Information Systems Assessment/Readiness Reviews

HSAG has more than nine years of experience conducting readiness reviews and auditing health care provider information systems at the managed care organization (MCO) level, individual provider level, and state agency level. These reviews ensure that plans have the system capacity needed to enroll recipients in expanded service areas and accommodate anticipated increases in enrollment.

HSAG assesses the integrity of information systems and the completeness and accuracy of the data produced by that system. HSAG's validation team then reviews the findings and identifies particular system or procedural weakness that may impact the accuracy of the performance measures. HSAG is then able to provide technical assistance and suggest system enhancements to ensure that plans meet requirements.

For new MCOs entering the Medicaid program, HSAG can conduct readiness reviews to assess the new MCO for compliance. HSAG will determine, prior to enrollment, whether each new MCO’s internal monitoring processes are sufficient to ensure ongoing compliance with contract requirements, quality oversight, and monitoring (of the quality assurance plan—QAP). After one year, HSAG will conduct an assessment of the adequacy of the MCO’s QAP and ongoing monitoring of the MCO’s QAP implementation, including the MCO’s development and implementation of quality improvement plans.

HSAG reviews the following areas to ensure that plans have the system capacity needed to enroll recipients in expanded service areas and accommodate anticipated increases in enrollment:

• Member enrollment/disenrollment
• Capitation reconciliation
• Claims processing
• Encounter data submission
• Member service line
• 24-hour call center
• Case management
• Prior authorizations
• Provider relations