Compliance Monitoring Review

The federal managed care regulations require that a state, or its designee, conduct a review to determine the compliance of managed care organizations (MCOs) and prepaid inpatient health plans (PIHPs) with Medicaid managed care standards and state contracts. Oversight activities must focus on evaluating quality outcomes and the timeliness of, and access to, care and services provided to Medicaid beneficiaries by the MCO/PIHP.

As an external quality review organization (EQRO), HSAG either performs or evaluates the on-site compliance audit process for each contracted state, ensuring that the review process is in alignment with federal regulations. HSAG reviews findings regarding MCOs’ and PIHPs’ compliance with federal managed care regulations and standards, validates findings through review of the MCOs’/PIHPs’ documents and ad hoc interviews, and analyzes and evaluates the degree to which the monitoring protocol is consistent with the Centers for Medicare & Medicaid (CMS) established compliance monitoring protocol.

HSAG is uniquely qualified to conduct on-site reviews of MCOs/PIHPs to evaluate compliance with regulatory and contractual standards, identify opportunities for improvement, and make recommendations for implementing improvements. HSAG staff members have performed on-site quality reviews of Medicaid health plans for more than 25 years in numerous states across the nation. These reviews have been conducted for a variety of delivery system models, and HSAG’s approach takes into account the unique aspects of the state, its contracted health plans, and the types of beneficiaries served. Where plan performance is not at the state-desired levels, HSAG has been instrumental in helping the plans and the states implement and re-evaluate corrective actions and achieve performance improvement.

HSAG’s audit staff members bring a wealth of knowledge, experience, and expertise to each state’s compliance review process, including clinical qualifications and skills in physical and behavioral health and acute as well as long term care; proficiency in applying managed care principles; an understanding of the state Medicaid agency’s role and challenges in monitoring and improving its MCOs and PIHPs; and mastery of data collection and interview processes required to conduct a compliance review. States and the entities HSAG has reviewed consistently acknowledge the skill and professionalism with which HSAG provides feedback on opportunities to improve and guidance on how to make those improvements.