Table Of Content

2008 MO HealthNet Managed Care Program External Quality Review Amy McCurry Schwartz, Esq., MHSA, EQRO Project Director Mona Prater, MPA, EQRO Assistant Project Director Stephani Worts, MBA, EQRO Research Analyst Contract Number: C301154801, Amendment 007 Review Period: January 1, 2008 to December 31, 2008 Draft Submitted on: October 1, 2009 Final Copy Submitted on: December 1, 2009 Submitted by: Behavioral Health Concepts, Inc. Performance Management Solutions Group Prepared and Submitted by: The Performance Management Solutions Group Is a division of Behavioral Health Concepts, Inc. 2716 Forum Blvd, Suite 4 Columbia, MO 65203 (573) 446-0405 :Local Ph. (866) 463-6242 :Toll-free Ph. (573) 446-1816 :Fax http://www.PMSGinfo.com http://www.BHCinfo.com Email: [email protected] TABLE OF CONTENTS LIST OF ACRONYMS .................................................................................................... XI  GLOSSARY AND OPERATIONAL DEFINITIONS .......................................... XIV  LIST OF TABLES ........................................................................................................ XVII  LIST OF FIGURES ........................................................................................................X XI  1.0 EXECUTIVE SUMMARY ....................................................................................... 23  I.1 Introduction .................................................................................................................................... 25  1.2 Preparation for the 2008 External Quality Review .............................................................. 27  Preparation with the State Medicaid Agency ......................................................................................... 27  Preparation of MO HealthNet Managed Care Health Plans .............................................................. 27  Development of Worksheets, Tools, and Rating Criteria ................................................................. 28  1.3 Validation of Performance Improvement Projects ................................................................ 30  Conclusion ..................................................................................................................................................... 34  1.4 Validation of Performance Measures ....................................................................................... 35  Quality of Care ............................................................................................................................................. 35  Access to Care ............................................................................................................................................. 38  Timeliness of Care ....................................................................................................................................... 40  1.5 Encounter Data Validation ......................................................................................................... 42  Strengths ......................................................................................................................................................... 45  Areas for Improvement .............................................................................................................................. 45  1.6 MO HealthNet MCHP Compliance with Managed Care Regulations .............................. 46  Quality of Care ............................................................................................................................................. 47  Access to Care ............................................................................................................................................. 48  Timeliness of Care ....................................................................................................................................... 49  Conclusion ..................................................................................................................................................... 50  1.7 MO HealthNet Managed Care Health Plan Best Practices .............................................. 51  2.0 VALIDATION OF PERFORMANCE IMPROVEMENT PROJECTS (PIPS) ................................................................................................................................... 61  2.1 Definition ........................................................................................................................................ 63  Analysis of the Statewide PIP .................................................................................................................... 77  History ....................................................................................................................................................................... 77  Findings ...................................................................................................................................................................... 77  Conclusion ................................................................................................................................................................ 79  3.0 VALIDATION OF PERFORMANCE MEASURES ......................................... 87  3.1 Definition ........................................................................................................................................ 89  iii Performance Management Solutions Group A division of Behavioral Health Concepts, Inc. 3.2 Purpose and Objectives .............................................................................................................. 89  Reviewers ....................................................................................................................................................... 89  3.3 Technical Methods ....................................................................................................................... 90  HEDIS 2008 Adolescent Well-Care Visits (AWC) .............................................................................. 91  HEDIS 2008 Use of Appropriate Medications for People With Asthma (ASM)........................... 94  HEDIS 2008 Annual Dental Visit (ADV) ................................................................................................. 98  Methods of Calculating Performance Measures ................................................................................ 100  Time Frame ................................................................................................................................................. 101  Procedures for Data Collection ............................................................................................................ 101  3.4 Findings ......................................................................................................................................... 113  HEDIS 2008 Annual Dental Visit ........................................................................................................... 115  HEDIS 2008 Adolescent Well-Care Visits .......................................................................................... 127  HEDIS 2008 Use of Appropriate Medications for People With Asthma .................................... 148  3.5 Conclusions .................................................................................................................................. 163  Quality of Care .......................................................................................................................................... 163  Access to Care .......................................................................................................................................... 164  Timeliness of Care .................................................................................................................................... 165  Recommendations ..................................................................................................................................... 165  4.0 VALIDATION OF ENCOUNTER DATA ...................................................... 167  4.1 Definition ...................................................................................................................................... 169  4.2 Purpose and Objectives ............................................................................................................ 169  4.3 Technical Methods ..................................................................................................................... 171  Time Frame ................................................................................................................................................. 171  Procedures for Data Collection ............................................................................................................ 171  Analyses ....................................................................................................................................................... 172  4.4 Findings ......................................................................................................................................... 174  4.5 Conclusions .................................................................................................................................. 202  Strengths ...................................................................................................................................................... 202  Areas for Improvement ........................................................................................................................... 202  Recommendations ..................................................................................................................................... 203  5.0 MO HEALTHNET MCHP COMPLIANCE WITH MANAGED CARE REGULATIONS ........................................................................................................... 205  5.1 Purpose and Objectives ............................................................................................................ 207  iv Performance Management Solutions Group A division of Behavioral Health Concepts, Inc. 5.2 Technical Methods ..................................................................................................................... 208  Planning Compliance Monitoring Activities ........................................................................................ 208  Obtaining Background Information from the State Medicaid Agency .......................................... 211  Document Review .................................................................................................................................... 211  Conducting Interviews ............................................................................................................................. 212  Collecting Accessory Information ......................................................................................................... 213  Analyzing and Compiling Findings ......................................................................................................... 213  Reporting to the State Medicaid Agency ............................................................................................. 214  Compliance Ratings .................................................................................................................................. 214  5.3 Findings ......................................................................................................................................... 215  Enrollee Rights and Protections ............................................................................................................ 215  Compliance Interviews – Member Services staff and Case Management (Behavioral Health) 219  Quality Assessment and Performance Improvement: ...................................................................... 221  Access Standards ....................................................................................................................................... 221  Member Service Staff and Case Manager Interviews ........................................................................ 225  Quality Assessment and Performance Improvement: ...................................................................... 225  Structure and Operation Standards ...................................................................................................... 225  Quality Assessment and Performance Improvement: Measurement and Improvement ......... 228  Grievance Systems .................................................................................................................................... 231  5.4 Conclusions .................................................................................................................................. 234  Quality of Care .......................................................................................................................................... 235  Access to Care .......................................................................................................................................... 236  Timeliness of Care .................................................................................................................................... 237  Recommendations ..................................................................................................................................... 238  6.0 BLUE-ADVANTAGE PLUS OF KANSAS CITY .......................................................... 241  6.1 Performance Improvement Projects ...................................................................................... 243  Methods ....................................................................................................................................................... 243  Document Review ................................................................................................................................................. 243  Interviews ................................................................................................................................................................ 243  Findings ........................................................................................................................................................ 244  Conclusions ................................................................................................................................................ 249  Quality of Care ...................................................................................................................................................... 249  Access to Care ....................................................................................................................................................... 250  Timeliness to Care ................................................................................................................................................ 250  Recommendations ................................................................................................................................................. 251  6.2 Validation of Performance Measures ..................................................................................... 252  Methods ....................................................................................................................................................... 252  Document Review ................................................................................................................................................. 252  Interviews ................................................................................................................................................................ 253  v Performance Management Solutions Group A division of Behavioral Health Concepts, Inc. Findings ........................................................................................................................................................ 253  Data Integration and Control ............................................................................................................................. 255  Documentation of Data and Processes ............................................................................................................ 255  Processes Used to Produce Denominators ..................................................................................................... 256  Processes Used to Produce Numerators......................................................................................................... 256  Sampling Procedures for Hybrid Methods ....................................................................................................... 257  Submission of Measures to the State ................................................................................................................ 257  Determination of Validation Findings and Calculation of Bias ..................................................................... 257  Final Audit Rating ................................................................................................................................................... 258  Conclusions ................................................................................................................................................ 258  Quality of Care ...................................................................................................................................................... 258  Access to Care ....................................................................................................................................................... 259  Timeliness of Care ................................................................................................................................................ 260  Recommendations ................................................................................................................................................. 260  6.3 Validation of Encounter Data ................................................................................................... 261  Findings ........................................................................................................................................................ 261  Conclusions ................................................................................................................................................ 266  Strengths .................................................................................................................................................................. 266  Areas for Improvement ........................................................................................................................................ 266  Recommendations ................................................................................................................................................. 266  6.4 MO HealthNet MCHP Compliance with Managed Care Regulations ............................ 267  7.0 CHILDREN’S MERCY FAMILY HEALTH PARTNERS ............................................... 291  7.1 Performance Improvement Projects ...................................................................................... 293  Methods ....................................................................................................................................................... 293  Document Review ................................................................................................................................................. 293  Interviews ................................................................................................................................................................ 293  Findings ........................................................................................................................................................ 294  Conclusions ................................................................................................................................................ 298  Quality of Care ...................................................................................................................................................... 298  Access to Care ....................................................................................................................................................... 298  Timeliness to Care ................................................................................................................................................ 299  Recommendations ................................................................................................................................................. 299  7.2 Validation of Performance Measures ..................................................................................... 300  Methods ....................................................................................................................................................... 300  Document Review ................................................................................................................................................. 300  Interviews ................................................................................................................................................................ 301  Findings ........................................................................................................................................................ 301  Data Integration and Control ............................................................................................................................. 303  Documentation of Data and Processes ............................................................................................................ 304  Processes Used to Produce Denominators ..................................................................................................... 304  Processes Used to Produce Numerators......................................................................................................... 304  Sampling Procedures for Hybrid Methods ....................................................................................................... 305  Submission of Measures to the State ................................................................................................................ 306  Determination of Validation Findings and Calculation of Bias ..................................................................... 306  Final Audit Rating ................................................................................................................................................... 306  Conclusions ................................................................................................................................................ 307  Quality of Care ...................................................................................................................................................... 307  Access to Care ....................................................................................................................................................... 308  Timeliness of Care ................................................................................................................................................ 308  Recommendations ................................................................................................................................................. 309  vi Performance Management Solutions Group A division of Behavioral Health Concepts, Inc. 7.3 Validation of Encounter Data ................................................................................................... 310  Findings ........................................................................................................................................................ 310  Conclusions ................................................................................................................................................ 316  Strengths .................................................................................................................................................................. 316  Areas for Improvement ........................................................................................................................................ 316  Recommendations ................................................................................................................................................. 316  7.4 MO HealthNet MCHP Compliance with Managed Care Regulations ............................ 317  8.0 HARMONY HEALTH PLAN OF MISSOURI ............................................................... 339  8.1 Performance Improvement Projects ...................................................................................... 341  Methods ....................................................................................................................................................... 341  Document Review ................................................................................................................................................. 341  Interviews ................................................................................................................................................................ 341  Findings ........................................................................................................................................................ 342  Conclusions ................................................................................................................................................ 346  Quality of Care ...................................................................................................................................................... 346  Access to Care ....................................................................................................................................................... 346  Timeliness of Care ................................................................................................................................................ 346  Recommendations ................................................................................................................................................. 347  8.2 Validation of Performance Measures ..................................................................................... 348  Methods ....................................................................................................................................................... 348  Document Review ................................................................................................................................................. 348  Interviews ................................................................................................................................................................ 349  Findings ........................................................................................................................................................ 349  Data Integration and Control ............................................................................................................................. 350  Documentation of Data and Processes ............................................................................................................ 350  Processes Used to Produce Denominators ..................................................................................................... 351  Processes Used to Produce Numerators......................................................................................................... 351  Sampling Procedures for Hybrid Methods ....................................................................................................... 352  Submission of Measures to the State ................................................................................................................ 352  Determination of Validation Findings and Calculation of Bias ..................................................................... 352  Final Audit Rating ................................................................................................................................................... 353  Conclusions ................................................................................................................................................ 353  Quality of Care ...................................................................................................................................................... 353  Access to Care ....................................................................................................................................................... 354  Timeliness of Care ................................................................................................................................................ 354  Recommendations ................................................................................................................................................. 355  8.3 Validation of Encounter Data ................................................................................................... 356  Findings ........................................................................................................................................................ 356  Conclusions ................................................................................................................................................ 358  Strengths .................................................................................................................................................................. 358  Areas for Improvement ........................................................................................................................................ 358  Recommendations ................................................................................................................................................. 358  8.4 MO HealthNet MCHP Compliance with Managed Care Regulations ............................ 359  vii Performance Management Solutions Group A division of Behavioral Health Concepts, Inc. 9.0 HEALTHCARE USA ................................................................................................... 381  9.1 Performance Improvement Projects ...................................................................................... 383  Methods ....................................................................................................................................................... 383  Document Review ................................................................................................................................................. 383  Interviews ................................................................................................................................................................ 383  Findings ........................................................................................................................................................ 384  Conclusions ................................................................................................................................................ 388  Quality of Care ...................................................................................................................................................... 388  Access to Care ....................................................................................................................................................... 389  Timeliness of Care ................................................................................................................................................ 389  Recommendations ................................................................................................................................................. 390  9.2 Validation of Performance Measures ..................................................................................... 391  Methods ....................................................................................................................................................... 391  Document Review ................................................................................................................................................. 391  Interviews ................................................................................................................................................................ 392  Findings ........................................................................................................................................................ 392  Data Integration and Control ............................................................................................................................. 394  Documentation of Data and Processes ............................................................................................................ 395  Processes Used to Produce Denominators ..................................................................................................... 395  Processes Used to Produce Numerators......................................................................................................... 396  Sampling Procedures for Hybrid Methods ....................................................................................................... 396  Submission of Measures to the State ................................................................................................................ 396  Determination of Validation Findings and Calculation of Bias ..................................................................... 397  Final Audit Rating ................................................................................................................................................... 397  Conclusions ................................................................................................................................................ 398  Quality of Care ...................................................................................................................................................... 398  Access to Care ....................................................................................................................................................... 398  Timeliness of Care ................................................................................................................................................ 399  Recommendations ................................................................................................................................................. 400  9.3 Validation of Encounter Data ................................................................................................... 401  Findings ........................................................................................................................................................ 401  Conclusions ................................................................................................................................................ 406  Strengths .................................................................................................................................................................. 406  Areas for Improvement ........................................................................................................................................ 407  Recommendations ................................................................................................................................................. 407  9.4 MO HealthNet MCHP Compliance with Managed Care Regulations ............................ 408  10.0 MERCY CAREPLUS .................................................................................................. 433  10.1 Performance Improvement Projects .................................................................................... 435  Methods ....................................................................................................................................................... 435  Document Review ................................................................................................................................................. 435  Findings ........................................................................................................................................................ 436  Conclusions ................................................................................................................................................ 441  Quality of Care ...................................................................................................................................................... 441  Access to Care ....................................................................................................................................................... 441  Timeliness of Care ................................................................................................................................................ 442  Recommendations ................................................................................................................................................. 442  viii Performance Management Solutions Group A division of Behavioral Health Concepts, Inc. 10.2 Validation of Performance Measures ................................................................................... 443  Methods ....................................................................................................................................................... 443  Document Review ................................................................................................................................................. 443  Interviews ................................................................................................................................................................ 444  Findings ........................................................................................................................................................ 444  Data Integration and Control ............................................................................................................................. 446  Documentation of Data and Processes ............................................................................................................ 447  Processes Used to Produce Denominators ..................................................................................................... 447  Processes Used to Produce Numerators......................................................................................................... 448  Sampling Procedures for Hybrid Methods ....................................................................................................... 448  Submission of Measures to the State ................................................................................................................ 449  Determination of Validation Findings and Calculation of Bias ..................................................................... 449  Final Audit Rating ................................................................................................................................................... 449  Conclusions ................................................................................................................................................ 450  Quality of Care ...................................................................................................................................................... 450  Access to Care ....................................................................................................................................................... 450  Timeliness of Care ................................................................................................................................................ 451  Recommendations ................................................................................................................................................. 451  10.3 Validation of Encounter Data ................................................................................................ 452  Findings ........................................................................................................................................................ 452  Conclusions ................................................................................................................................................ 457  Strengths .................................................................................................................................................................. 457  Areas for Improvement ........................................................................................................................................ 457  Recommendations ................................................................................................................................................. 458  10.4 MO HealthNet MCHP Compliance with Managed Care Regulations.......................... 459  11.0 MISSOURI CARE ....................................................................................................... 483  11.1 Performance Improvement Projects .................................................................................... 485  Methods ....................................................................................................................................................... 485  Document Review ................................................................................................................................................. 485  Interviews ................................................................................................................................................................ 485  Findings ........................................................................................................................................................ 486  Conclusions ................................................................................................................................................ 492  Quality of Care ...................................................................................................................................................... 492  Access to Care ....................................................................................................................................................... 492  Timeliness of Care ................................................................................................................................................ 492  Recommendations ................................................................................................................................................. 493  11.2 Validation of Performance Measures ................................................................................... 494  Methods ....................................................................................................................................................... 494  Document Review ................................................................................................................................................. 494  Interviews ................................................................................................................................................................ 495  Findings ........................................................................................................................................................ 495  Data Integration and Control ............................................................................................................................. 497  Documentation of Data and Processes ............................................................................................................ 497  Processes Used to Produce Denominators ..................................................................................................... 497  Processes Used to Produce Numerators......................................................................................................... 498  Sampling Procedures for Hybrid Methods ....................................................................................................... 499  Submission of Measures to the State ................................................................................................................ 499  Determination of Validation Findings and Calculation of Bias ..................................................................... 500  Final Audit Rating ................................................................................................................................................... 500  ix Performance Management Solutions Group A division of Behavioral Health Concepts, Inc. Conclusions ................................................................................................................................................ 501  Quality of Care ...................................................................................................................................................... 501  Access to Care ....................................................................................................................................................... 501  Timeliness of Care ................................................................................................................................................ 502  Recommendations ................................................................................................................................................. 503  11.3 Validation of Encounter Data ................................................................................................ 504  Findings ........................................................................................................................................................ 504  Conclusions ................................................................................................................................................ 509  Strengths .................................................................................................................................................................. 509  Areas for Improvement ........................................................................................................................................ 510  Recommendations ................................................................................................................................................. 510  11.4 MO HealthNet MCHP Compliance with Managed Care Regulations.......................... 511  APPENDICES .................................................................................................................... 531  Appendix 1 – MCHP Orientation PowerPoint Slides ............................................................... 533  Appendix 2 – Performance Improvement Project Worksheets ............................................ 555  Appendix 3 – Performance Measures Request Documents .................................................... 566  Appendix 4 – Performance Improvement Project Request Documents. ............................ 580  Appendix 5 – Performance Measures Worksheets................................................................... 583  Appendix 6 – Encounter Data Minimum Criteria ...................................................................... 589  Appendix 7 – Encounter Data Request Documents ................................................................. 590  Appendix 8 – Medical Record (MR) Request Letters ............................................................... 599  Performance Measures MR Request Letter ........................................................................................ 599  Encounter Data MR Request Letter ..................................................................................................... 600  Appendix 9 – Table of Contents for Medical Record Training Manual ................................ 602  Appendix 10 – Abstraction Tools ................................................................................................. 603  Encounter Data Medical Record Abstraction Tool .......................................................................... 603  Performance Measures Medical Record Abstraction Tool - AWC .............................................. 608  Appendix 11 – Agenda for Site Visits ........................................................................................... 611  Appendix 12 – Site Visit Information Request Letter ............................................................... 613  Appendix 13 – Compliance Review Scoring Form .................................................................... 617  x Performance Management Solutions Group A division of Behavioral Health Concepts, Inc.

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External Quality Review of MO HealthNet Managed Care in Missouri CY 2008 PDF

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Preview External Quality Review of MO HealthNet Managed Care in Missouri CY 2008

2008 MO HealthNet Managed Care Program External Quality Review Amy McCurry Schwartz, Esq., MHSA, EQRO Project Director Mona Prater, MPA, EQRO Assistant Project Director Stephani Worts, MBA, EQRO Research Analyst Contract Number: C301154801, Amendment 007 Review Period: January 1, 2008 to December 31, 2008 Draft Submitted on: October 1, 2009 Final Copy Submitted on: December 1, 2009 Submitted by: Behavioral Health Concepts, Inc. Performance Management Solutions Group Prepared and Submitted by: The Performance Management Solutions Group Is a division of Behavioral Health Concepts, Inc. 2716 Forum Blvd, Suite 4 Columbia, MO 65203 (573) 446-0405 :Local Ph. (866) 463-6242 :Toll-free Ph. (573) 446-1816 :Fax http://www.PMSGinfo.com http://www.BHCinfo.com Email: [email protected] TABLE OF CONTENTS LIST OF ACRONYMS .................................................................................................... XI  GLOSSARY AND OPERATIONAL DEFINITIONS .......................................... XIV  LIST OF TABLES ........................................................................................................ XVII  LIST OF FIGURES ........................................................................................................X XI  1.0 EXECUTIVE SUMMARY ....................................................................................... 23  I.1 Introduction .................................................................................................................................... 25  1.2 Preparation for the 2008 External Quality Review .............................................................. 27  Preparation with the State Medicaid Agency ......................................................................................... 27  Preparation of MO HealthNet Managed Care Health Plans .............................................................. 27  Development of Worksheets, Tools, and Rating Criteria ................................................................. 28  1.3 Validation of Performance Improvement Projects ................................................................ 30  Conclusion ..................................................................................................................................................... 34  1.4 Validation of Performance Measures ....................................................................................... 35  Quality of Care ............................................................................................................................................. 35  Access to Care ............................................................................................................................................. 38  Timeliness of Care ....................................................................................................................................... 40  1.5 Encounter Data Validation ......................................................................................................... 42  Strengths ......................................................................................................................................................... 45  Areas for Improvement .............................................................................................................................. 45  1.6 MO HealthNet MCHP Compliance with Managed Care Regulations .............................. 46  Quality of Care ............................................................................................................................................. 47  Access to Care ............................................................................................................................................. 48  Timeliness of Care ....................................................................................................................................... 49  Conclusion ..................................................................................................................................................... 50  1.7 MO HealthNet Managed Care Health Plan Best Practices .............................................. 51  2.0 VALIDATION OF PERFORMANCE IMPROVEMENT PROJECTS (PIPS) ................................................................................................................................... 61  2.1 Definition ........................................................................................................................................ 63  Analysis of the Statewide PIP .................................................................................................................... 77  History ....................................................................................................................................................................... 77  Findings ...................................................................................................................................................................... 77  Conclusion ................................................................................................................................................................ 79  3.0 VALIDATION OF PERFORMANCE MEASURES ......................................... 87  3.1 Definition ........................................................................................................................................ 89  iii Performance Management Solutions Group A division of Behavioral Health Concepts, Inc. 3.2 Purpose and Objectives .............................................................................................................. 89  Reviewers ....................................................................................................................................................... 89  3.3 Technical Methods ....................................................................................................................... 90  HEDIS 2008 Adolescent Well-Care Visits (AWC) .............................................................................. 91  HEDIS 2008 Use of Appropriate Medications for People With Asthma (ASM)........................... 94  HEDIS 2008 Annual Dental Visit (ADV) ................................................................................................. 98  Methods of Calculating Performance Measures ................................................................................ 100  Time Frame ................................................................................................................................................. 101  Procedures for Data Collection ............................................................................................................ 101  3.4 Findings ......................................................................................................................................... 113  HEDIS 2008 Annual Dental Visit ........................................................................................................... 115  HEDIS 2008 Adolescent Well-Care Visits .......................................................................................... 127  HEDIS 2008 Use of Appropriate Medications for People With Asthma .................................... 148  3.5 Conclusions .................................................................................................................................. 163  Quality of Care .......................................................................................................................................... 163  Access to Care .......................................................................................................................................... 164  Timeliness of Care .................................................................................................................................... 165  Recommendations ..................................................................................................................................... 165  4.0 VALIDATION OF ENCOUNTER DATA ...................................................... 167  4.1 Definition ...................................................................................................................................... 169  4.2 Purpose and Objectives ............................................................................................................ 169  4.3 Technical Methods ..................................................................................................................... 171  Time Frame ................................................................................................................................................. 171  Procedures for Data Collection ............................................................................................................ 171  Analyses ....................................................................................................................................................... 172  4.4 Findings ......................................................................................................................................... 174  4.5 Conclusions .................................................................................................................................. 202  Strengths ...................................................................................................................................................... 202  Areas for Improvement ........................................................................................................................... 202  Recommendations ..................................................................................................................................... 203  5.0 MO HEALTHNET MCHP COMPLIANCE WITH MANAGED CARE REGULATIONS ........................................................................................................... 205  5.1 Purpose and Objectives ............................................................................................................ 207  iv Performance Management Solutions Group A division of Behavioral Health Concepts, Inc. 5.2 Technical Methods ..................................................................................................................... 208  Planning Compliance Monitoring Activities ........................................................................................ 208  Obtaining Background Information from the State Medicaid Agency .......................................... 211  Document Review .................................................................................................................................... 211  Conducting Interviews ............................................................................................................................. 212  Collecting Accessory Information ......................................................................................................... 213  Analyzing and Compiling Findings ......................................................................................................... 213  Reporting to the State Medicaid Agency ............................................................................................. 214  Compliance Ratings .................................................................................................................................. 214  5.3 Findings ......................................................................................................................................... 215  Enrollee Rights and Protections ............................................................................................................ 215  Compliance Interviews – Member Services staff and Case Management (Behavioral Health) 219  Quality Assessment and Performance Improvement: ...................................................................... 221  Access Standards ....................................................................................................................................... 221  Member Service Staff and Case Manager Interviews ........................................................................ 225  Quality Assessment and Performance Improvement: ...................................................................... 225  Structure and Operation Standards ...................................................................................................... 225  Quality Assessment and Performance Improvement: Measurement and Improvement ......... 228  Grievance Systems .................................................................................................................................... 231  5.4 Conclusions .................................................................................................................................. 234  Quality of Care .......................................................................................................................................... 235  Access to Care .......................................................................................................................................... 236  Timeliness of Care .................................................................................................................................... 237  Recommendations ..................................................................................................................................... 238  6.0 BLUE-ADVANTAGE PLUS OF KANSAS CITY .......................................................... 241  6.1 Performance Improvement Projects ...................................................................................... 243  Methods ....................................................................................................................................................... 243  Document Review ................................................................................................................................................. 243  Interviews ................................................................................................................................................................ 243  Findings ........................................................................................................................................................ 244  Conclusions ................................................................................................................................................ 249  Quality of Care ...................................................................................................................................................... 249  Access to Care ....................................................................................................................................................... 250  Timeliness to Care ................................................................................................................................................ 250  Recommendations ................................................................................................................................................. 251  6.2 Validation of Performance Measures ..................................................................................... 252  Methods ....................................................................................................................................................... 252  Document Review ................................................................................................................................................. 252  Interviews ................................................................................................................................................................ 253  v Performance Management Solutions Group A division of Behavioral Health Concepts, Inc. Findings ........................................................................................................................................................ 253  Data Integration and Control ............................................................................................................................. 255  Documentation of Data and Processes ............................................................................................................ 255  Processes Used to Produce Denominators ..................................................................................................... 256  Processes Used to Produce Numerators......................................................................................................... 256  Sampling Procedures for Hybrid Methods ....................................................................................................... 257  Submission of Measures to the State ................................................................................................................ 257  Determination of Validation Findings and Calculation of Bias ..................................................................... 257  Final Audit Rating ................................................................................................................................................... 258  Conclusions ................................................................................................................................................ 258  Quality of Care ...................................................................................................................................................... 258  Access to Care ....................................................................................................................................................... 259  Timeliness of Care ................................................................................................................................................ 260  Recommendations ................................................................................................................................................. 260  6.3 Validation of Encounter Data ................................................................................................... 261  Findings ........................................................................................................................................................ 261  Conclusions ................................................................................................................................................ 266  Strengths .................................................................................................................................................................. 266  Areas for Improvement ........................................................................................................................................ 266  Recommendations ................................................................................................................................................. 266  6.4 MO HealthNet MCHP Compliance with Managed Care Regulations ............................ 267  7.0 CHILDREN’S MERCY FAMILY HEALTH PARTNERS ............................................... 291  7.1 Performance Improvement Projects ...................................................................................... 293  Methods ....................................................................................................................................................... 293  Document Review ................................................................................................................................................. 293  Interviews ................................................................................................................................................................ 293  Findings ........................................................................................................................................................ 294  Conclusions ................................................................................................................................................ 298  Quality of Care ...................................................................................................................................................... 298  Access to Care ....................................................................................................................................................... 298  Timeliness to Care ................................................................................................................................................ 299  Recommendations ................................................................................................................................................. 299  7.2 Validation of Performance Measures ..................................................................................... 300  Methods ....................................................................................................................................................... 300  Document Review ................................................................................................................................................. 300  Interviews ................................................................................................................................................................ 301  Findings ........................................................................................................................................................ 301  Data Integration and Control ............................................................................................................................. 303  Documentation of Data and Processes ............................................................................................................ 304  Processes Used to Produce Denominators ..................................................................................................... 304  Processes Used to Produce Numerators......................................................................................................... 304  Sampling Procedures for Hybrid Methods ....................................................................................................... 305  Submission of Measures to the State ................................................................................................................ 306  Determination of Validation Findings and Calculation of Bias ..................................................................... 306  Final Audit Rating ................................................................................................................................................... 306  Conclusions ................................................................................................................................................ 307  Quality of Care ...................................................................................................................................................... 307  Access to Care ....................................................................................................................................................... 308  Timeliness of Care ................................................................................................................................................ 308  Recommendations ................................................................................................................................................. 309  vi Performance Management Solutions Group A division of Behavioral Health Concepts, Inc. 7.3 Validation of Encounter Data ................................................................................................... 310  Findings ........................................................................................................................................................ 310  Conclusions ................................................................................................................................................ 316  Strengths .................................................................................................................................................................. 316  Areas for Improvement ........................................................................................................................................ 316  Recommendations ................................................................................................................................................. 316  7.4 MO HealthNet MCHP Compliance with Managed Care Regulations ............................ 317  8.0 HARMONY HEALTH PLAN OF MISSOURI ............................................................... 339  8.1 Performance Improvement Projects ...................................................................................... 341  Methods ....................................................................................................................................................... 341  Document Review ................................................................................................................................................. 341  Interviews ................................................................................................................................................................ 341  Findings ........................................................................................................................................................ 342  Conclusions ................................................................................................................................................ 346  Quality of Care ...................................................................................................................................................... 346  Access to Care ....................................................................................................................................................... 346  Timeliness of Care ................................................................................................................................................ 346  Recommendations ................................................................................................................................................. 347  8.2 Validation of Performance Measures ..................................................................................... 348  Methods ....................................................................................................................................................... 348  Document Review ................................................................................................................................................. 348  Interviews ................................................................................................................................................................ 349  Findings ........................................................................................................................................................ 349  Data Integration and Control ............................................................................................................................. 350  Documentation of Data and Processes ............................................................................................................ 350  Processes Used to Produce Denominators ..................................................................................................... 351  Processes Used to Produce Numerators......................................................................................................... 351  Sampling Procedures for Hybrid Methods ....................................................................................................... 352  Submission of Measures to the State ................................................................................................................ 352  Determination of Validation Findings and Calculation of Bias ..................................................................... 352  Final Audit Rating ................................................................................................................................................... 353  Conclusions ................................................................................................................................................ 353  Quality of Care ...................................................................................................................................................... 353  Access to Care ....................................................................................................................................................... 354  Timeliness of Care ................................................................................................................................................ 354  Recommendations ................................................................................................................................................. 355  8.3 Validation of Encounter Data ................................................................................................... 356  Findings ........................................................................................................................................................ 356  Conclusions ................................................................................................................................................ 358  Strengths .................................................................................................................................................................. 358  Areas for Improvement ........................................................................................................................................ 358  Recommendations ................................................................................................................................................. 358  8.4 MO HealthNet MCHP Compliance with Managed Care Regulations ............................ 359  vii Performance Management Solutions Group A division of Behavioral Health Concepts, Inc. 9.0 HEALTHCARE USA ................................................................................................... 381  9.1 Performance Improvement Projects ...................................................................................... 383  Methods ....................................................................................................................................................... 383  Document Review ................................................................................................................................................. 383  Interviews ................................................................................................................................................................ 383  Findings ........................................................................................................................................................ 384  Conclusions ................................................................................................................................................ 388  Quality of Care ...................................................................................................................................................... 388  Access to Care ....................................................................................................................................................... 389  Timeliness of Care ................................................................................................................................................ 389  Recommendations ................................................................................................................................................. 390  9.2 Validation of Performance Measures ..................................................................................... 391  Methods ....................................................................................................................................................... 391  Document Review ................................................................................................................................................. 391  Interviews ................................................................................................................................................................ 392  Findings ........................................................................................................................................................ 392  Data Integration and Control ............................................................................................................................. 394  Documentation of Data and Processes ............................................................................................................ 395  Processes Used to Produce Denominators ..................................................................................................... 395  Processes Used to Produce Numerators......................................................................................................... 396  Sampling Procedures for Hybrid Methods ....................................................................................................... 396  Submission of Measures to the State ................................................................................................................ 396  Determination of Validation Findings and Calculation of Bias ..................................................................... 397  Final Audit Rating ................................................................................................................................................... 397  Conclusions ................................................................................................................................................ 398  Quality of Care ...................................................................................................................................................... 398  Access to Care ....................................................................................................................................................... 398  Timeliness of Care ................................................................................................................................................ 399  Recommendations ................................................................................................................................................. 400  9.3 Validation of Encounter Data ................................................................................................... 401  Findings ........................................................................................................................................................ 401  Conclusions ................................................................................................................................................ 406  Strengths .................................................................................................................................................................. 406  Areas for Improvement ........................................................................................................................................ 407  Recommendations ................................................................................................................................................. 407  9.4 MO HealthNet MCHP Compliance with Managed Care Regulations ............................ 408  10.0 MERCY CAREPLUS .................................................................................................. 433  10.1 Performance Improvement Projects .................................................................................... 435  Methods ....................................................................................................................................................... 435  Document Review ................................................................................................................................................. 435  Findings ........................................................................................................................................................ 436  Conclusions ................................................................................................................................................ 441  Quality of Care ...................................................................................................................................................... 441  Access to Care ....................................................................................................................................................... 441  Timeliness of Care ................................................................................................................................................ 442  Recommendations ................................................................................................................................................. 442  viii Performance Management Solutions Group A division of Behavioral Health Concepts, Inc. 10.2 Validation of Performance Measures ................................................................................... 443  Methods ....................................................................................................................................................... 443  Document Review ................................................................................................................................................. 443  Interviews ................................................................................................................................................................ 444  Findings ........................................................................................................................................................ 444  Data Integration and Control ............................................................................................................................. 446  Documentation of Data and Processes ............................................................................................................ 447  Processes Used to Produce Denominators ..................................................................................................... 447  Processes Used to Produce Numerators......................................................................................................... 448  Sampling Procedures for Hybrid Methods ....................................................................................................... 448  Submission of Measures to the State ................................................................................................................ 449  Determination of Validation Findings and Calculation of Bias ..................................................................... 449  Final Audit Rating ................................................................................................................................................... 449  Conclusions ................................................................................................................................................ 450  Quality of Care ...................................................................................................................................................... 450  Access to Care ....................................................................................................................................................... 450  Timeliness of Care ................................................................................................................................................ 451  Recommendations ................................................................................................................................................. 451  10.3 Validation of Encounter Data ................................................................................................ 452  Findings ........................................................................................................................................................ 452  Conclusions ................................................................................................................................................ 457  Strengths .................................................................................................................................................................. 457  Areas for Improvement ........................................................................................................................................ 457  Recommendations ................................................................................................................................................. 458  10.4 MO HealthNet MCHP Compliance with Managed Care Regulations.......................... 459  11.0 MISSOURI CARE ....................................................................................................... 483  11.1 Performance Improvement Projects .................................................................................... 485  Methods ....................................................................................................................................................... 485  Document Review ................................................................................................................................................. 485  Interviews ................................................................................................................................................................ 485  Findings ........................................................................................................................................................ 486  Conclusions ................................................................................................................................................ 492  Quality of Care ...................................................................................................................................................... 492  Access to Care ....................................................................................................................................................... 492  Timeliness of Care ................................................................................................................................................ 492  Recommendations ................................................................................................................................................. 493  11.2 Validation of Performance Measures ................................................................................... 494  Methods ....................................................................................................................................................... 494  Document Review ................................................................................................................................................. 494  Interviews ................................................................................................................................................................ 495  Findings ........................................................................................................................................................ 495  Data Integration and Control ............................................................................................................................. 497  Documentation of Data and Processes ............................................................................................................ 497  Processes Used to Produce Denominators ..................................................................................................... 497  Processes Used to Produce Numerators......................................................................................................... 498  Sampling Procedures for Hybrid Methods ....................................................................................................... 499  Submission of Measures to the State ................................................................................................................ 499  Determination of Validation Findings and Calculation of Bias ..................................................................... 500  Final Audit Rating ................................................................................................................................................... 500  ix Performance Management Solutions Group A division of Behavioral Health Concepts, Inc. Conclusions ................................................................................................................................................ 501  Quality of Care ...................................................................................................................................................... 501  Access to Care ....................................................................................................................................................... 501  Timeliness of Care ................................................................................................................................................ 502  Recommendations ................................................................................................................................................. 503  11.3 Validation of Encounter Data ................................................................................................ 504  Findings ........................................................................................................................................................ 504  Conclusions ................................................................................................................................................ 509  Strengths .................................................................................................................................................................. 509  Areas for Improvement ........................................................................................................................................ 510  Recommendations ................................................................................................................................................. 510  11.4 MO HealthNet MCHP Compliance with Managed Care Regulations.......................... 511  APPENDICES .................................................................................................................... 531  Appendix 1 – MCHP Orientation PowerPoint Slides ............................................................... 533  Appendix 2 – Performance Improvement Project Worksheets ............................................ 555  Appendix 3 – Performance Measures Request Documents .................................................... 566  Appendix 4 – Performance Improvement Project Request Documents. ............................ 580  Appendix 5 – Performance Measures Worksheets................................................................... 583  Appendix 6 – Encounter Data Minimum Criteria ...................................................................... 589  Appendix 7 – Encounter Data Request Documents ................................................................. 590  Appendix 8 – Medical Record (MR) Request Letters ............................................................... 599  Performance Measures MR Request Letter ........................................................................................ 599  Encounter Data MR Request Letter ..................................................................................................... 600  Appendix 9 – Table of Contents for Medical Record Training Manual ................................ 602  Appendix 10 – Abstraction Tools ................................................................................................. 603  Encounter Data Medical Record Abstraction Tool .......................................................................... 603  Performance Measures Medical Record Abstraction Tool - AWC .............................................. 608  Appendix 11 – Agenda for Site Visits ........................................................................................... 611  Appendix 12 – Site Visit Information Request Letter ............................................................... 613  Appendix 13 – Compliance Review Scoring Form .................................................................... 617  x Performance Management Solutions Group A division of Behavioral Health Concepts, Inc.

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