MOC 3 Scoring Guidelines

MOC 3: Provider Network

The SNP provider network is a network of health care providers who are contracted to provide health care services to SNP beneficiaries. SNPs must ensure that their MOC identifies, fully describes and implements the following elements for their SNP provider networks.

Element A: Specialized Expertise

The organization must establish a provider network with specialized expertise that describes the following components of the network:

  1. How providers with specialized expertise correspond to the target population identified in MOC 1.
  2. How the SNP oversees its provider network facilities and oversees that its providers are competent and have active licenses.
  3. How the SNP documents, updates and maintains accurate provider information.
  4. How providers collaborate with the ICT and contribute to a beneficiary’s ICP to provide necessary specialized services.

Scoring

100%: The organization meets all 4 factors
80%: The organization meets 3 factors
50%: The organization meets 2 factors
20%: The organization meets 1 factors
0%: The organization meets no factors

Explanation

The organization must have an adequate and specialized provider network that maintains the appropriate licensure and competency to address the needs of the target population.

Factor 1: Specialized network

The provider network’s specialized expertise may include, but is not limited to, internal medicine, endocrinologists, cardiologists, oncologists, mental health specialists and other specialists that address the needs of the SNP’s target population identified in MOC 1.

Factors 2 & 3: Licensure and certification

The organization must describe how it determines that its providers have active licenses and are competent to provide specialized health care services to SNP beneficiaries (e.g., confirmation of applicable board certification), The MOC should describe how it maintains current information on providers to maintain an accurate provider network directory.

Factor 4: Collaboration with the ICT

The MOC must describe how providers in the network collaborate with members of the ICT and help contribute to each beneficiary’s ICP, including how providers either deliver or coordinate care, particularly specialized services. The MOC must describe how providers communicate beneficiary care needs to the ICT and to other stakeholders or providers, how the organization shares information (e.g., as reports on services) with the ICT and how providers incorporate relevant clinical information into beneficiaries’ ICPs.

Element B: Use of Clinical Practice Guidelines and Care Transition Protocols

The organization must oversee how network providers use evidence-based medicine, when appropriate, by:

  1. Explaining the processes for monitoring how network providers utilize appropriate clinical practice guidelines and nationally recognized protocols appropriate to each SNP’s target population.
  2. Identifying challenges where the use of clinical practice guidelines and nationally recognized protocols need to be modified or are inappropriate for specific vulnerable SNP beneficiaries.
  3. Providing details regarding how decisions to modify clinical practice guidelines or nationally recognized protocols are made, incorporated into the ICP, communicated to the ICT and acted upon by the ICT.
  4. Describing how SNP providers maintain continuity of care using the care transition protocols outlined in MOC 2, Element E.

Scoring

100%: The organization meets all 4 factors
80%: The organization meets 3 factors
50%: The organization meets 2 factors
20%: The organization meets 1 factors
0%: The organization meets no factors

Explanation

Factor 1: Utilization of guidelines and protocols

Evidence-based clinical guidelines and protocols promote the use of nationally recognized and accepted practices for providing the right care at the right time. The organization must monitor how network providers utilize these guidelines, when appropriate. The organization may use electronic databases, Web technology, manual medical record review or other methods to oversee use of clinical practice guidelines.

Factors 2 & 3: Exceptions to guidelines

Certain clinical practice guidelines and protocols may not always be appropriate for some patients with complex health care needs. In these cases, the organization must identify challenges to using clinical practice guidelines and nationally recognized protocols for certain beneficiaries with complex health care needs and detail how the decision to modify or ignore such guidelines is made, incorporated into the patient’s ICP, communicated with the ICT and acted on by the patient’s ICT or by other providers.

Factor 4: Care transition protocols

Care transitions offer challenges for organizations to maintain continuity of care. The organization must explain how it oversees network providers to ensure that they follow the required care transition protocols outlined in MOC 2, Element E.

Element C: MOC Training for the Provider Network

The organization’s description of oversight of provider network training on the MOC must include:

  1. Requiring initial and annual training for network providers and out-of-network providers seen by beneficiaries on a routine basis.
  2. Documenting evidence that the organization makes available and offers training on the MOC to network providers.
  3. Explaining challenges associated with the completion of MOC training for network providers.
  4. Taking action when the required MOC training is deficient or has not been completed.

Scoring

100%: The organization meets all 4 factors
80%: The organization meets 3 factors
50%: The organization meets 2 factors
20%: The organization meets 1 factors
0%: The organization meets no factors

Explanation

Factor 1: Initial and annual training

The MOC must describe how the organization provides initial and annual training for network providers and any out-of-network providers seen by beneficiaries on a routine basis; and must describe the process for annual training for current providers, including how training is conducted (e.g., in-person meetings, computer-based training), how often training occurs, training materials and examples of training content.

Factor 2: Evidence of training

The MOC must describe how the organization documents and maintains records (e.g., copies of dated attendee lists, Web-based training confirmation, electronic training records, physician attestation) as evidence that it makes training on the MOC available and offers it to all network providers.

Factors 3 & 4: Deficient or incomplete training

The MOC must describe specific actions taken by the organization if providers do not receive the required training and must explain challenges (e.g., geographically distant network, very large number of providers in network) associated with completion of the MOC trainings for network providers. The MOC may also describe actions the organization takes to offer incentives or other best practices to encourage provider training participation and compliance.