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

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 2

3. 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 3

4. 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 4

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) 5

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 6

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 7

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 8

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 9

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 10

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 11

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 12

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 13

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 14

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

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

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 17

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 18

19. Scoring Logic Strengths Recommendations Findings 19

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 20

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 21

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

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

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

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 25

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 26

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 27

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

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

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 30

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

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

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 33

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

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 appeal and continue benefits  Process for monitoring timelines 35

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

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 37

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 38

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

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 40

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

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 42

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 43

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 44

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 45

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 46

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

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. 49

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. 50

51. 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 51

52. 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. 52

53. 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 53

54. 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 54

55. 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 55

56. 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 56

57. 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 57

58. Section I: Data Processing Procedures and Personnel Information Systems (dataflow) Staffing  Claims and encounters  Authorizations Hardware Systems Security  Incident management  Risk management 58

59. 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) 59

60. 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 60

61. CCO Activities Included in ISCA Physical Health Mental Health Chemical Dependency Pharmacy Dental Vision 61

62. 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. 62

63. Questions? Thank You! Contact: Amy Pfleiger, CISA apfleiger@acumentra.org 63

64. EQR 101: Performance Improvement Projects (PIPs) January 16, 2013 Nancy Siegel, MPH, PA-C Quality Improvement Specialist

65. Overview Federal requirements CMS PIP Protocol PIPs under Oregon waiver 65

66. 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 66

67. 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% 67

68. 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) 68

69. 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.” 69

70. 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 70

71. 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 71

72. PIP Standards based on 2012 Protocol (cont’d) 6. Study Results 7. Interpretation of Results 8. Improvement Strategies 9. Repeated Measurement 10. Sustained Improvement 72

73. 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. 73

74. 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 74

75. 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. 75

76. 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 76

77. 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. 77

78. 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 78

79. 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 79

80. Questions? Thank You! Contact: pipteam@acumentra.org 80