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Programs

Medicaid External Quality Review

HSAG is the largest External Quality Review Organization (EQRO) in the nation and provides quality review services for states that operate Medicaid managed care programs and fee-for-service programs.

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OVERVIEW

External Quality Review for All Managed Care Types

As an EQRO, HSAG evaluates managed care organizations (MCOs), prepaid inpatient health plans (PIHPs), prepaid ambulatory health plans (PAHPs), and primary care case management (PCCM) programs as required by the code of federal regulations 42 CFR Part 438, Subpart E, and aggregates information on the timeliness, access, and quality of healthcare services furnished to Medicaid enrollees.

The EQR process currently consists of four mandatory activities and seven optional activities, in addition to producing an annual EQR technical report and providing technical assistance, as needed. HSAG follows the corresponding EQR protocol when performing each EQR activity.

By the Numbers

Our Impact

19

states officially designate HSAG as an EQRO

44000000

Medicaid recipients affected by HSAG’s quality review services

Why HSAG?

HSAG develops a customized EQR strategy for each state that is designed to achieve the state’s specific quality goals and objectives.

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This customized approach has proven effective in helping HSAG’s customers achieve higher quality services in their managed care programs. HSAG can provide quality review technical assistance to states that do not operate managed care programs but wish to monitor the healthcare delivery and health outcomes of the population served in the Medicaid program.

Unparalleled Expertise

HSAG is the only EQRO that is also a National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS®) Certified Survey Vendor and NCQA Licensed Organization with the capability of conducting certified HEDIS®1 Compliance Audits™2.

Experienced Professionals

HSAG staffs its contracts with highly skilled and credentialed professionals, such as Certified HEDIS Compliance Auditors (CHCAs), Certified Professionals in Healthcare Quality (CPHQs), registered nurses, master’s-prepared social workers, statisticians, biostatisticians, and epidemiologists.

Technical Guidance

HSAG has extensive experience working with states that are implementing Medicaid managed care programs for the first time in their state (Arizona, California, Colorado, Florida, Hawaii, Iowa, Nevada, and New Hampshire). HSAG provides technical guidance on each EQR activity so the state may effectively meet its federal EQR requirements.

Impactful Reporting

HSAG has the capacity to compare a large volume of data and create customized reports that assist states in monitoring their Medicaid programs. HSAG’s customized reporting for each state enables the state to use its EQR reports to make data-driven decisions about its program.

Innovative Solutions

HSAG has proven success in developing and implementing innovative electronic tools and websites for states to use. In some states, HSAG has become an extension of the state’s data staff members, providing accurate and timely training, support, and helpdesk service for all hours of business.

Program Activities

Mandatory EQR Activities

  • Performance Improvement Projects (PIPs)
  • Performance Measure Validation
  • Compliance Monitoring Review
  • Validation of Network Adequacy

Optional EQR Activities

  • Encounter Data Validation
  • Consumer or Provider Survey Administration/Validation
  • Performance Measures Calculation
  • PIP Facilitation
  • Focused Studies
  • Quality Rating System Assistance
  • Evaluate in lieu of services (ILOS), state quality strategies, and state-directed payments

Areas we serve

HSAG currently serves as the EQRO in 19 states:

 

Arizona

California

Colorado

Florida

Georgia

Hawaii

Illinois

Iowa

Louisiana

Michigan

Nebraska

Nevada

New Hampshire

North Carolina

Oregon

Tennessee

Utah

Vermont

Virginia

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