The Code of Federal Regulations (CFR) at 42 CFR 438 requires states that operate prepaid inpatient health plans (PIHPs) and managed care organizations (MCOs) to provide for external quality reviews (EQRs). To meet these obligations, states contract with a qualified external quality review organization (EQRO).
MetaStar’s Medicaid managed care experts design methods to evaluate mandatory and optional review activities identified in The Centers for Medicare & Medicaid External Quality Review Protocols. The software development team creates secure web-based tools to gather results or reviews, providing data and narrative reports to identify strengths and opportunities at the managed care organization and statewide level. Results from reviews are reported in two annual technical reports.
Mandatory Review Activities:
- Protocol 1, Validation of Performance Improvement Projects
- Protocol 2, Validation of Performance Measures
- Protocol 3, Review of Compliance with Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Regulations
Optional Review Activities:
- Protocol 9, Conducting Focus Studies of Healthcare Quality
- Care Management Review (record review)
MetaStar experts design methods to evaluate managed care programs’ performance and quality. MetaStar has expertise in developing mechanisms to collect data for the quality strategy and performance measures during member record reviews, and in preparing and reporting accurate, reliable data. The software development team creates secure web-based tools to gather results or reviews, providing data and narrative reports to identify strengths and opportunities at agency and statewide levels.
Current Medicaid Managed Care Programs MetaStar Evaluates:
- BadgerCare Plus
- Family Care
- Family Care-Partnership
- Program for All-Inclusive Care for the Elderly (PACE)
- Supplemental Security Income (SSI) Managed Care
- Wraparound Milwaukee
MetaStar External Quality Review-Annual Technical Reports
- Family Care, Family Care Partnership, and PACE: External Quality Review Activities
- Quality for BadgerCare Plus and Medicaid SSI
- Obstetric Medical Home Initiative
The Centers for Medicare & Medicaid-External Quality Review Protocols
