Maryland, District of Columbia, West Virginia
Federal regulations require that states operating Medicaid managed care programs contract with an independent External Quality Review Organization (EQRO) to assess the quality, access and timeliness of health care services provided to Medicaid beneficiaries enrolled in managed care organizations (MCOs).
Mandatory External Quality Review (EQR) Activities
- Review of MCOs to determine compliance with federal and state requirements
- Validation of MCOsā performance measures
- Validation of MCOsā performance improveĀment projects
- Validation of MCOsā network adequacy (new)
- Annual Technical Report on the quality of, access to, and timeliness of healthcare and services for Medicaid enrollees
Optional EQR Activities
- Validation of encounter data
- Validation of consumer surveys
- Calculation of performance measures
- Development of performance measures
- Conduct performance improvement projects
- Conduct focused clinical and non-clinical studies
- Readiness review of new MCOs
EQRO ā Living the Mission
The External Quality Review Team identifies opportunities for improvement and recommends interventions that address barriers and aim to improve performance. For example, based on recommendations provided by the EQR Team, one ND MCO improved compliance in its Well-Child Visits in the 3rd, 4th, 5th and 6th Years of Life perforĀmance measure. Results improved from 34% compliance to 52% complianceāan 18 percentage point improvement.
