Validating performance improvement projecrts

Eric Jackson, MA Research Analyst October 19, 2009. Meeting Logistics Validation Process CMS Protocol Activities Tips and Hints Resources Questions and Answers Other Training Topics.An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.Meta Star evaluates performance improvement projects (PIPs) that are required by the Wisconsin Department of Health Services (DHS) as specified in its contract with managed care organizations (MCOs) and health maintenance organizations (HMOs), in order to comply with federal regulations.The purpose of a PIP is to assess and improve the processes and outcomes of health care provided by an MCO or HMO.This will enable the Secretary to include results and lessons learned from State intervention strategies to improve care as part of that annual reporting process. In addition, the MCO, on an ad 1 This protocol relies heavily on a guidebook produced by the National Committee for Quality Assurance (NCQA) that identifies key concepts in quality improvement (QI) studies.Additionally, States may incorporate specific PIPs as part of their State quality strategy, required by Section 1932(c)(1) of the Social Security Act, to align with the HHS National Quality Strategy for Quality Improvement in Health Care. Please see References at the end of this protocol for a list of references that were used to develop this protocol.

EQR Protocol 2: Validation of Performance Measures Reported by the MCO Validation of performance improvement projects (PIPs) Describes the process that states or their designees may use to validate PIPs required by the state that were underway during the preceding 12 months.

The Centers for Medicare & Medicaid Services (CMS) revised the EQR protocols in 2012 to address significant changes in national health care policy that offered new opportunities in measuring and improving the quality of health care (including changes effected by CHIPRA, the American Recovery and Reinvestment Act (ARRA), and the Affordable Care Act).

Review, within the previous three-year period, to determine MCO/PIHP compliance with state standards for access to care, structure and operations, and quality measurement and improvement Describes the process that states or their designees may use to determine an MCO’s or PIHP’s compliance with federal Medicaid managed care regulations and, upon the state’s discretion, applicable elements of the contract between the MCO/PIHP and the state.

Federal regulations at 42 CFR Part 438, subpart E (External Quality Review (EQR)) set forth the parameters that states must follow when conducting an EQR of its contracted managed care organizations (MCOs) and prepaid inpatient health plans (PIHPs).

An EQR is the analysis and evaluation by an external quality review organization (EQRO) of aggregated information on quality, timeliness, and access to the health care services that an MCO or PIHP, or their contractors, furnish to Medicaid recipients.

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