External Quality Review - dss.mo.gov MO HealthNet Managed Care External Quality Review Report of Findings

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  • Amy McCurry Schwartz, Esq., MHSA, EQRO Project Director

    Mona Prater, MPA, EQRO Assistant Project Director

    Contract Number: C312155001

    Review Period: January 1, 2012 to December 31, 2012

    Draft Submitted on: October 1, 2013

    Final Submitted on: December 2, 2013

    Submitted by: Behavioral Health Concepts, Inc.

    2012

    MO HealthNet Managed

    Care Program

    External Quality Review

  • Prepared and Submitted by:

    The Performance Management Solutions Group Is a division of Behavioral Health Concepts, Inc.

    4250 East Broadway, Ste. 1055 Columbia, MO 65201 (573) 446-0405 :Local Ph. (866) 463-6242 :Toll-free Ph. (573) 446-1816 :Fax http://www.PMSGinfo.com http://www.BHCinfo.com Email: EQRO@pmsginfo.com

  • MO HealthNet Managed Care External Quality Review

    Report of Findings – 2012 Table of Contents

    Performance Management Solutions Group 3 A division of Behavioral Health Concepts, Inc.

    3

    TABLE OF CONTENTS

    LIST OF TABLES ............................................................................................................ 9

    LIST OF FIGURES ....................................................................................................... 11

    1.0 EXECUTIVE SUMMARY ..................................................................................... 13

    I.1 Introduction .................................................................................................................................... 15

    1.2 Validation of Performance Improvement Projects ................................................................ 17 Access to Care ............................................................................................................................................. 18 Quality of Care ............................................................................................................................................. 18 Timeliness of Care ....................................................................................................................................... 18 Conclusions ................................................................................................................................................... 19

    1.3 Validation of Performance Measures ....................................................................................... 21 Quality of Care ............................................................................................................................................. 22 Access to Care ............................................................................................................................................. 26 Timeliness of Care ....................................................................................................................................... 27

    1.4 MO HealthNet MCHP Compliance with Managed Care Regulations .............................. 29 Quality of Care ............................................................................................................................................. 30 Access to Care ............................................................................................................................................. 31 Timeliness of Care ....................................................................................................................................... 31 Conclusions ................................................................................................................................................... 32

    1.5 MO HealthNet MCHP Special Project – Case Management Performance Review .... 34 Introduction ................................................................................................................................................... 34 Observations and Conclusions ................................................................................................................. 35

    Introduction to Case Management .......................................................................................................................... 35 Assessment .................................................................................................................................................................... 36 Face-to-Face Contacts ................................................................................................................................................ 38 Case/Care Coordination ............................................................................................................................................ 39

    Conclusions ................................................................................................................................................... 40 Quality of Care ............................................................................................................................................. 40 Access to Care ............................................................................................................................................. 41 timeliness of care.......................................................................................................................................... 42

    2.0 VALIDATION OF PERFORMANCE IMPROVEMENT PROJECTS (PIPS) ................................................................................................................................ 45

    3.0 VALIDATION OF PERFORMANCE MEASURES ........................................ 61

    3.1 Purpose and Objectives .............................................................................................................. 63

    3.2 Findings ........................................................................................................................................... 64 HEDIS 2012 Annual Dental Visit .............................................................................................................. 65

  • MO HealthNet Managed Care External Quality Review

    Report of Findings – 2012 Table of Contents

    Performance Management Solutions Group 4 A division of Behavioral Health Concepts, Inc.

    4

    HEDIS 2012 Childhood Immunizations Status, Combination 3 ........................................................ 70 HEDIS 2012 Follow-Up After Hospitalization for Mental Illness...................................................... 77 Health Plan Information Systems Capabilities Assessment ................................................................ 88

    3.3 Conclusions.................................................................................................................................... 90 Quality of Care ............................................................................................................................................. 90 Access to Care ............................................................................................................................................. 91 Timeliness of Care ....................................................................................................................................... 92 Recommendations........................................................................................................................................ 93

    4.0 MO HEALTHNET MCHP COMPLIANCE WITH MANAGED CARE REGULATIONS ........................................................................................................... 95

    4.1 Purpose and Objectives .............................................................................................................. 97 Obtaining Background Information from the State Medicaid Agency ............................................. 97 Document Review........................................................................................................................................ 98 Conducting interviews ................................................................................................................................ 99 Analyzing and Compiling Findings............................................................................................................. 99 Reporting to the State Medicaid Agency ............................................................................................. 100 Compliance Ratings .................................................................................................................................. 100

    4.2 Findings ......................................................................................................................................... 101 Enrollee Rights and Protections ............................................................................................................ 101 Compliance Interviews ............................................................................................................................ 102 Quality Assessment and Performance Improvement: ...................................................................... 102 Access Standards ....................................................................................................................................... 102 Quality Assessment and Performance Improvement: Structure and Operation Standards .. 104 Quality Assessment and Performance Improvement: Measurement and Improvement ......... 104 Grievance Systems ..................................................................................