Humana 2003 Annual Report Download - page 20

Accreditation Assessment
Our accreditation assessment program consists of several internal programs such as those that credential
providers and those designed to meet the audit standards of federal and state agencies and external accreditation
standards. We also offer quality and outcome measurement and improvement programs such as the Health Plan
Employer Data Information Sets, or HEDIS, which is used by employers, government purchasers and the
National Committee for Quality Assurance, or NCQA, to evaluate HMOs based on various criteria, including
effectiveness of care and member satisfaction.
Physicians participating in our HMO networks must satisfy specific criteria, including licensing, patient
access, office standards, after-hours coverage, and other factors. Most participating hospitals also meet
accreditation criteria established by CMS and/or the Joint Commission on Accreditation of Healthcare
Organizations, or JCAHO.
Recredentialing of participating providers occurs every two to three years, depending on applicable state
laws. Recredentialing of participating physicians includes verification of their medical license; review of their
malpractice liability claims history; review of their board certification, if applicable; and review of any
complaints, including any member appeals and grievances. Committees, composed of a peer group of physicians,
review the applications of physicians being considered for credentialing and recredentialing.
We request accreditation for certain of our HMO plans from NCQA and the American Accreditation
Healthcare Commission/Utilization Review Accreditation Commission, or AAHC/URAC. Accreditation or
external review by an approved organization is mandatory in the states of Florida and Kansas for licensure as an
HMO. Accreditation specific to the utilization review process is also required in the state of Georgia for licensure
as an HMO or PPO. Certain commercial businesses, like those impacted by United Auto Workers contracts and
those where the request comes from the employer, require or prefer accredited health plans.
NCQA performs reviews of standards for quality improvement, credentialing, utilization management, and
member rights and responsibilities. We continue to maintain accreditation in select markets through NCQA. Two
markets maintain NCQA accredited status for all HMO products: Humana Health Plan of Ohio, Inc. in
Cincinnati, Ohio (excellent); and Humana Health Plan, Inc., Kentucky (Commendable). Humana Health Plan,
Inc. in Kansas and Missouri completed the NCQA survey process in November 2003 and awaits its decision.
AAHC/URAC performs reviews of standards for utilization management, and for health plan standards in
quality management, credentialing, rights and responsibilities, and network management. Several markets have
achieved URAC health plan accreditation for all HMO products: Humana Medical Plan, Inc. in north Florida,
south Florida, central Florida (Daytona, Tampa and Orlando), and Humana Health Plan, Inc. in Kansas. The
Atlanta market has URAC utilization management accreditation for HMO and PPO product lines. AAHC/URAC
utilization management accreditation was received by Humana Military Healthcare Services, Inc., which
administers the TRICARE program and for the Green Bay service center.
Some of our HMO entities are unaccredited because we sought accreditation only where regulatory
requirements were in place, such as in Florida, which requires accreditation for HMO licensing, or in market
areas where commercial groups use it as part of the criteria for choosing carriers. We are piloting ISO 9001:2000
certification as an alternative to accreditation. ISO is the international standards organization, which has
developed an international commercial set of certifications as to quality and process, called ISO 9001:2000. At
this time, the following clinical programs have received ISO registration: transplant management, centralized
clinical operations providing personal nurse services, pharmacy management, and disease management.
Sales and Marketing
Individuals become members of our commercial HMOs and PPOs through their employers or other groups
which typically offer employees or members a selection of health insurance products, pay for all or part of the
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