MCO Participation in External Quality Review Mandatory Activities

During the SMMC Transition

October 30, 2013

Presenter:

Mary Wiley, BSW, RN, M.Ed.Project Director, State and Corporate Services

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• Presentation Objectives• BBA Mandatory Activities• Definitions• Decision Guiding Principles• Validation of Performance Improvement

Projects (PIPs)

Agenda

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Agenda

• Validation of Performance Measures• Compliance Monitoring Reviews• Encounter Data Validation• Question/Answer Period

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Presentation Objectives

• Review the three mandatory external quality review (EQR) activities, including encounter data validation (EDV)

• Discuss which EQR mandatory activities must be conducted during the SMMC transition period

• Discuss which plans will be impacted• Discuss what factors determine if a plan will

be included in a mandatory EQR activity

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BBA Mandatory EQR Activities

• Overview of the federal Medicaid managed care requirement for states– Validating performance improvement projects

(PIPs)– Validating performance measures (PMs)–Monitoring MCO compliance with State

contract requirements and Medicaid managed care standards

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• AHCA is also requiring the MCOs to participate in an encounter data validation study as a special terms and conditions (STCs) requirement from the Centers for Medicare and Medicaid Services (CMS)

• EDV will be an ongoing annual study

Encounter Data Validation

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Definitions

For purposes of this presentation, “MCO” includes the following plan types:• HMO• PSN• PDHP• PMHP/CWPMHP• SIPP

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Guiding Principles

• The requirements and periodicity for the EQR activities, as described in the federal Medicaid managed care regulations, the State’s waivers, Special Terms and Conditions, and the Agency’s contracts with the MCOs must be met.

• The data resulting from the EQR activity must be of significant value to the State and necessary for its measurement and reporting purposes or population trending and comparisons over time.

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Guiding Principles

• The conclusions and recommendations resulting from each EQR activity must be of significant value to the MCO and be actionable or present opportunities for improvement that could feasibly be implemented during the MCO’s remaining contract period.

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VALIDATION OF PERFORMANCE IMPROVEMENT PROJECTS (PIPS)

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Current MCO Contract

• Continue PIP activities for duration of the current contract

• Continue implementation of improvements and/or system interventions

• All PIP documentation, including remeasurement results, must be submitted if it is due before the end of the MCO’s current contract

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Current MCO Contract

• AHCA will review the submitted PIPs from the HMOs/PSNs for contract compliance

• HSAG may or may not be requested to validate PIPs for all plans (this will be determined on a case-by-case basis)

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VALIDATION OF PERFORMANCE MEASURES (PMs)

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Current MCO Contract

• Collect and report performance measure data as contractually required for the duration of their contract, as well as post-operations reporting if required by contract

• If an annual measure validation activity (or HEDIS® Compliance Audit) is due before the end of the MCO’s contract, such activity must be performed and results submitted to AHCA

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COMPLIANCE MONITORING REVIEWS

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Current MCO Contract

• All MCOs had compliance monitoring evaluations performed within the previous three-year period

• Contract-required deliverables must continue to be submitted

• Contract oversight activities and follow-up with the MCOs will be performed by AHCA throughout the duration of the MCOs’ contract

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VALIDATION OF ENCOUNTER DATA

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Current MCO Contract

• During state fiscal year (SFY) 2013-2014, AHCA contracted with HSAG to conduct an annual encounter data validation (EDV) study

• The goal of this study is to examine the extent to which encounters submitted to AHCA by its contracted managed care plans are accurate and complete

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Current MCO Contract

• During the current contract year, HSAG is required to review 33% of all plans operational as of January 2013 with a minimum review of 50 records per plan

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QUESTIONS?