External Quality Review Organization (EQRO)

KFMC has held the Kansas EQRO contract since 1995, when the State of Kansas implemented Medicaid Managed Care. EQRO activities focus on quality review and improvement related to access, quality, and timeliness of healthcare. Currently, Social & Rehabilitation Services' (SRS) Disability and Behavioral Health Services, and the Kansas Department of Health and Environment, Division of Health Care Finance (KDHE-DHCF), formerly KHPA, contract with KFMC for EQR services. The work for KDHE-DHCF has entailed external quality review activities related to HealthConnect Kansas (the Medicaid Primary Care Case Management program) and HealthWave (Medicaid and CHIP Managed Care program). The SRS contract includes review of Mental Health and Substance Abuse programs.

The KFMC EQRO team is knowledgeable and experienced in using the CMS protocols to monitor and evaluate MCO and PIHP activities. The EQRO team also has experience in conducting surveys, calculating performance measures and completing focused studies that meet the CMS EQR protocol requirements. The EQRO team strives to meet and exceed the CMS requirements for all EQR activities and reviews, and works with State Medicaid agencies and their stakeholders to provide actionable recommendations geared toward improvement of access, quality and timeliness of care for their consumers.

Performance Improvement Projects (PIPs)

KFMC has reviewed, validated and conducted PIPs, including statewide collaborative PIPs, to assess and improve managed care processes, and thereby outcomes, of care.

Performance Measures

KFMC has conducted, validated and compared health plan performance measures, including both state-defined and industry standard HEDIS measures, designed to measure access to, quality of and timeliness of care provided to healthcare consumers. The KFMC EQRO team is knowledgeable about the NCQA guidelines for calculating and reporting performance measures, and can provide technical assistance to State Medicaid agencies to ensure consistency of measures reported by their managed care plans. KFMC staff have developed data abstraction tools and completed medical record review for calculation of hybrid measures.

Focused Studies

Focused studies, which may be conducted on a one-time basis or on-going basis, help ensure effective quality improvement activities for State Medicaid programs. KFMC has conducted and validated focused studies to enhance State Medicaid program effectiveness.

Data Validation

KFMC staff have broad experience in providing data validation services. KFMC has conducted a variety of data validation projects, including information system capability assessments, encounter data validation, and State system data assessments.

Surveys

The EQRO team has conducted and validated Medicaid consumer and provider surveys. These surveys may use industry standard survey tools, such as CAHPS and MHSIP, or customized survey tools developed through cooperation with State agencies and other stakeholders. KFMC staff have the background and experience needed to validate and test customized survey tools, field surveys, analyze survey data and present survey results to a variety of audiences.

Audits

The EQRO team conducts contractual, compliance and regulatory reviews of MCOs and PIHPs. Audit activities include assessment of quality assurance plans, BBA compliance of managed care organizations, and assessment of Medicaid Waiver programs.

Monitoring MCO and PIHP contract deliverables

KFMC’s EQRO team can assist State Medicaid programs in monitoring the status and timely submission of MCO and PIHP contract deliverables, needed to complete quality assessment and assurance activities.

Technical Assistance and Training

The EQRO team can assist State Medicaid agencies with stakeholder interfaces, including presentations about the CMS EQR requirements, meeting planning and facilitation, and statewide project development.