Case Studies

From multi-year task orders with a team of subcontractors to smaller-scale individual research efforts, L&M has led dozens of research projects from government agencies, as well as private clients.


District of Columbia Health Care Finance (under subcontract to Qlarant Quality Solutions), March 2009 through June 2017

Objective

Assist the District of Columbia’s Department of Health Care Finance (DHCF) in evaluating the quality of care provided to Medicaid recipients enrolled in a managed care organization (MCO) by serving (with Qlarant) as the External Quality Review Organization (EQRO).

Challenges

Because of the number of standards and the short timeframe for conducting the compliance reviews, the project requires a thorough understanding of health care regulations, as well as an efficient, organized, and detail-oriented approach that helped the MCOs prepare the required information for the on-site reviews.

Approach

Prior to the most recent review in 2015, the team assisted with the development of comprehensive guidance for the MCOs, detailing the specific items required to document compliance with Medicaid regulations and DHCF contract standards, in addition to outlining the objectives, timelines, and process for the annual review. The team annually conducts desk and on-site reviews with each MCO operating a Medicaid plan in the District of Columbia, assessing the plans’ compliance with a set of performance standards based on the Centers for Medicare & Medicaid Services (CMS) document, “A Health Care Quality Improvement System (HCQIS) for Medicaid Managed Care,” the Code of Federal Regulations, and DHCF requirements. In its review findings, the team documented the level of compliance for each element and component and provided detailed recommendations to assist DHCF and MCOs in addressing any compliance issues. During the 2015 contract year, in light of a court case around the Early Periodic Screening Diagnosis and Treatment (EPSDT) Program - Salazar Salazar v. District of Columbia, the EQR review focused on validating EPSDT performance measures reported by the MCOs. L&M reviewed medical records and supplemental data provided by MCOs to document their compliance with requirements of the EPSDT Program and to ensure that elements such as blood lead screenings occur. The team provided detailed recommendations to assist DHCF and MCOs in addressing any compliance issues.


Results

Our Team:

  • Improved the transparency of the review process by working with DHCF to identify key objectives for the 2015 review and assisting with the development of written guidance to communicate these objectives to the MCOs.
  • Optimized review efficiency by developing and implementing a pre-site visit survey, standardizing the process for collecting and cataloging plan documentation, and drafting and employing detailed checklists to ensure thorough, consistent, and fair reviews
  • Provided actionable recommendations to assist DHCF and Medicaid MCOs in improving the quality of care for more than 130,000 Medicaid managed care enrollees in the District of Columbia.