Lesson1: Introduction to External Quality Review (EQR)
Listen
Start
Introduction to EQR
Navigating the EQR Training Series
Navigating the EQR Training Series
As you start your training here at Qsource, we want to give you an idea of how to navigate our learning modules. Here are a few helpful tips to get you started. Click on the pointer icon to learn more.
Library of Resources
Introduction to EQR
📚 Library of Resources
Listen
There are several tools and resources we use to complete the activities associated with EQR. As you begin your training, these three resources will be your "go to" references. You might find it helpful to bookmark these links for easy access.
💻
📖
Click for Link
Click for Link
Click for Link
2023 CMS EXTERNAL
QUALITY REVIEW (EQR)
PROTOCOLS
CODE OF FEDERAL REGULATIONS (E-CFR)
CMS GLOSSARY OF TERMS AND ABBREVIATIONS
+INFO
+INFO
+INFO
Introduction to EQR
🎯 Key Definitions
🎯 Key Definitions
Listen
External Quality Review Organization (EQRO)
Managed Care Plan (MCP)
External Quality Review (EQR)
EQR-Related Activities
Click to learn more
Click to learn more
Click to learn more
Click to learn more
+INFO
xterna+INFO
+INFO
+INFO
Introduction to EQR
🎯 Key Definitions and Abbreviations
🎯 Key Definitions and Abbreviations
MCO
PIHP
PAHP
PCCM
Prepaid Ambulatory Health Plans
Managed Care Organizations
Prepaid Inpatient Health Plans
Primary Care Case Management
+INFO
+INFO
+INFO
+INFO
Introduction to EQR
Introduction to EQR
🎯 History of External Quality Review
History of External Quality Review
2010
Subtitle
2009
2003
1997
2017
2012
2016
2019
2023
2021
2020
2018
Click on the timeline to read more about the history of EQR
📖 How EQR Improves Quality Care
Introduction to EQR
How EQR Improves Quality of Care
EQR is one part of a larger approach to improving the quality of care Medicaid and CHIP beneficiaries recieve. These managed care quality tools are interconnected, with each tool working together with one goal...improving patient care.
QSQuality Strategy
EQRExternal Quality Review
QAPIQuality Assessment and Performance Improvement
📖 How EQR Improves Quality Care
Introduction to EQR
How EQR Improves Quality of Care
State delivery and payment reform efforts Directed payment arrangements
Quality Strategy
QSQuality Strategy
State performance on Child and Adult Core Measures
Quality Assessment and Performance Improvement
External Quality Review
Managed Care Quality
EQRExternal Quality Review
QAPIQuality Assessment and Performance Improvement
Quality Rating System
Introduction to EQR
📋 Managed Care State Quality Strategy
📋 Managed Care State Quality Strategy
Each state that delivers health care services through an MCO, PIHP, PAHP, or a PCCM entity must have a Managed Care State Quality Strategy in place. Click on the pointer icon below to learn more.
A state's quality strategy must include certain elements as described in the e-CFR, § 438.340
A state's quality strategy must also describe and define quality elements as described in the e-CFR, § 438.340
Introduction to EQR
🎯 Quality Assessment and Performance Improvement Program (QAPI)
Quality Assessment and Performance Improvement Program (QAPI)
Click on "INFO" to learn more about each QAPI requirement
General Rules for QAPI for EQR- Activities
Basic Elements for QAPI Programs
Performance Measurement
Performance Improvement Projects (PIPs)
ener+INFO
+INFO
+INFO
+INFO
📚 External Quality Review Organization
Introduction to EQR
External Quality Review Organization (EQRO)
States that deliver Medicaid and CHIP services through managed care must contract with at least one EQRO. The EQRO, under contract with a state, conducts the annual EQR and produces the annual EQR technical report.
💻
📖
An EQRO must be experienced and knowledgable of Medcaid and managed care plans
An EQRO must have the skills necessary to conduct EQR-related activities
An EQRO must be independent from the State Medcaid agency and any MCP they review
+INFO
+INFO
+INFO
Introduction to EQR
🎯 External Quality Review
External Quality Review Process
How do all of these elements work together in the external quality review process?
State quality strategies inform managed care goals for quality improvement
Performance measures are then validated during the annual EQR
QAPI programs reflect the goals outlined in the quality strategy
The EQR Technical Report provides guidance for improvements
Introduction to EQR
💻 The EQR Process
The EQR Process
States must publicly post the EQR technical report to their website by 4/30 of each year and to CMS by request
The EQRO summarizes the annual EQR results in an annual tehnical report and submits to the state
An EQRO performs the EQR and/or other EQR-related activities
EQR protocols guide corresponding EQR-related activities
State contracts with an EQRO to perform the EQR
CMS reviews EQR technical reports
States that contract with MCOs, PIHPs, PAHPs, or certain PCCM entities to provide services for all or some of their Medicaid and/or CHIP beneficiaries must follow EQR requirements
📖 EQR-Related Activities
Introduction to EQR
Mandatory EQR-Related Activities
The EQR process includes a series of mandatory and optional EQR-related activities designed to determine the strengths and weaknesses of Medicaid and CHIP MCP performance related to quality, timeliness, and access to care.
Optional EQR-Related Activities
Mandatory EQR-Related Activities
Validate performance improvement projects (PIPs)
Validate performance measures
Review compliance with managed care regulations
Validate network adequacy
📖 EQR-Related Activities
Introduction to EQR
Optional EQR-Related Activities
Validate encounter data reported by MCPs
Calculate additional performance measures
Administer or validate quality of care surveys
Optional EQR-Related Activities
Mandatory EQR-Related Activities
Assist with quality rating of MCPs (reserved)
Conduct additional PIPs
Conduct focus studies of health care quality
Validate performance improvement projects (PIPs)
📖 Application of EQR Activities
Introduction to EQR
Application of EQR Activities
Mandatory and Optional EQR Activities by MCP Type
DatA
EQR Related Activity
MCO
PIHP
PCCM Entity
PAHP
Amazing subtitle here
State Discretion
Validation of Performance Improvement Projects
Required
Required
Required
Required
Required
Required
Required
Validation of Performance Measures
Review of Compliance with Mediciaid MCP Regulations
Required
Required
Required
Required
Validation of Network Adequacy
NA
Required
Required
Required
📖 Application of EQR Activities Cont.
Introduction to EQR
MCP Type
EQR Related Activity
PAHP
PIHP
MCO
PCCM Entity
State Discretion
State Discretion
State Discretion
State Discretion
Validation of Encounter Data Reported by MCP
State Discretion
State Discretion
State Discretion
State Discretion
Validation of Quality of Care Surveys
State Discretion
State Discretion
State Discretion
State Discretion
Calculation of Additional Performance Measures
State Discretion
State Discretion
State Discretion
Implementation of Additional PIPS
State Discretion
State Discretion
State Discretion
State Discretion
Conducting Focus Studies of Health Care Quality
State Discretion
State Discretion
Assist w/Quality Rating of Medicaid/CHIP MCOs, PIHPs and PAHPs
State Discretion
State Discretion
NA
Introduction to EQR
🤔 Knowledge Check
Knowledge Check
🤔 Knowledge Check
Introduction to EQR
Knowledge Check
1/3
📖 Code of Federal Regulations
Introduction to EQR
Code of Federal Regulations
The Code of Federal Regulations (CFR) annual edition is the codification of the general and permanent rules published in the Federal Register by the departments and agencies of the Federal Government. It is divided into 50 titles that represent broad areas subject to Federal regulation. The 50 subject matter titles contain one or more individual volumes, which are updated once each calendar year, on a staggered basis.
CFR Title 42 - Public Health is one of fifty titles comprising the United States Code of Federal Regulations (CFR). Title 42 is the principal set of rules and regulations issued by federal agencies of the United States regarding public health.
📖 Navigating the e-CFR
Introduction to EQR
Navigating the e-CFR
Click Here for a tour of the e-CFR webpage
📖 Title 42: Public Health
Introduction to EQR
Title 42: Public Health
42 CFR § 438 Subpart E for Quality Measurement and Improvement; External Quality Review
Definitions of MCPs, PIHPs, PAHPs, and PCCMs – 42 CFR § 438.2
42 CFR §§ 457.1240 and 1250 for CHIP
Definitions of EQR Activities – 42 CFR § 438.358
Definition of EQRO – 42 CFR § 438.354
Definition of EQR – 42 CFR § 438.320
Click on the pointer icon in each box for links to the CFR reference
🤔 Knowledge Check
Introduction to EQR
Medicaid Managed Care Organizations (MCOs)
Prepaid Inpatient Health Plans (PIHP)
Knowledge Check: According to 42 CFR §438.350-370, managed care plans include the following entities:
Rural Health Clinics
CHIP MCOs
Accountable Care Organizations
Prepaid Ambulatory Health Plans (PAHP)
Primary Care Case Management (PCCM)
Medicare Advantage Plans
📖 HIPAA Compliance
Introduction to EQR
HIPAA Compliance
Whenever we are working with protected health information (PHI), it is important to remember the patient's rights to privacy and confidentiality.
States must ensure that the privacy of patient information is protected in a manner consistent with the Health Insurance Portability and Accountability Act of 1996, or commonly known as HIPAA. The EQR final rule requires that EQR technical reports do not disclose a patient's identity, or any PHI.
🔵 Congratulations!
Introduction to EQR
Congratulations! You have completed Introduction to EQR
If you have any questions about this lesson, please contact your instructor or leave a message in the chat boards. You are now ready to move onto the next lesson, Introduction to EQR Protocols
📩 mhoover@qsource.org 🗓 Michelle Hoover 🌍 Team Trainer for EQRO Divsion
Lesson 1: Introduction to EQR
Michelle Hoover
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Transcript
Lesson1: Introduction to External Quality Review (EQR)
Listen
Start
Introduction to EQR
Navigating the EQR Training Series
Navigating the EQR Training Series
As you start your training here at Qsource, we want to give you an idea of how to navigate our learning modules. Here are a few helpful tips to get you started. Click on the pointer icon to learn more.
Library of Resources
Introduction to EQR
📚 Library of Resources
Listen
There are several tools and resources we use to complete the activities associated with EQR. As you begin your training, these three resources will be your "go to" references. You might find it helpful to bookmark these links for easy access.
💻
📖
Click for Link
Click for Link
Click for Link
2023 CMS EXTERNAL QUALITY REVIEW (EQR) PROTOCOLS
CODE OF FEDERAL REGULATIONS (E-CFR)
CMS GLOSSARY OF TERMS AND ABBREVIATIONS
+INFO
+INFO
+INFO
Introduction to EQR
🎯 Key Definitions
🎯 Key Definitions
Listen
External Quality Review Organization (EQRO)
Managed Care Plan (MCP)
External Quality Review (EQR)
EQR-Related Activities
Click to learn more
Click to learn more
Click to learn more
Click to learn more
+INFO
xterna+INFO
+INFO
+INFO
Introduction to EQR
🎯 Key Definitions and Abbreviations
🎯 Key Definitions and Abbreviations
MCO
PIHP
PAHP
PCCM
Prepaid Ambulatory Health Plans
Managed Care Organizations
Prepaid Inpatient Health Plans
Primary Care Case Management
+INFO
+INFO
+INFO
+INFO
Introduction to EQR
Introduction to EQR
🎯 History of External Quality Review
History of External Quality Review
2010
Subtitle
2009
2003
1997
2017
2012
2016
2019
2023
2021
2020
2018
Click on the timeline to read more about the history of EQR
📖 How EQR Improves Quality Care
Introduction to EQR
How EQR Improves Quality of Care
EQR is one part of a larger approach to improving the quality of care Medicaid and CHIP beneficiaries recieve. These managed care quality tools are interconnected, with each tool working together with one goal...improving patient care.
QSQuality Strategy
EQRExternal Quality Review
QAPIQuality Assessment and Performance Improvement
📖 How EQR Improves Quality Care
Introduction to EQR
How EQR Improves Quality of Care
State delivery and payment reform efforts Directed payment arrangements
Quality Strategy
QSQuality Strategy
State performance on Child and Adult Core Measures
Quality Assessment and Performance Improvement
External Quality Review
Managed Care Quality
EQRExternal Quality Review
QAPIQuality Assessment and Performance Improvement
Quality Rating System
Introduction to EQR
📋 Managed Care State Quality Strategy
📋 Managed Care State Quality Strategy
Each state that delivers health care services through an MCO, PIHP, PAHP, or a PCCM entity must have a Managed Care State Quality Strategy in place. Click on the pointer icon below to learn more.
A state's quality strategy must include certain elements as described in the e-CFR, § 438.340
A state's quality strategy must also describe and define quality elements as described in the e-CFR, § 438.340
Introduction to EQR
🎯 Quality Assessment and Performance Improvement Program (QAPI)
Quality Assessment and Performance Improvement Program (QAPI)
Click on "INFO" to learn more about each QAPI requirement
General Rules for QAPI for EQR- Activities
Basic Elements for QAPI Programs
Performance Measurement
Performance Improvement Projects (PIPs)
ener+INFO
+INFO
+INFO
+INFO
📚 External Quality Review Organization
Introduction to EQR
External Quality Review Organization (EQRO)
States that deliver Medicaid and CHIP services through managed care must contract with at least one EQRO. The EQRO, under contract with a state, conducts the annual EQR and produces the annual EQR technical report.
💻
📖
An EQRO must be experienced and knowledgable of Medcaid and managed care plans
An EQRO must have the skills necessary to conduct EQR-related activities
An EQRO must be independent from the State Medcaid agency and any MCP they review
+INFO
+INFO
+INFO
Introduction to EQR
🎯 External Quality Review
External Quality Review Process
How do all of these elements work together in the external quality review process?
State quality strategies inform managed care goals for quality improvement
Performance measures are then validated during the annual EQR
QAPI programs reflect the goals outlined in the quality strategy
The EQR Technical Report provides guidance for improvements
Introduction to EQR
💻 The EQR Process
The EQR Process
States must publicly post the EQR technical report to their website by 4/30 of each year and to CMS by request
The EQRO summarizes the annual EQR results in an annual tehnical report and submits to the state
An EQRO performs the EQR and/or other EQR-related activities
EQR protocols guide corresponding EQR-related activities
State contracts with an EQRO to perform the EQR
CMS reviews EQR technical reports
States that contract with MCOs, PIHPs, PAHPs, or certain PCCM entities to provide services for all or some of their Medicaid and/or CHIP beneficiaries must follow EQR requirements
📖 EQR-Related Activities
Introduction to EQR
Mandatory EQR-Related Activities
The EQR process includes a series of mandatory and optional EQR-related activities designed to determine the strengths and weaknesses of Medicaid and CHIP MCP performance related to quality, timeliness, and access to care.
Optional EQR-Related Activities
Mandatory EQR-Related Activities
Validate performance improvement projects (PIPs)
Validate performance measures
Review compliance with managed care regulations
Validate network adequacy
📖 EQR-Related Activities
Introduction to EQR
Optional EQR-Related Activities
Validate encounter data reported by MCPs
Calculate additional performance measures
Administer or validate quality of care surveys
Optional EQR-Related Activities
Mandatory EQR-Related Activities
Assist with quality rating of MCPs (reserved)
Conduct additional PIPs
Conduct focus studies of health care quality
Validate performance improvement projects (PIPs)
📖 Application of EQR Activities
Introduction to EQR
Application of EQR Activities
Mandatory and Optional EQR Activities by MCP Type
DatA
EQR Related Activity
MCO
PIHP
PCCM Entity
PAHP
Amazing subtitle here
State Discretion
Validation of Performance Improvement Projects
Required
Required
Required
Required
Required
Required
Required
Validation of Performance Measures
Review of Compliance with Mediciaid MCP Regulations
Required
Required
Required
Required
Validation of Network Adequacy
NA
Required
Required
Required
📖 Application of EQR Activities Cont.
Introduction to EQR
MCP Type
EQR Related Activity
PAHP
PIHP
MCO
PCCM Entity
State Discretion
State Discretion
State Discretion
State Discretion
Validation of Encounter Data Reported by MCP
State Discretion
State Discretion
State Discretion
State Discretion
Validation of Quality of Care Surveys
State Discretion
State Discretion
State Discretion
State Discretion
Calculation of Additional Performance Measures
State Discretion
State Discretion
State Discretion
Implementation of Additional PIPS
State Discretion
State Discretion
State Discretion
State Discretion
Conducting Focus Studies of Health Care Quality
State Discretion
State Discretion
Assist w/Quality Rating of Medicaid/CHIP MCOs, PIHPs and PAHPs
State Discretion
State Discretion
NA
Introduction to EQR
🤔 Knowledge Check
Knowledge Check
🤔 Knowledge Check
Introduction to EQR
Knowledge Check
1/3
📖 Code of Federal Regulations
Introduction to EQR
Code of Federal Regulations
The Code of Federal Regulations (CFR) annual edition is the codification of the general and permanent rules published in the Federal Register by the departments and agencies of the Federal Government. It is divided into 50 titles that represent broad areas subject to Federal regulation. The 50 subject matter titles contain one or more individual volumes, which are updated once each calendar year, on a staggered basis.
CFR Title 42 - Public Health is one of fifty titles comprising the United States Code of Federal Regulations (CFR). Title 42 is the principal set of rules and regulations issued by federal agencies of the United States regarding public health.
📖 Navigating the e-CFR
Introduction to EQR
Navigating the e-CFR
Click Here for a tour of the e-CFR webpage
📖 Title 42: Public Health
Introduction to EQR
Title 42: Public Health
42 CFR § 438 Subpart E for Quality Measurement and Improvement; External Quality Review
Definitions of MCPs, PIHPs, PAHPs, and PCCMs – 42 CFR § 438.2
42 CFR §§ 457.1240 and 1250 for CHIP
Definitions of EQR Activities – 42 CFR § 438.358
Definition of EQRO – 42 CFR § 438.354
Definition of EQR – 42 CFR § 438.320
Click on the pointer icon in each box for links to the CFR reference
🤔 Knowledge Check
Introduction to EQR
Medicaid Managed Care Organizations (MCOs)
Prepaid Inpatient Health Plans (PIHP)
Knowledge Check: According to 42 CFR §438.350-370, managed care plans include the following entities:
Rural Health Clinics
CHIP MCOs
Accountable Care Organizations
Prepaid Ambulatory Health Plans (PAHP)
Primary Care Case Management (PCCM)
Medicare Advantage Plans
📖 HIPAA Compliance
Introduction to EQR
HIPAA Compliance
Whenever we are working with protected health information (PHI), it is important to remember the patient's rights to privacy and confidentiality.
States must ensure that the privacy of patient information is protected in a manner consistent with the Health Insurance Portability and Accountability Act of 1996, or commonly known as HIPAA. The EQR final rule requires that EQR technical reports do not disclose a patient's identity, or any PHI.
🔵 Congratulations!
Introduction to EQR
Congratulations! You have completed Introduction to EQR
If you have any questions about this lesson, please contact your instructor or leave a message in the chat boards. You are now ready to move onto the next lesson, Introduction to EQR Protocols
📩 mhoover@qsource.org 🗓 Michelle Hoover 🌍 Team Trainer for EQRO Divsion