Humana 2009 Annual Report Download - page 23

Accreditation Assessment
Our accreditation assessment program consists of several internal programs, including those that credential
providers and those designed to meet the audit standards of federal and state agencies, as well as external
accreditation standards. We also offer quality and outcome measurement and improvement programs such as the
Health Care Effectiveness Data and Information Sets, or HEDIS, which is used by employers, government
purchasers and the National Committee for Quality Assurance, or NCQA, to evaluate health plans based on
various criteria, including effectiveness of care and member satisfaction.
Physicians participating in our 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.
Recredentialing of participating providers occurs every two to three years, depending on applicable state
laws. Recredentialing of participating physicians includes verification of their medical licenses; review of their
malpractice liability claims histories; review of their board certifications, if applicable; and review of applicable
quality information. 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 health plans from NCQA, the Accreditation Association for
Ambulatory Health Care, and the Utilization Review Accreditation Commission, or URAC. URAC performs
reviews for utilization management standards and for health plan and health network standards in quality
management, credentialing, rights and responsibilities, and network management. Accreditation or external
review by an approved organization is mandatory in the states of Florida and Kansas for licensure as an HMO.
Certain commercial businesses, like those impacted by a third-party labor agreement or those where a request is
made by the employer, may require or prefer accredited health plans.
NCQA performs reviews of our compliance with standards for quality improvement, credentialing,
utilization management, member connections, and member rights and responsibilities. We have achieved and
maintained NCQA accreditation in all of our commercial HMO/POS markets except Puerto Rico, in all of our
Medicare HMO markets with the exception of Illinois which will be surveyed in 2010, and for nearly all our PPO
markets.
Sales and Marketing
We use various methods to market our Medicare, Medicaid, and commercial products, including television,
radio, the Internet, telemarketing, and direct mailings.
At December 31, 2009, we employed approximately 1,700 sales representatives, as well as approximately
900 telemarketing representatives who assisted in the marketing of Medicare products by making appointments
for sales representatives with prospective members. We also market our Medicare products via a strategic
alliance with Wal-Mart Stores, Inc., or Wal-Mart. This alliance includes stationing Humana representatives in
certain Wal-Mart stores, SAM’S CLUB locations, and Neighborhood Markets across the country providing an
opportunity to enroll Medicare eligible individuals in person. In addition, we market our Medicare products
through licensed independent brokers and agents including strategic alliances with State Farm®and United
Services Automobile Association, or USAA. Commissions paid to employed sales representatives and
independent brokers and agents are based on a per unit commission structure approved by CMS.
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
premiums, and make payroll deductions for any premiums payable by the employees. We attempt to become an
employer’s or group’s exclusive source of health insurance benefits by offering a variety of HMO, PPO, and
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