External Quality Review Process

August 6, 2009

The Carolinas Center for Medical Excellence (CCME)

• A physician-sponsored, nonprofit health care quality improvement organization

• Designated by the Centers for Medicare & Medicaid Services (CMS) as the Quality Improvement Organization (QIO) for North and South Carolina

• CCME provides External Quality Review for Medicaid Managed Care in North and South Carolina and utilization review services for North Carolina Medicaid

Presentation Agenda

• SC External Quality Review (EQR) activities• Timeline• EQR components and process• Standards• Roles and responsibilities• Questions

EQR Activities– Federal regulation 42 CFR 438 requires State

Medicaid Agencies that contract with Managed Care Organizations (MCO) and Medical Home Networks (MHN) to evaluate their compliance with the state and federal requirements

– SCDHHS contracts with CCME to perform:• Readiness review of new MCOs and MHNs• Annual EQR of all MCOs and MHNs

Readiness Review• New Medicaid MCOs and MHNs• Performed prior to enrollment of members• Desk review conducted at CCME of all policies,

procedures, manuals and other supporting material• On-site review of systems and staff interviews

Annual Review

• Performed each year to determine the MCO’s/MHN’s compliance with Federal Regulations (CFR 438) and SCDHHS contract requirements

• Desk review conducted at CCME of all policies and procedures, program descriptions, committee minutes, manuals, handbooks, and quality data

• On-site visit conducted in the MCO/MHN office to review credentialing files, medical records, conduct staff interviews and provide feedback

EQR Timeline• MCO/MHN receives initial notification • CCME conducts conference call with MCO/MHN,

SCDHHS• CCME receives desk materials• Desk review conducted at CCME• On site visit scheduled• On site visit conducted• CCME sends draft report to SCDHHS• SCDHHS sends final report to MCO/MHN

EQR Components

• Assessment of the MCO/MHN compliance with Federal managed care regulations and State contract requirements

• Information Systems Capabilities Assessment• Validation of performance measures• Validation of performance improvement projects

EQR Process

• Consistent with the CMS protocols for EQR

• CMS protocols can be found at http://www.cms.hhs.gov/MedicaidManagCare

Standards• Administrative • Provider Services• Member Services• Quality Improvement• Utilization Management• Delegation• State Mandated Services

Administrative

• Organizational structure• Staffing levels• Policies and procedures• Compliance Plan• Information Systems Capabilities Assessment

(ISCA)

Provider Services• Credentialing/Re-credentialing file review

– Physician profiling – Site evaluation

• Adequacy of the Provider Network and Service Access

• Provider education• Preventive and clinical practice guidelines

Member Services• Member rights and responsibilities• Preventive health and chronic disease

management education• Disenrollment• Grievances and complaints• Satisfaction survey

Quality Improvement

• Validation of performance measures and quality improvement projects

• Activities of the Quality Improvement Committee• Provider involvement in quality activities• Annual evaluation of the quality improvement

program

Utilization Management• Program structure and evaluation• Medical necessity determinations

– Utilization process– File review of approvals and denials

• Appeals– Member and provider appeal process– Appeal file review

• Case Management– Case management file review

• Evaluation of over and under utilization data

Delegation

• Review of activities and monitoring of contractors and/or agencies performing delegated activities for MCO/MHN

State Mandated Services

• Provider compliance with immunizations and EPSDTs• Review of core benefits• Follow-up review of identified deficiencies from the

previous EQR

CCME Responsibilities• Send initial notification and desk materials request list• Schedule and conduct teleconference in conjunction with

MCO/MHN and SCDHHS• Schedule on-site visit• Send on-site materials list and agenda• Entrance and exit conference during on-site• Submit detailed report of EQR findings to SCDHHS

within 30 days of completion• Technical support to MCOs/MHNs as requested

MCO/MHN Responsibilities

• Participate in teleconference

• Provide desk and on-site materials as requested and timely

• Have appropriate staff available during on-site visit for interviews and questions

• Submit corrective action plan if necessary

SCDHHS Responsibilities• MCO/MHN contract requirements• Review and approve all standards and the EQR process• Facilitate communications between CCME and

MCO/MHN• Participate in Teleconference• Review EQR report, request changes as needed• Forward final EQR report to the MCO/MHN and request

and corrective action if necessary

CCME Contact Information

• Sandi Owens

(803) 251-2215 ex 3228

• Karen Smith

(919) 380-9860 ex 2040

QUESTIONS ?