external quality review (eqr) 101: overview

January 16, 2014

Jody Carson RN, MSW, CPHQAccount Manager

External Quality Review (EQR) 101: Overview

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

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CMS Requirements for EQR• Balanced Budget Act 1997 directed

DHHS to 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

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State’s Role

• 2012 protocols rely on state to define the specific requirements for EQR

• Waiver defines scope of CCO required activities and which CMS requirements are waived

• State’s quality strategy outlines state and CCO roles in meeting quality standards

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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)

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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

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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

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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

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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

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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

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• 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

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• 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

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• 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

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• 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

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Questions?

Thank you !

Contact: Jody Carson, RN, MSW, [email protected]

January 16, 2014

Priscilla Swanson, RN, CCM, CHC, CPHQClinical Project Coordinator

EQR 101: Compliance

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

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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

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Scoring Logic

• Strengths• Recommendations • Findings

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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

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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

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OHA

• Determines the corrective action• Notifies the CCO of requested action

and timeline• Requests Acumentra Health perform

follow-up the next year

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Annual Report

• Key components Statewide CCO performance of

timeliness, quality, and access Executive summary State findings and recommendations CCO profiles

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Components of Compliance Review

• Enrollee Rights• Quality Assessment and Performance

Improvement• Grievance System• Certifications and Program Integrity

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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

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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

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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

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Enrollee Rights

• Specific rights (cont’d) Nondiscrimination Easily accessible physical location Interpreter free of charge Emergency services do not require

preauthorization Second opinion

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Enrollee Rights

• Information format Easily understood language Alternative methods, formats

• Information timing Annually 30 days prior to significant changes

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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

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• Coordination and continuity of care Person centered and integrated Special healthcare needs Team based services Culturally and linguistically appropriate

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• Credentialing Excluded provider Provider selection and nondiscrimination

• Delegation and subcontractual relationships Routine monitoring Annual evaluation

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• 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

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• Health Information Systems Support management decisions Identify unmet enrollee needs Ensure accurate, timely, and appropriate

claim/encounter submission

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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 appeal and

continue benefits Process for monitoring timelines

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Grievance System

• Information about grievance system to providers/subcontractors• Record keeping and reporting

requirements• Incorporation into QAPI activities

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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

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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

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Certification

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

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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

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Program Integrity

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

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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

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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

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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

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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

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Resources

• External Quality Review Protocols September 2012

• Assessing MCO Compliance with Medicaid and CHIP Managed Care Regulations December 2011

• 2014 CCO contract

• 2013 OARs

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Questions?

Thank you!

Contact Priscilla Swanson: [email protected]

or call 503-382-3965

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EQR 101: Performance Measure Validation including ISCA

January 16, 2014

Amy Pfleiger, CISA

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.

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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.

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PM Validation Process

• Review of PM specifications• Review of code used to calculate PM

validation• Interview with State or CCO to review

process to calculate measures• Performance of ISCA review of

calculating entity’s information system

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ISCA Purpose

• Define desired capabilities of the MCO’s information system and assess strength of the information system’s capabilities.

• ISCAs are performed at least every 2 years.

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Federal Requirements

42 C.F.R. § 438.242• The system must be able to achieve the

following: Collect data on enrollee and provider

characteristics as specified by the State and on services furnished to enrollees through an encounter data system or other methods, which may be specified by the State

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Federal Requirements (cont’d)

Ensure that data received from providers are accurate and complete by– verifying accuracy and timeliness of

reported data

– screening data for completeness, logic, and consistency

– collecting service information in standardized formats to the extent feasible and appropriate

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CCO ISCAs

• Many CCOs are in a transition period with their information systems and are refining their infrastructures to support the CCO model.

• The ISCA review focuses on CCOs’ current systems and

planned transitions identifies CCO-delegated activities,

outsourced services, and other IT relationships

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2013 ISCA Readiness Reviews

• Many CCOs were in a transition period during 2013.

• Readiness reviews were meant to help guide CCOs through this transitional period. Fewer questions, focused at a higher level Recommendations provided but not scores

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2014 Full ISCA Review

• CCOs’ information systems have made many of the changes need to support CCO activities.

• Review period: 2013-current

• Full set of questions based on 2012 CMS protocol (similar to 2011 reviews conducted for AMH/DMAP).

• Follow up on 2013 recommendations

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Section I: Data Processing Procedures and Personnel

• Information Systems (dataflow)

• Staffing Claims and encounters Authorizations

• Hardware Systems

• Security Incident management Risk management

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Section II: Data Acquisition Capabilities

• Administrative Data (claims and encounter data)

• Enrollment Systems (Medicaid eligibility)

• Integration and Control of Data for Performance Measure Reporting

• Vendor Data Integration

• Report Production

• Provider Data (compensation and profiles)

• Electronic Health Records (added with 2012 CMS update)

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CCO Review Process

• CCO submit ISCA tool and requested documents

• Half-day interview on site with CCO and partners

• Opportunity to resubmit documents

• 1-hour interviews with 4 providers

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CCO Activities Included in ISCA

• Physical Health• Mental Health• Chemical Dependency • Pharmacy • Dental• Vision

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2013 ISCA Readiness Themes

• Expired policies and procedures

• Varied stages of Disaster Recovery/Business Continuity Planning recovery strategies

• Separate reporting databases for physical and mental health data

• Lack of monitoring of third parties and partnered organizations

• Wide differences in the volume of paper claims between CCOs and claim types.

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Questions?

Thank You!

Contact: Amy Pfleiger, [email protected]

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EQR 101: Performance Improvement Projects (PIPs)

January 16, 2013

Nancy Siegel, MPH, PA-CQuality Improvement Specialist

Overview

• Federal requirements

• CMS PIP Protocol

• PIPs under Oregon waiver

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Glossary

CCO - Coordinated Care Organization

CMS – Centers for Medicare and Medicaid Services

OHA – Oregon Health Authority

PIP – Performance Improvement Project

QHOC – Quality and Health Outcomes Committee

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Why is Quality Improvement Important?

• People with serious mental illness die, on average, 25 years younger than the general population. (Parks et al, 2006)

• Developmental screening in the first 36 months of life: Oregon statewide benchmark: 50.0% Oregon statewide 2011 baseline: 20.9%

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Federal Regulations

Validation of Performance Improvement Projects (PIP) during the preceding 12 months is one of three mandatory EQR activities for states which contract with Medicaid Managed Care Organizations (MCO) or Prepaid Inpatient Health Plans (PIHP).

(www.Medicaid.gov)

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Federal Regulations

CFR 438.240“These projects must be designed to achieve, through ongoing measurements and intervention, significant improvement, sustained over time, in clinical care and non clinical care areas that are expected to have a favorable effect on health outcomes and enrollees satisfaction.”

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Changes in 2012 CMS PIP Validation Protocol

• New emphases Analysis of enrollee characteristics Cultural and linguistic appropriateness Input from enrollees Consider CMS national health priorities Adequacy of indicators to measure real change Root cause analysis Sufficiency of intervention to improve processes

or outcomes

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PIP Standards based on 2012 Protocol

Standards provide an outline on how to conduct PIPs:

1. Study Topic

2. Study Question

3. Study Population

4. Study Indicator

5. Data Collection/Data Analysis

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PIP Standards based on 2012 Protocol (cont’d)

6. Study Results

7. Interpretation of Results

8. Improvement Strategies

9. Repeated Measurement

10. Sustained Improvement

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Oregon Waiver

• In December 2012, OHA reached agreement with CMS on the Special Terms and Conditions of the 1115 Medicaid Demonstration (waiver).

• According to the 2012 waiver: Each CCO must address 4 of 7 quality

improvement focus areas, three of which will serve as PIPs, and one as a focus study.

CCOs should use rapid-cycle methodology (PDSA) to aid with the transformative process.

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Focus Areas

• Reduce preventable hospitalizations• Address population health issues• Deploy care teams• Integrate primary care and behavioral health• Ensure appropriate care is delivered in

appropriate settings • Improve perinatal and maternity care• Increase adoption of PCPCH model of care

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Statewide PIP

• OHA selected integration of primary care and behavioral health to be conducted as a statewide collaborative PIP (all CCOs are participating).

• CCOs selected monitoring LDL-C and HbA1c in enrollees with co-occurring diabetes and schizophrenia or bipolar disorder as topic.

• CCOs are responsible for implementing interventions and providing a written report about their progress to date every quarter.

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Acumentra Health’s Role

For the statewide PIP, Acumentra Health

• provides technical assistance to CCOs every quarter

• facilitates group discussions and makes presentations at monthly QHOC meetings

• writes a PIP report (following the CMS Standards) and submits the report to OHA

• summarizes findings in an annual report to OHA

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OHA Tasks

• OHA QI Coordinators review quarterly reports on the two CCO-specific PIPs and focus studies and provide feedback to CCOs.

• OHA reviews and submits PIP reports to CMS every quarter and annually.

• OHA reviews and submits the Acumentra Health Annual Report to CMS.

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Summary of CCO-Specific PIP Topics

CCOs chose the following PIP topics:• Improve perinatal and maternity care - 9• Reduce preventable hospitalizations - 4• Address population health issues - 4• Deploy care teams - 4• Ensure appropriate care is delivered in

appropriate settings - 4• Increase adoption of PCPCH model of care - 2

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Summary of Focus Study Topics

CCOs chose the following focus studies:

• Increase adoption of PCPCH model of care - 6

• Integrate primary care and behavioral health - 2

• Address population health issues – 2

• Improve perinatal and maternity care - 2

• Deploy care teams- 1

• Ensure appropriate care is delivered in appropriate settings - 1

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Questions?

Thank You!

Contact: [email protected]

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external quality review (eqr) 101: overview

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