CaliforniaCare Scores Poorly in Quality Review : Health care: The large HMO has appealed the decision by an industry accrediting group.

One of California’s largest health maintenance organizations, CaliforniaCare, has received low marks in a quality review by a leading national health care accrediting group, industry sources said.

CaliforniaCare, the HMO operated by WellPoint Health Networks, a Woodland Hills-based managed care firm, has appealed the decision by the Washington-based National Committee for Quality Assurance, a well-regarded accrediting group. An NCQA spokesman said the group is reviewing its rating of CaliforniaCare, and a final decision is likely before year’s end.

“Almost any plan that is denied accreditation is going to appeal that decision,” said Barry Scholl, an NCQA spokesman. “I don’t know of any case where a denial has been overturned.”

Scholl would not confirm whether the NCQA had denied accreditation to CaliforniaCare, saying only that the group’s initial decision was “under review” at the request of CaliforniaCare, which has more than 834,000 California members. The NCQA has reviewed 191 of the roughly 575 HMOs in the United States, denying accreditation to 13% of the plans reviewed.

The NCQA has been at the forefront of efforts to develop standard indicators for tracking and reporting on the performance of HMOs. Many employers are demanding such indicators as a way to better monitor the quality of medical care provided to members of these low-cost health plans.

Failure to win accreditation from NCQA could prove embarrassing to WellPoint, which is completing a merger with Health Net’s corporate parent, Woodland Hills-based Health Systems International, that will create one of the nation’s largest managed care companies.

A bad review from NCQA, said one HMO official, would be a real problem for WellPoint as it bids for employers’ business in California’s hotly competitive health care market. Larger employers, in particular, are placing more emphasis on quality and customer service measurements for health plans as “industry consolidation makes many plans almost indistinguishable when it comes to price,” said the official, who did not want his name used.

Although the NCQA process is voluntary for health plans, accreditation by the group has become “sort of de facto mandatory . . . because employers are saying the plans have to go through this process,” NCQA spokesman Scholl said.

The NCQA has developed 50 criteria for rating health plans in six categories: quality improvement, physician credentials, members’ rights and responsibilities, preventive health, medical record-keeping and “utilization management,” or whether the plan’s process for approving or denying health care services is appropriate.