Program Policies

Portfolio Sponsors (hereafter referred to as Sponsors) are organizations that have demonstrated a commitment to improving patient care through developing and supporting physician associated quality improvement (QI) initiatives and have been approved by the Multi-Specialty MOC Portfolio Approval Program (hereafter referred to as the Portfolio Program). Physicians who meaningfully participate in QI efforts that meet the Portfolio Program standards and guidelines will be granted Maintenance of Certification (MOC) Part IV credit. Sponsors can approve QI efforts for MOC Part IV credit using the Portfolio Program standards and guidelines and report physician participation in those efforts to the ABMS Member Boards participating in the Portfolio Program.  Sponsor organizations therefore develop a “portfolio” of approved QI initiatives for MOC Part IV credit that align physician involvement in quality improvement with organizational improvement goals.

Responsibilities of a Sponsor

Sponsors who successfully complete the initial application process are approved for a period of two years from the date of the initial approval letter. Continued approval is subject to meeting the following requirements. Sponsors must:

  • Approve only activities for MOC Part IV credit that meet the Portfolio Program standards and guidelines for quality improvement efforts.
  • Approve MOC Part IV credit only for those individual physicians who meet Portfolio Program requirements for meaningful participation in an approved activity. The standards for meaningful participation can be found in the Portfolio Program standards and guidelines.
  • Submit QI efforts and physician completion data to the Portfolio Program in a timely and accurate manner.
  • Adjudicate disputes about physician participation for MOC Part IV credit within the organization.
  • Notify the Portfolio Program if there are substantial changes in organizational structure or governance or if there are changes that affect the Sponsor’s ability to continue to meet the Portfolio Program requirements.
  • Pay required program fees, including fees for application and participation. Sponsors are responsible for all costs associated with operating their internal review processes as well as QI efforts.
  • Meet the Sponsor reporting requirements as described below.

Sponsor Reporting Requirements

Sponsors must periodically submit detailed reports of their approved QI efforts as well as institutional processes to the Portfolio Program. These reports are reviewed to determine if the activities meet the Portfolio Program standards and guidelines and if participating physicians have met the requirements for meaningful participation. The review process and consequences include:

  • Six Month Progress Report (due six months after initial approval): Sponsors must supply a brief progress report for each QI effort approved for MOC Part IV credit by the Sponsor in the first six months of the initial approval period. These reports will be used as part of a formative review to ensure the Sponsor is maintaining appropriate documentation and reporting systems and to identify any issues related to implementation of the review process. Sponsors must use a report format approved by the Portfolio Program.
  • First Annual Progress Report (due one year after initial approval): Supply a report at the end of the first year describing a sample of up to five QI efforts approved by the Sponsor and a brief report on the development of the review and reporting processes. This report must comply with a format approved by the Portfolio Program. If the Sponsor has approved more than five QI efforts during the year, the five to be included in the report will be chosen by the Portfolio Program. These reports will be reviewed by the Portfolio Program reviewers and feedback reported to the Sponsor with the following possible outcomes:
    • If the Portfolio Program determines that the Sponsor is meeting the Portfolio Program standards and guidelines, the Sponsor will continue in the program and must meet the standard reporting requirements described below.
    • If significant issues are identified during the review of the first annual report, such as multiple QI efforts that do not meet the Portfolio Program standards and guidelines, issues related to meaningful physician participation, or timely/accurate reporting of completion data, then the Sponsor will be asked to work with the Portfolio Program in an intensified review process to remedy the issues.
    • If the issues cannot be resolved satisfactorily within three months, the Sponsor may be referred to the Portfolio Program Board of Managers for review and Sponsor status may be withdrawn.
    • If the outstanding issues are resolved through the intensified review process, the Sponsor will continue in the program and must meet the  standard requirements described below.
  • Standard reporting requirements (every two years after initial approval or renewal): Unless otherwise requested by the Portfolio Program, Sponsors must supply a report describing a sample of up to five QI efforts approved during the past two years and submit an application for renewal of Sponsor status which will include a report on the overall performance of the review and reporting processes and organizational impact. QI efforts submitted as part of this report should have already been submitted and reviewed by the program unless they are ongoing activities with substantive additional information to report. The Sponsor will be required to pay a renewal fee. The report must comply with a format approved by the Portfolio program. If the Sponsor has approved more than five QI efforts during the past two years, the five to be included in the report will be chosen by the Portfolio Program. These reports will be reviewed by the Portfolio program reviewers and feedback reported to the Sponsor with the following possible outcomes:
    • If the Portfolio Program determines that the Sponsor is meeting Portfolio Program standards and guidelines, the Sponsor will continue in the program for another two year period and must continue to meet standard reporting requirements.
    • If significant issues are identified during the review of the first annual report, such as multiple QI efforts that do not meet the Portfolio Program standards and guidelines, issues related to meaningful physician participation, or timely/accurate reporting of completion data, then the Sponsor will be asked to work with the Portfolio Program in an intensified review process to remedy the issues.
    • If the outstanding issues are resolved through the intensified review process, the Sponsor will continue in the program or be renewed as applicable, and must meet the  standard requirements.
    • If the issues cannot be resolved satisfactorily within three months, the Sponsor may be referred to the Portfolio Program Board of Managers for review and Sponsor status may be withdrawn or renewal denied.

Withdrawing Sponsor Status

The Board of Managers of the Portfolio Program will have sole authority to withdraw Portfolio Sponsor Status from an institution. Sponsors whose status has been withdrawn will be notified within two weeks of the Board of Managers’ decision.

If Sponsor status is withdrawn from an institution by the Portfolio Program, physicians who have already been approved by that institution for MOC Part IV credit will continue to receive that credit. The institution will not be able to approve any additional QI efforts for MOC Part IV credit or designate additional physicians who have meaningfully participated in those QI efforts to receive MOC Part IV credit. The Portfolio Program will work with the institution to determine how to handle any physicians who may already be participating in previously approved QI efforts with the expectation of receiving MOC Part IV credit.

Reinstating Portfolio Sponsor Status

Organizations that have elected not to continue in the Portfolio Program voluntarily may renew their Sponsor status at any time by re-applying to the Portfolio Program using the following process:

  • Organizations that have been inactive in the Portfolio Program for less than a year should complete the initial application form but need not have three quality improvement activities reviewed and approved
  • Organization that have been inactive for over one year should complete the initial application form in its entirety including three quality improvement activities for review by the Portfolio Program

Organizations whose Sponsor status has not been renewed or has been withdrawn by the Portfolio Program may reapply using the initial application process. Approval after withdrawal of Sponsor status may be associated with a more intensive review by the Portfolio Program following approval to assure that prior issues have been resolved.

Updating Program Standards, Requirements and Policies

The Board of Managers of the Portfolio Program may from time to time update the standards and requirements of the program. Every attempt will be made to publish in advance the schedule of anticipated updates to these standards and requirements. Sponsors and participating ABMS Member Boards will be notified promptly of any changes to the standards and requirements, and the new standards will be made available through the MOC Activity Manager and/or program website. Sponsors will be expected to come into compliance with revised standards within one year of the date of issue of the updated standards.

The Board of Managers may also update these policies from time to time. Sponsors and participating ABMS Member Boards will be notified promptly of any changes to the policies, which will also be posted on the program website. With each change to the policies, the Board of Managers will establish a schedule by which Sponsors and participating ABMS Member Boards must come into compliance with the changes. Every effort will be made to assure that Sponsors and participating ABMS Member Boards have adequate time to come into compliance with any policy changes that involve a substantive change in program operations.

Privacy Policy

In the course of working with organizations in the Portfolio Program, the participating ABMS Member Boards collect, utilize, and in some cases share with third parties, various forms of information. This includes information from and regarding participating Diplomates and the QI efforts submitted to the Portfolio Program. The Portfolio Program has issued the following privacy policy to govern the collection, use, and disclosure of such information, and to explain the Program and the Boards’ policies and practices regarding the privacy of information. This privacy policy governs only the data and information not currently in the public domain collected by the Boards through the Portfolio Program and does not govern the individual privacy policies of each of the individual Boards. Our goal in establishing this privacy policy is to assure each person and organization that discloses information to the Program and the Boards that we understand the sensitivity of the information and the care that needs to be utilized by the Program and the Boards in protecting the confidential nature of the information and material.

Waiver of Privacy Policy

There may be limited instances where a person or organization may desire to waive the application of the privacy policy. In order to waive the application of the privacy policy, the organization must contact the Program and provide written acknowledgement of its intent to waive the policy. Any organization waiver of the privacy policy does not override the individual privacy policies governed by the participating ABMS Member Boards.

Information Collected

In order to identify Diplomates and assign correct completion information, the participating ABMS Member Boards require that organizations provide personal and identifying information about Diplomates participating in their QI efforts who wish to receive MOC Part IV credit for their participation. Diplomate data is governed by the privacy policies of the appropriate Board. Each Board has its own policies about the use of personal information and the Diplomate can request a copy of the applicable Board’s privacy policy.

Identifiable patient data shall not be provided to the Program by any organization or Diplomate.

Disclosure of Information to Third Parties

The Boards will not disclose any organization’s specifically identifiable organizational structure, processes, documents, forms, financial information, or content that was provided in confidence as part of the Portfolio Program with any person or organization outside of the Boards unless previously approved by the organization or as required to operate the Portfolio Program.

The Program will disclose an organization’s participation in the Portfolio Program. Aggregate data, such as approval rates, may additionally be disclosed. Any research, if published, will be based on information and analyses of the Portfolio Program and will not contain specifically identifiable information from the organization’s work in QI.

The Program will inform the organization immediately upon learning of any disclosure of confidential information not in compliance with this privacy policy. Neither the Program nor the organization will directly or indirectly acquire any interest in or design, create, sell, or otherwise deal with, any item or product containing or based on confidential information from the other party, except as necessary to perform services for the other party.

Program Fees

Program fees are set by the Multi-Specialty Portfolio Approval Program Board of Directors and are based on the ability of the Portfolio Program to self-sustain. Sponsors are expected to pay an application fee as well as a two-year participation and renewal fee.

Effective January 1, 2015, Portfolio Program fees are as follows:

1.  Sponsor Application fee:  $1,500, due upon submission of final Sponsor Application

2.  Sponsor two-year participation/renewal fee:  $6,000, due upon approval as a Portfolio Program Sponsor, or at time of renewal.

Confidentiality

The Portfolio Program will not disclose confidential or sensitive Sponsor information or data without the written approval of the Sponsor. The Portfolio Program reserves the right to use de-identified aggregated data supplied by Sponsors for purposes of evaluating the effectiveness of the Portfolio Program and for research on the effectiveness of MOC Part IV in improving patient care.

The Portfolio Program will identify Sponsors by name on the program website and will provide a link to a contact person unless the Sponsor requests not to be identified. The titles and a brief description of each approved QI effort, which is provided by the Sponsor, may also be visible on the program website, the MOC Activity Manager and/or the websites of the participating ABMS Member Boards.

Conflict of Interest Policy

The Portfolio Program standards and guidelines for approving QI efforts prohibit the use of commercial pharmaceutical or medical device funding for topic selection, content development or selection of interventions.

Board Participation and Withdrawal from the Program

From time to time additional ABMS Member Boards may join or remove themselves from the program. As soon as an ABMS Member Board joins the Portfolio Program, Sponsors will be notified of the effective date of their participation. Physicians certified by that Board who meaningfully participate in approved QI efforts after the date at which that Board joins the program can receive MOC Part IV credit.

Sponsors will be notified at least six months before the end of a calendar year in which a Board withdraws from the program. QI efforts related to that specialty can be approved up to the end of that calendar year. Physicians from that specialty can receive MOC Part IV credit for participation in those QI efforts up to the end of that calendar year.

Boards participating in the Portfolio Program must give notice of their intent to withdraw at least six months before the end of the calendar year at which they intend to withdraw.

Requirements for Participating Boards

 Boards that participate in the Portfolio Program agree to grant MOC Part IV credit to diplomates who meaningfully participate in QI efforts approved through this program. Boards agree:

  •  To inform the Portfolio Program, so that the program can inform Sponsors, of the specific type and quantity of MOC credit to be granted a physician who meaningfully participates in an approved activity.
  • To give appropriate MOC credit to all physicians who are reported by the Portfolio Program as having met the standards and guidelines of the program, and who are enrolled in that Board’s MOC program at the time at which the completion information is reported to the Board.
  • To grant MOC credit within thirty days of receiving physician completion information from the program.
  • To make reasonable efforts to resolve administrative issues related to MOC credit, for example incorrect physician identification information, in a timely manner.
  • To pay Program fees as approved by the Board of Managers.
  • To withdraw from the program only at the end of a calendar year, and to notify the program of their intent to withdraw at least six months before the end of the calendar year in which the Board intends to withdraw.