Técnicas de procedimiento y análisis de datos

21.1 Financial Performance Measures

Contractor shall provide reports quarterly on trends in utilization for each category of eligibility in a format as directed by the Department. These categories of eligibility trends should include but not necessarily be limited to:

inpatient hospital admissions and days per thousand Member months;

outpatient hospital visits per thousand Member month; emergency room visits per thousand Member months; percent of emergency room visits resulting in admission;

ambulatory surgery / procedures per thousand Member months; hospital readmissions within 30 days per thousand Member months;

PRTF admits and days per thousand;

mental hospital admits and days per thousand;

prescriptions dispensed by major drug class per thousand Member months;

pharmacy cost per Member per month.

In addition a report shall be provided that displays expenditures by category of service by both month of service and month of payment; this report should distinguish between the five major categories of eligibility (i.e. Families and Children, SSI Adults, SSI Children, Foster Care, and Dual Eligibles).

21.2 Monitoring Requirements

The Contractor is responsible for the faithful performance of the contract and shall have internal monitoring procedures and processes in place to ensure compliance. The Contractor shall cooperate with the Department, its agent and/or Contractor in the annual contract monitoring, tracking and/or auditing activity, which may require the Contractor to report progress and problems, provide documents, allow random inspections of its facilities, participate in scheduled meetings and monitoring, respond to requests for corrective action plans and provide reports as requested by the Department. Cooperation in the annual contract monitoring and provision of documents during contract monitoring will be at no additional cost to the Department.

21.3 External Quality Review

Section 1902(a)(30)(c) of Title XIX of the Social Security Act, requires the Commonwealth to acquire an independent external review body for the purpose of performing an annual review of the quality of services provided by an MCO under contract with the Commonwealth, including the evaluation of quality outcomes and timeliness of access to services. Requirements relating to the External Quality Review (EQR) are further defined and described under 42 CFR 433 and 438. The results of EQR are made available, upon request, to specified groups and to interested stakeholders. The Contractor shall provide information to the External Quality Review Organization EQRO as requested to fulfill the requirements of the mandatory and optional activities required in 42 CFR Parts 433 and 438.

The Contractor shall cooperate and participate in EQR activities in accordance with protocols identified under 42 CFR 438, Subpart E. These protocols guide the independent external review of quality outcomes and

In an effort to avoid duplication, the Department may also use, in place of such audit, information obtained about the Contractor from a Medicare or private accreditation review in accordance with 42 CFR 438.360.

21.4 EQR Administrative Reviews

In the event that the Department selects an EQRO, it will obtain an agreement from EQRO to hold and keep all information and materials it reviews from the Contractor as part of such audit with the utmost confidence, and for the EQRO to agree that it will not use such information in any matter whatsoever, including for its own benefit, and that it will not provide comparable services of Contractor in the Service Area for twelve months after this Contractor no longer provides services to the Department in the Service Area, and to further hold the Contractor and the Department harmless for any and all damages for its violation of the agreement, including but not limited to attorneys fees and court costs. The Contractor shall assist the EQRO in completing all Contractor reviews and evaluations in accordance with established protocols previously described. The Contractor shall assist the Department and the EQRO in identification of Provider and Member information required to carry out annual, external independent reviews of the quality outcomes, and timeliness of on-site or off-site medical chart reviews. Timely notification of Providers and subcontractors of any necessary medical chart review shall be the responsibility of the Contractor.

21.5 EQR Performance

If during the conduct of an EQR by an EQRO acting on behalf of the Department, an adverse quality finding or deficiency is identified, the Contractor shall respond to and correct the finding or deficiency in a timely manner in accordance with guidelines established by the Department and EQRO. The Contractor shall:

A. Assign a staff person(s) to conduct follow-up concerning review

findings;

B. Inform the Contractor’s Quality Improvement Committee of the final

findings and involve the committee in the development, implementation and monitoring of the corrective action plan;

C. Submit a corrective action plan in writing to the EQRO and

Department within 60 days that addresses the measures the Contractor intends to take to resolve the finding. The Contractor’s final resolution of all potential quality concerns shall be completed within six (6) months of the Contractor’s notification;

D. The Contractor shall demonstrate how the results of the External

Quality Review (EQR) are incorporated into the Contractor’s overall Quality Improvement Plan and demonstrate progressive and

measurable improvement during the term of this Contract; and

E. If Contractor disagrees with the EQRO’s findings, it shall submit its

position to the Commissioner of the Department whose decision is final.