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 2017 Symposium theme is “Trust in Healthcare,” highlighting security, regulatory, and legal topics as IROs work in a changing healthcare environment. Attendees are gathering at the Renaissance Hotel in Nashville, Tennessee on October 16th-18th to hear from NAIRO leadership and a roster of industry thought leaders.
One of the most anticipated speakers on this year’s Symposium agenda is Donna Merrick, Program Enhancement Principal at URAC. Donna will be presenting on URAC Core Standards and the URAC 2018 Agenda, a topic of extreme interest for all NAIRO members and the industry at large.
URAC has developed evidence-based measures and standards for healthcare since 1990. Their mission is to promote continuous improvement in the quality and efficiency of healthcare management through accreditation, certification, and measures. URAC is an independent standards body; NAIRO is an association comprised of accredited IROs and other industry stakeholders. By working closely with URAC leadership and principals including Donna, NAIRO helps shape the evolution and implementation of accreditation standards in independent medical review.
Before her presentation, we thought it would be interesting to hear some of Donna’s background, her thoughts on working with URAC, and her insights into industry trends.
NAIRO: How did you come to be involved with URAC?
Donna Merrick: I moved back to the Washington, DC area in 1996. As a registered nurse, I had been working as a “review nurse” for the VNA (Visiting Nurse Association). In that role, I was 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 a URAC ad in the Washington Post. It turned out to be a good fit given my clinical experience, review background, and training in education. Conducting formal 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 broaden my experience by doing many things during my tenure here at URAC.
NAIRO: How long have you been working with URAC?
Donna Merrick: For over 19 years; 8 ½ as a Reviewer, and 9 ½ focusing on program revisions.
NAIRO: Describe your current role with URAC?
Donna Merrick: Primarily, I’m responsible for revising existing accreditation and certification programs – my job title changed just this month, I’m now known as “Program Enhancement Principal.” I also handle some of the standards interpretation questions, which in some cases are reviewed by the Health Standards Committee. In addition, I oversee publications and developing support materials for new and revised programs.
NAIRO: What is your favorite aspect about working for URAC?
Donna Merrick: 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.
NAIRO: What would you say the best professional advice you have ever received?
Donna Merrick: “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.
NAIRO: What are some challenges you see our industry facing in the next few years?
Donna Merrick: Across the industry, healthcare needs to demonstrate quality by achieving positive health outcomes while reigning in costs. Value-based reimbursement in some form will eventually become the norm, and that shift is having an impact on all types of companies.
NAIRO: 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 Merrick: The short answer is that for many years, states as well as the federal government have been moving toward requiring accreditation to ensure quality in programs. Most states now have accreditation requirements for IROs and utilization management organizations, and there is increased interest in accreditation to support quality efforts in other areas. For example, the Pennsylvania General Assembly is considering accreditation requirements for workers’ compensation utilization review organizations.
Federal and state governments are also relying on accreditation to support the transition to value-based payment. Under MACRA (Medicare Access and CHIP Reauthorization Act of 2015), physicians can support their performance, and ultimately their level of reimbursement, by achieving Patient-Centered Medical Home (PCMH) Certification from URAC.
NAIRO: What is the most significant impact you feel holding a URAC accreditation ensures for Utilization Review agents?
Donna Merrick: Holding a URAC accreditation signals to the marketplace and key stakeholders that your organization has made a commitment to quality. Having an independent accrediting body evaluate your utilization review program gives your customers and review experts added confidence in working with you.
NAIRO: How often are URAC accreditation and/or URAC Core Standards reviewed?
Donna Merrick: All programs are reviewed annually, evaluating if a major revision is needed the following year. Standards typically undergo a major revision every 4 to 5 years. A minor revision can occur at any time, as items arise.
NAIRO: What does this review process look like?
Donna Merrick: First, research is conducted to determine areas that should be addressed in a major revision. This includes analyzing reports to identify issues applicants experienced when responding to the standards. We also meet with industry experts and thought leaders such as NAIRO 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.
NAIRO: What are some key points you hope Symposium attendees will take away from your presentation?
- Become familiar with the major changes to the URAC Core Standards, and learn 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 re-accreditation applicants.
NAIRO is greatly honored to have Donna Merrick present for the Symposium, and is also thankful to URAC for their sponsorship of this year’s event. Donna is slated to give her presentation at 1pm CDT on Tuesday, October 17th. For more information on NAIRO’s 2017 Symposium including a downloadable agenda with all speakers and times, visit http://www.nairo.org/symposium.