External Quality Review (EQR) 101: Overview

1. External Quality Review (EQR) 101: Overview January 16, 2014 Jody Carson RN, MSW, CPHQ Account Manager

2. Purpose • Provides a mechanism to assess how managed care entities meet statutory requirements pertaining to quality outcomes, timeliness of, and access to services provided to Medicaid enrollees • Aligns with the current Triple Aim goals to improve patient experience, health of population, and to reduce costs

3. CMS Requirements for EQR • Balanced Budget Act 1997 directed • DHHSto contract with an independent quality review organization to develop protocol • State Medicaid agencies that contract with PHIPs to develop a state quality assessment and improvement strategy • Final regulations, June 2002, specify • States establish an EQR with entities that meet competence and independence criteria • States contract with an EQR organization (EQRO) by 2004 • Revised regulations, September 2012

4. State’s Role • 2012 protocols rely on state to define the specific requirements for EQR • Waiver defines scope of CCOrequired activities and which CMS requirements are waived • State’s quality strategy outlines state and CCO roles in meeting quality standards

5. State’s Role • CCO contract further defines requirements • State determines: • Scoring criteria for compliance levels (fully met, partially met, not met) • Criteria weighting • Scoring system (2, 3, 4, or 5-point scale) • Additional requirements for review (i.e., contractor/provider interviews)

6. State’s Role • State determines: • What corrective action is needed and what follow-up activities will occur • If the PIHP contract needs changes to address systemic issues or to advance quality initiatives • Which additional activities will be conducted

7. Components of EQR • Mandatory Compliance Monitoring (Protocol 1) • Review of each element needs to occur once every three years • Follow-up on findings in the next reporting year • Optional Activities • Certification and Program Integrity review • Technical assistance to CCOs by EQRO

8. Components of EQR • Mandatory Performance Measure Validation (PMV) (Protocol 2) • Required annually on state-defined/required PMs • Information Systems Capability Assessment (ISCA) (Appendix V) required at least every two years with follow-up on findings next review year • Optional activities include contractor and provider interviews

9. Components of EQR • Mandatory Performance Improvement Project (PIP) Validation (Protocol 3) • Needs to occur annually • Topic or focus area can be determined by the state • At least two remeasurement periods • Needs to cover a variety of topic areas over time • Optional activities may include technical assistance and/or training

10. Additional EQR Activities • Validation of Encounter Data reported by PIHP/MCO (Protocol 4) • Highly recommended by CMS • Based on state’s requirements for collecting and submitting encounter data • Assesses completeness and accuracy of encounter data submitted to state • Optional activities may include trainings or instructional manuals

11. Additional EQR Activities • Validation and Implementation of Surveys (Protocol 5) • EQRO can either administer the survey or validate a survey administered by another party • Surveys can be of enrollees (MSHIP or YSS), enrollees’ families (YSS-F), or providers • Can be nationally validated tool or locally created survey • Can be done annually or in other time frame

12. Additional EQR Activities • Calculation of Performance Measures (Protocol 6) • PMs calculated can be in addition to other state or MCO calculated measures • Can be based on encounter data reported to the state or on clinical record review conducted by the EQRO

13. Additional EQR Activities • Implementation of PIPs (Protocol 7) • Utilizes the same process to conduct PIP as required of MCOs • Topic can be defined by state or in agreement with MCOs • Interventions can be determined by state, MCOs, or by EQRO

14. Additional EQR Activities • Focused Studies (Protocol 8) • Defined by the state • Can be focused on: • waiver requirements • areas of concern (e.g., prevention) • baseline and/or measurement of system changes • review of the implementation of the state’s quality strategy

15. Questions? Thank you ! Contact: Jody Carson, RN, MSW, CPHQ jcarson@acumentra.org

16. EQR 101: Compliance January 16, 2014 Priscilla Swanson, RN, CCM, CHC, CPHQ Clinical Project Coordinator

17. Review Activities • Establish contact with the CCO • Gather information on characteristics of CCO • Determine length of visit and visit dates • Identify number and types of reviewers • Establish agenda • Provide preparation instructions and guidance to the CCO

18. Review Activities • Pre-visit telephone meeting with selected CCO staff • Document review and pre-visit preparation • Onsite interview at CCO • Exit summary for each activity

19. Scoring Logic • Strengths • Recommendations • Findings

20. Report Writing • Gather information from document review, previous reviews, and interviews • Re-submission of documents • Meet with team members to discuss audit results with the protocols • Write report using report template

21. Submission to OHA • Submit report OHA • OHA reviews report • OHA sends to CCO for review • Response sent to Acumentra Health • Review, research, and revise as needed • Submit final report to OHA

22. OHA • Determines the corrective action • Notifies the CCO of requested action and timeline • Requests Acumentra Health perform follow-up the next year

23. Annual Report • Key components • Statewide CCO performance of timeliness, quality, and access • Executive summary • State findings and recommendations • CCO profiles

24. Components of Compliance Review • Enrollee Rights • Quality Assessment and Performance Improvement • Grievance System • Certifications and Program Integrity

25. Enrollee Rights • Information content • Information on providers • How to obtain benefits (in/out of plan), specialists, emergency/post-stabilization • Free choice of providers • Structure and operation of CCO • Provider incentive plan • Lack of liability for payment

26. Enrollee Rights • Specific rights • Free from seclusion and restraint • Advance directives • Emergency services do not require preauthorization • Request/amend clinical record • Benefits in plan and out of plan

27. Enrollee Rights • Specific rights (cont’d) • Grievance and appeal • Treated with dignity and respect • Privacy protection • Informed of available treatment options • Participation in treatment planning • Right to refuse

28. Enrollee Rights • Specific rights (cont’d) • Nondiscrimination • Easily accessible physical location • Interpreter free of charge • Emergency services do not require preauthorization • Second opinion

29. Enrollee Rights • Information format • Easily understood language • Alternative methods, formats • Information timing • Annually • 30 days prior to significant changes

30. Quality Assessment and Performance Improvement • Network planning and availability of services • Cultural considerations • Timely access • Second opinion • Out of plan • Direct access • Per standards defined in CCO contract and OAR

31. Quality Assessment and Performance Improvement • Coordination and continuity of care • Person centeredand integrated • Special healthcare needs • Team based services • Culturally and linguistically appropriate

32. Quality Assessment and Performance Improvement • Credentialing • Excluded provider • Provider selection and nondiscrimination • Delegation and subcontractual relationships • Routine monitoring • Annual evaluation

33. Quality Assessment and Performance Improvement • Quality Management Program • Effectiveness and quality • Includes ability to assess services furnished to enrollees with special health care needs • Utilization Management Activities • Authorization of services • Consistent application of criteria • Use of evidence-based guidelines and criteria in decision making • Analysis of under/overutilization

34. Quality Assessment and Performance Improvement • Health Information Systems • Support management decisions • Identify unmet enrollee needs • Ensure accurate, timely, and appropriate claim/encounter submission

35. Grievance System • General Requirements • Ability to translate enrollee communication into appropriate language and write in easily understood language • State-required format and timelines • Informing enrollees of rights to appealand continue benefits • Process for monitoring timelines

36. Grievance System • Information about grievance system to providers/subcontractors • Record keeping and reporting requirements • Incorporation into QAPI activities

37. Grievance System • Handling of notice of action • Decision made by the person with clinical expertise in treating condition and not previously involved in the case • Standard vs. expedited • Handling of grievance, appeal • Acknowledgement (oral/written) • Resolution • Ombuds available if requested

38. Certification and Program Integrity • Certification and Program Integrity (sub-part B and H) • Methods of administration necessary for proper and efficient operation of plan • Safeguards to ensure that services are provided to eligible individuals in a manner consistent with simplicity of administration and the best interests of recipients • Prohibits affiliation with excluded individuals or organizations

39. Certification • Data must be certified • Source of certification • Content • Accurate, complete, and timely

40. Program Integrity • General • Administrative arrangements and procedures designed to guard against fraud and abuse • Management arrangements and procedures designed to guard against fraud and abuse • A mandatory compliance plan • Assess risk

41. Program Integrity • Specific requirements • Policies and procedures • Standards of conduct • Compliance Officer • Compliance Committee • Effective training and education • Lines of communication

42. Program Integrity • Specific requirements (cont’d) • Enforcement of disciplinary guidelines • Internal monitoring and auditing • Prompt response to detected offenses • Development of corrective action • Ongoing program evaluation • When applicable, modify to make compliance program more effective

43. Program Integrity • General • Excluded individuals or organizations prohibited from participating • Specific • Applies to: director, officer, partner, owner, employees, consultants, or contractors • Reporting requirements • Sanctions • Remediation based on effective compliance program

44. Common Gaps • Lack of oversight of delegated entities (no annual evaluation) • Not tracking and trending all expressions of dissatisfaction (grievances) and appeals • Inadequate QI, special needs, utilization program evaluation • Lack mechanisms to monitor second opinions, direct access, accuracy/appropriateness of encounters, grievances and appeals, out of network and translation services

45. Common Gaps • Lack of mechanism to ensure consistent application of access to care guidelines • Reason for denial does not include rationale or cite criteria referenced in decision-making process • NOAs lack user-friendly language • Not following specific timelines listed in managed care contract

46. Resources • External Quality Review Protocols September 2012 • Assessing MCO Compliance with Medicaid and CHIP Managed Care Regulations December 2011 • 2014 CCO contract • 2013 OARs

47. Questions? Thank you! Contact Priscilla Swanson: pswanson@acumentra.org or call 503-382-3965

48. EQR 101: Performance Measure Validation including ISCA January 16, 2014 Amy Pfleiger, CISA

49. Validation Definition • Validation: review of information, data, and procedures to determine the extent to which they are accurate, reliable, free from bias, and in accord with standards for data collection and analysis.

50. PM Validation Annual validation of performance measures to determine: • the accuracy of the performance measures reported by the MCO/State • the MCO/State’s compliance with rules outlined by the State as set forth in 42 C.F.R. § 438.240(b)(2) for calculating performance measures.