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MCO External Quality Review Annual Technical Reports

The Code of Federal Regulations (42 CFR §438.350) requires states contracting with Managed Care Organizations (MCOs) to conduct annual, independent reviews of the Medicaid managed care program. To meet these requirements, DHCF contracts with Qlarant, formerly known as Delmarva Foundation for Medical Care, Inc. Qlarant, an independent External Quality Review Organization (EQRO), evaluates the quality, accessibility, and timeliness of healthcare services furnished by the MCOs through a variety of mandatory and optional activities in accordance to the Centers for Medicare and Medicaid Services (CMS)-developed EQRO Protocols.[1] Qlarant completed the following External Quality Review (EQR) activities in 2017:

  • Compliance Review, known as the Operational Systems Review (OSR)
  • Performance Improvement Project (PIP) Review
  • Performance Measure Validation (PMV)
  • Network Adequacy Validation (NAV)

In addition to completing federally mandated EQR activities, 42 CFR §438.364(a) requires the EQRO to produce a detailed technical report that describes the manner in which data from all activities conducted were aggregated and analyzed, and conclusions drawn as to the quality, accessibility, and timeliness of the care furnished by the MCOs. This document is Qlarant’s report to DHCF on the assessment of MCO performance as evaluated during the 2017 measurement year (MY), January 1, 2017 through December 31, 2017.

On October 1, 2017, the District’s new five(5)-year Managed Care program began with the entry of one (1) new MCO, Amerigroup DC and the exit of MedStar Family Choice (MFC), whose contract terminated on September 30, 2017.  For EQR activities completed January 1, 2017 through September 30, 2017, MFC was included in the review activities.  From October 1, 2017 through December 31, 2017, Amerigroup District of Columbia was also included in the review activities.

This Annual Technical Report (ATR) describes EQR methodologies for completing activities; provides MCO performance measure results; summarizes compliance results; and includes an overview of the quality, access, and timeliness of healthcare services provided to the District’s Medicaid managed care beneficiaries. Recommendations for improvement are made, and if acted upon, may positively impact beneficiary outcomes.

MCO External Quality Review Annual Technical Reports