Objective:

Assist the District of Columbia’s Department of Health Care Finance (DHCF) in evaluating the quality of care provided to Medicaid recipients enrolled in a managed care organization (MCO) by serving (with Delmarva Foundation) as the External Quality Review Organization (EQRO).

Challenges:

Because of the number of standards and the short timeframe for conducting the compliance reviews, the project required a thorough understanding of health care regulations, as well as an efficient, organized, and detail-oriented approach that helped the MCOs prepare the required information for the on-site reviews.

Approach:

Prior to the 2010 review, the team assisted with the development of comprehensive guidance for the MCOs, detailing the specific items required to document compliance with Medicaid regulations and DHCF contract standards, in addition to outlining the objectives, timelines, and process for the annual review.

The team completed desk and on-site reviews with each MCO operating a Medicaid plan in the District of Columbia, assessing the plans’ compliance with a set of performance standards based on the Centers for Medicare & Medicaid Services (CMS) document, “A Health Care Quality Improvement System (HCQIS) for Medicaid Managed Care,” the Code of Federal Regulations, and DHCF requirements. In its review findings, the team documented the level of compliance for each element and component and provided detailed recommendations to assist DHCF and MCOs in addressing any compliance issues.