Medicaid Managed Care Oversight

Partner with IPRO to ensure that your state's Medicaid managed care beneficiaries receive high-quality, efficiently administered care.

State Medicaid managed care programs cover over 57% of the more than 40 million people enrolled in Medicaid, and account for a significant share of total state spending. IPRO's team of experts specializing in Medicaid-funded managed care programs will help you ensure that public dollars are being put to good use.

The IPRO Solution

External Quality Review

IPRO has extensive experience in all mandated and optional activities and can customize programs to meet your state's needs. IPRO coordinates External Quality Review (EQR) activities with Medicaid managed care organizations, managed long term care plans, behavioral health MCOs and SCHIP plans. Our EQR services include:

Validation of performance improvement projects
Automated data collection tools and medical record abstraction and tracking systems
Quality improvement program development and administration
Assessment of MCO administrative processes to ensure compliance with state and federal requirements
Educational programs
Provider and member satisfaction, and access and availability surveys
State level and health plan-specific technical reports
Individual case review
Focused clinical studies

Encounter Data Validation

Reliable encounter data is the basis of quality assessments, HEDIS® rates, risk-adjusted payments, and provider and MCO profiling. IPRO's comprehensive encounter data review and validation program, designed to help states develop reliable and complete encounter data, includes:

Encounter data questionnaires
Assessment of accepted and rejected encounters
On-site review of systems and processes
Comparison of encounters to medical records
Comparison of encounters to transactional data and reports
Encounter data management project reports
Technical assistance

HEDIS Compliance Audits

IPRO has worked as an NCQA-licensed HEDIS organization since the inception of the HEDIS Compliance Audit™ program in 1997, and has performed or overseen more than 1,000 Medicare, Medicaid and commercial HEDIS audits. IPRO's NCQA-certified auditors strive to identify issues and develop solutions that maximize the number of reportable measures and reported rates.

IPRO's auditors are experts in evaluating complex systems, such as: multiple claims, enrollment and provider systems; ensuring the proper integration of data into HEDIS data warehouses; validating plans that have recently undergone merger or acquisition; evaluating source code prepared in multiple languages; and evaluating vendor data. IPRO's HEDIS staff includes registered nurses skilled in medical record abstraction and quality improvement.

The IPRO Advantage

15 years experience in External Quality Review in multiple states
Currently evaluating health care provided to more than 2.5 million Medicaid recipients in 100+ managed care organizations
Conducted numerous studies of Medicaid data accuracy, completeness and quality
Administered several national Medicare encounter data projects
Played a key role in developing the HEDIS Compliance Audit program, including developing the standard Baseline Assessment Tool
Extensive experience working with regional and national plans
NCQA-certified HEDIS auditors skilled in evaluating complex systems

Contact Virginia Hill, RN, MPA, Vice President Managed Care, 516-209-5567 or GHill@ipro.org

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
NCQA HEDIS® Compliance Audits™ is a trademark of the National Committee for Quality Assurance (NCQA).

Since 1983, IPRO has been collaborating with federal, state and local government to improve health outcomes across the continuum of care. IPRO's staff of over 350 health care assessment and quality improvement professionals develop innovative solutions that help our clients optimize the quality of their health care programs and the value of their health care dollars.