doing the accreditation work and it always went through without a hitch.
NCQA, on the other hand, required all hands on deck for months prior to the audit. Based on my experience, for URAC to consider themselves the leader is a joke as long as NCQA is still around.