Mandatory EQRO Activities
The Medicaid Federal Managed Care Regulations require that a state, or its designee, conduct a review of the compliance of managed care organizations (MCOs), prepaid inpatient health plans (PIHPs), prepaid ambulatory health plans (PAHPs), and primary care case management (PCCM) programs with these regulations and state contracts. Oversight activities must focus on evaluating quality outcomes and the timeliness of and access to care and services provided to Medicaid beneficiaries by the MCO, PIHP, PAHP, and PCCM.
HSAG has performed compliance monitoring reviews since 1990 for a number of different entities. In addition to performing compliance reviews, HSAG also conducts:
- Readiness Reviews to determine the operational readiness of a contractor to perform the activities required by its Medicaid contract with a state.
- Information Systems Assessments for MCOs, PIHPs, PAHPs, PCCMs, state agencies, and provider organizations.
- Care Management Operational Reviews to determine compliance with the operational standards for fee-for-service care management programs.
- Accountable Care Organization Reviews.
- Regional Care Collaborative Organization Reviews.
- Primary Care Case Management Reviews.
- Independent Assessments as a requirement of 1915(b) waivers.
- Financial Alignment Demonstration Reviews.
HSAG's audit staff members bring a wealth of knowledge, experience, and expertise to each state's compliance review process, including:
- Clinical qualifications and skills in physical and behavioral health, acute care, and long-term care.
- Proficiency in applying managed care principles.
- Detailed understanding of the state Medicaid agency's role and challenges in monitoring and improving its contracted health plans and vendors.
- Mastery of data collection and interview processes required to conduct a compliance review.
The states and entities HSAG has reviewed consistently acknowledge the skill and professionalism with which HSAG provides feedback and guidance on opportunities for improvement and how to make those improvements.
HSAG has extensive experience in conducting performance measure validation. As an National Committee for Quality Assurance (NCQA) Licensed Organization with the capability of conducting certified Healthcare Effectiveness Data and Information Set (HEDIS)1 Compliance Audits™2, HSAG offers its External Quality Review Organization (EQRO) customers the flexibility to perform HEDIS audits of their contracted managed care organizations (MCOs), prepaid inpatient health plans (PIHPs), prepaid ambulatory health plans (PAHPs), and primary care case management (PCCM) programs as a way of validating the performance measure rates produced by Medicaid health plans.
HSAG's team of auditors effectively performs the following audits:
- HEDIS® compliance audits
- Pay-for-Performance audits
- Performance measure validation (for health plans that report HEDIS, non-HEDIS, or state-specific performance measures)
- Performance measure validation for nonmanaged care vendors and fee-for-service programs
HSAG's skilled and professional audit staff members also have the capability of developing state-specific performance measures and indicators. Each performance measure developed by HSAG can be tailored to the programmatic and population specifications of the state as a way to measure healthcare access, quality, utilization, processes, and outcomes.
1HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). 2NCQA HEDIS® Compliance Audit™ is a trademark of the National Committee for Quality Assurance (NCQA).
Validation of PIPs is one of the core activities that HSAG conducts on an annual basis. Since 1997, HSAG has successfully validated thousands of different PIPs conducted by a variety of managed care organizations (MCOs), prepaid inpatient health plans (PIHPs), prepaid ambulatory health plans (PAHPs), and primary care case management (PCCM) programs. HSAG validates more than 500 PIPs annually. In addition, HSAG has developed and facilitated a variety of statewide collaborative PIPs targeting specific areas for improvement that are high priorities for states. HSAG's exposure to a variety of topics and health plan models provides us with extensive experience to develop, structure, and conduct successful PIPs that bring about true sustained quality improvements.
HSAG developed a PIP validation approach that places greater emphasis on improving healthcare outcomes and processes through the integration of quality improvement science. HSAG's approach guides health plans through a process using rapid-cycle improvement methods to pilot small changes rather than implementing one large transformation. Performing small tests of change requires fewer resources and allows more flexibility for adjustments throughout the improvement process. By piloting on a smaller scale, health plans have an opportunity to determine the effectiveness of several changes prior to expanding the successful interventions to a larger scale.
HSAG's PIP Team consists of the following healthcare professionals:
- Registered nurses
- Licensed medical social workers
- Healthcare analysts
The registered nurses and social workers have and maintain their Certified Professional Healthcare Quality certification. HSAG's PIP team is prepared to provide technical assistance to MCOs and states to assist with interpreting Centers for Medicare & Medicaid Services (CMS) requirements, appropriately constructing and conducting valid PIPs, identifying barriers to improvement, and implementing interventions intended to bring about real improvements.
A robust, accessible provider network is critical to ensuring Medicaid recipients receive quality healthcare services in a timely manner. For the past 15 years, HSAG has planned, organized, and completed managed care provider network adequacy reviews. These reviews ensure that each managed care organization (MCO) has adequate provider networks in coverage areas to deliver healthcare services to its Medicaid members.
HSAG's multidisciplinary Network Adequacy Team works with state agencies to establish a methodology in support of the state's goals. HSAG's network adequacy activities involve retrospective and comparative data analyses to assess multiple dimensions of access, including:
- Network capacity.
- Geographic distribution.
- Availability of services.
In addition to providing results on provider-to-member ratios (i.e., network capacity), HSAG also provides results of time/distance analyses (i.e., geographic distribution) according to the state's specific requirements. During the past seven years, HSAG has conducted provider telephone surveys to verify the accuracy of MCOs' provider databases and assess the availability of appointments. HSAG uses both direct call and secret shopper type survey approaches to meet states' specific provider network review or validation needs.
Culminating from these activities is the generation of meaningful results and actionable recommendations for future monitoring, reporting, and development of standards.
Optional EQRO Activities
While tailored to the specific needs of each customer, their information systems, and overall encounter data environment, HSAG's approach to evaluating encounter data for completeness and accuracy aligns with the guiding principles set forth in the Centers for Medicare & Medicaid Services (CMS) External Quality Review (EQR) Protocol 4, Validation of Encounter Data Reported by the MCO. HSAG's experience in conducting encounter data evaluations began in 2003 and includes extensive work in both physical and behavioral health Medicaid managed care, as well as in private sector managed care. HSAG has conducted encounter data validations in nine states.
In accordance with the protocols, HSAG incorporates the following activities in its reviews:
- Review of state requirements for collecting and submitting encounter data.
- Review of health plans’ capacity to produce accurate and complete encounter data.
- Analysis of health plans’ electronic encounter data for accuracy and completeness.
- Review of medical records for confirmation of findings of encounter data analysis.
- Submission of findings.
HSAG has developed a core competency in evaluating encounter data integrity through feasibility assessments, information system assessments (i.e., surveys, key informant interviews, on-site audits, etc.), administrative profiles of a state's encounter data, comparative analyses of plan and state Medicaid encounter data, medical/clinical record review, and technical assistance. HSAG's approach provides an effective way to identify and confirm the quality of encounter data collected and maintained by states while providing a clear roadmap toward improvement.
Receiving data from a patient and provider perspective is a critical component of assessing the quality, access, and timeliness of care. The use of surveys allows this information to be captured in a standardized method that would not otherwise be available through other data sources. Since 1999, HSAG has performed survey work for numerous state Medicaid agencies, managed care organizations (MCOs), and federal organizations that address:
- Member and patient satisfaction
- Patient quality of life
- Patient experiences with dental care
- Patient experiences with care management services
- Provider satisfaction
HSAG works with its customers to perform all critical components of a survey project including:
- Selecting and/or developing a survey instrument that fulfills customers' survey requirements. Custom instruments have been translated to include a variety of languages (e.g., Spanish, Chinese, Korean, Ilocano, and Vietnamese).
- Developing and employing a survey administration methodology that maximizes response rates.
- Analyzing the survey data to address the objectives of the survey implementation.
- Providing comprehensive reports that leverage HSAG’s expertise in the area of surveys and quality improvement.
HSAG is currently recognized by the National Committee for Quality Assurance (NCQA) as an NCQA-certified Healthcare Effectiveness Data and Information Set (HEDIS®)1/Consumer Assessment of Healthcare Providers and Systems (CAHPS2) Survey Vendor and Patient-Centered Medical Home CAHPS Survey Vendor. HSAG has successfully administered health plan CAHPS surveys since the program was implemented by NCQA in 1999.
1HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
2CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality.
HSAG expertly conducts highly complex statistical analyses that help inform and educate policy decisions for state and federal customers, with experience in performance measure research, development, data collection, monitoring, and evaluation. HSAG's analytic and statistical experts calculate industry-accepted performance measures for customers, as well as develop customized performance measures that assess health plan and program performance. HSAG calculates performance measures across a wide array of domains, including:
- Prevention and screening
- Women’s health
- Pediatric health
- Behavioral health
- Respiratory, cardiovascular, and other medical conditions
- Medication management
- Access to care
- Cost effectiveness of care
- Patient harms
- Long-term support services
- Custom population-specific measures
HSAG provides its customers with sound methodologies, comprehensive statistical analyses, and actionable recommendations for improvement.
Focused studies represent a wide range of clinical and non-clinical research activities that are fundamental to effective quality-of-care measurement and improvement. HSAG has extensive experience conducting focused studies for a variety of healthcare delivery systems, including:
- Medicaid managed care and fee-for-service programs.
- Commercial populations in primary care case management.
HSAG has conducted these studies in numerous states including Arkansas, Arizona, California, Colorado, Florida, Michigan, Ohio, and Virginia.
A cornerstone of HSAG's services is its analytical expertise in study design and data management and its experience with a wide variety of study methodologies, clinical conditions, nonclinical areas of care, process and outcome measures, population characteristics, data collection and processing methodologies, statistical analyses, and provider/payer arrangements. HSAG uses a multidisciplinary team approach that features a core group of clinicians, healthcare analysts, epidemiologists, biostatisticians, and information management specialists. HSAG collaborates with states on key activity areas that include:
- Topic selections and literature reviews.
- Study questions, indicators, and populations.
- Sampling methodologies.
- Data collection, analyses, and interpretation.
- Quality improvement strategies and interventions.
HSAG facilitates PIPs on behalf of health plans and states on a variety of topics. HSAG developed a PIP validation approach that places greater emphasis on improving healthcare outcomes and processes through the integration of quality improvement science. HSAG's approach to facilitating PIPs, both at the health plan level and at the state level, guides entities through a process using rapid-cycle improvement methods to pilot small changes rather than implementing one large transformation. Performing small tests of change requires fewer resources and allows more flexibility for adjustments throughout the improvement process. By piloting on a smaller scale, health plans and state entities have an opportunity to determine the effectiveness of several changes prior to expanding the successful interventions to a larger scale.
HSAG has more than 15 years of experience developing and implementing QRSs for various state Medicaid agencies that assist consumers in choosing a health plan that best meets their healthcare needs. HSAG developed a methodology to compare plan performance across multiple domains of care based on HEDIS® performance measure and Consumer Assessment of Healthcare Providers and Systems (CAHPS2) survey results. Based on our extensive experience, HSAG is uniquely poised to assist states with meeting the requirements for Medicaid managed care QRS described in 42 CFR 438.334.