Protocol 4:Validation of Network Adequacy
Activities 5 and 6
Start
Protocol 4
Activity 5: Communicate Preliminary Findings to Each MCP
Activity 5: Communicate Preliminary Findings to Each MCP
- In Activity 5, the EQRO shares preliminary network adequacy validation findings with the MCP, and correct omissions and errors if necessary.
- The EQRO will prepare a preliminary report for each MCP.
Protocol 4
Activity 5: Communicate Preliminary Findings to Each MCP
Activity 5: Communicate Preliminary Findings to Each MCP
In the report, the EQRO should:
Provide validation ratings
Document findings
Identify areas of concern
Make suggestions for improvement
Protocol 4
Activity 6: Submit Findings to the State
Activity 6: Submit Findings to the State
- After completing Activities 1 through 5, the EQRO should compile the results for each MCP into the annual EQR Technical Report.
Protocol 4
Activity 6: Submit Findings to the State
Activity 6: Submit Findings to the State
In the annual EQR Technical Report, the EQRO will provide its assessment of each MCP's ability to:
Use sound methods to assess the adequacy of their managed care networks
Produce accurate results to support MCP and state network monitoring efforts
Collect reliable and vaild network adequacy monitoring data
Protocol 4: Activity 3
Step 1: Review the MCP's ISCA
Activity 6: Submit Findings to the State
The EQRO’s technical report to the state should follow the state’s required format, and include the following elements
Element 1
Element 4
Element 5
Element 2
Element 3
Element 6
08
Protocol 4
Review of Protocol 4
Review of Protocol 4
Now that we have discussed the activities that are involved in Protocol 4, let's take a few minutes to review the material we have covered.
Protocol 4
Review of Protocol 4
Review of Protocol 4
To ensure provider networks are sufficient to provide timely and accessible care to Medicaid and CHIP beneficiaries across the continuum of services, states must develop and enforce network adequacy standards.
- To ensure provider networks are sufficient to provide timely and accessible care to Medicaid and CHIP beneficiaries across the continuum of services, states must develop and enforce network adequacy standards.
Protocol 4
Review of Protocol 4
Review of Protocol 4: Quick Facts
Click on the pencil icon for some quick facts about Protocol 4
step 1
#2
#4
#3
#1
Duis autem vel eum iriure dolor in hendrerit in
+info
Protocol 4
Review of Protocol 4
Review of Protocol 4
The state could set different network adequacy standards for urban, rural, and frontier regions of the state.
States must set network adequacy standards for all geographic areas covered by by their MCP contracts
To ensure provider networks are sufficient to provide timely and accessible care to Medicaid and CHIP beneficiaries across the continuum of services, states must develop and enforce network adequacy standards.
These standards may vary by geographic area for the same provider type
Protocol 4
Review of Protocol 4
Review of Protocol 4
States must set quantitative network adequacy standards for provider types covered under their managed care contracts. Some examples include:
Minimum provider-to-enrollee ratios
Maximum wait times for an appointment
These standards may vary by geographic area for the same provider type
Maximum travel time or distance to providers
Hours of operation
Protocol 4
Review of Protocol 4
Review of Protocol 4
Other considerations include:
Protocol 4
Review of Protocol 4
Review of Protocol 4
- Medicaid and CHIP MCPs must conduct various activities to assess the adequacy of their networks and must maintain provider and beneficiary data sets that allow monitoring of network adequacy.
- States can determine the strategies used to assess network adequacy. These strategies will vary based on the quantitative standards set by the state.
Examples:
- Geomapping to determine if provider networks meet time and distance standards
- Calculation provider-to-patient ratios
- Analyzing utilization data to identify gaps in access
- Telephone surveys to validate provider directory information
Protocol 4
Review of Protocol 4
The 1, 2 and 3 of Protocol 4
There are three basic steps for EQROs completing Protocol 4. EQROs are required to:
Examples:
Validate the results submitted by the MCPs and generate a validation rating for each network adequacy indicator
- Geomapping to determine if provider networks meet time and distance standards
- Calculation provider-to-patient ratios
- Analyzing utilization data to identify gaps in access
- Telephone surveys to validate provider directory information
Validate the data and methods that MCPs use to assess the adequacy of their networks.
The EQRO will report the validation findings in the annual EQR technical report
Protocol 4
Review of Protocol 4
Protocol 4 Phases
Protocol 4 consists of three phases:
Reporting
Analysis
Planning
Examples:
- Establish definitions for each network adequacy standard and indicator, considering factors such as how the state defines provider types and how standards vary by region
- Review past EQR network adequacy validation reports to understand prior monitoring and validation approaches
- Ensure the report follows the state’s required format and meets federal requirements
- Identify recommendations from the previous year’s report, and discuss progress made based on information gathered during the validation process
- Compare the MCP’s data from previous years to the most recent data to assess reliability, as major changes could reflect data quality issues
- Assess if the MCP’s definitions and methods for calculating each network adequacy indicator align with the state’s expectations
Protocol 4
Review of Protocol 4
Protocol 4 Phases and Activities
There are six activites in Protocol 4, organized into the three phases:
Examples:
- Activity 3: Review of Information Systems
- Activity 4: Validate Network Adequacy Assessment Data, Methods and Results
- Activity 5: Communicate Preliminary Findings to MCP
- Activity 6: Submit Findings to the State
- Activity 1: Define the Scope of the Validation
- Activity 2: Identify Data Sources for Validation
Reporting
Planning
Analysis
Protocol 4
Review of Protocol 4
Activity 1 : Define the Scope of the Validation
In Activity 1, the EQRO will work with the state to obtain all of the information needed for the validation.
Examples:
Identify methods used by the state and MCPs to monitor network adequacy
Identify the state's network adequacy standards
Reporting
Planning
Establish an approach for network adequacy validation
Protocol 4
Review of Protocol 4
Activity 1: Define the Scope of the Validation
There are four steps for an EQRO to complete to meet the objectives for Activity 1
Examples:
Identify and define network adequacy indicators for validation
Step 2
Step 1
Identify methods used by the state and MCPs to monitor network adequacy
Obtain needed information from the state
Identify the state's network adequacy standards
Establish network adequacy validation activities and timeline
Planning
stablish an approach for network adequacy validation
Step 4
Step 3
Identify and define provider types
Protocol 4
Review of Protocol 4
Activity 1: Define the Scope of the Validation
What is the difference between network adequacy standards and indicators?
Examples:
Network Adequacy Standard
Network Adequacy Indicator
Identify methods used by the state and MCPs to monitor network adequacy
Identify the state's network adequacy standards
Step 1
A quantitative parameter that states establish to set expectations for contracted managed care plans’ provider networks
A metric used to measure adherence to network adequacy standards and to determine plan compliance with state network adequacy standards
Reporting
Planning
Example: All enrollees have access to a primary care provider (PCP) within 30 miles or 30 minutes of their home
Example: The proportion of enrollees who have access to a PCP within 30 miles or 30 minutes of their home
Protocol 4
Review of Protocol 4
Activity 1: Identify Network Adequacy Standards
Examples:
Identify the state's network adequacy standards
Step 1
Planning
Protocol 4
Review of Protocol 4
Activity 1: Identify Network Adequacy Indicators
Examples:
Identify the state's network adequacy standards
Step 1
Planning
Protocol 4
Review of Protocol 4
Protocol 4: Define the Scope of the Validation
Questions to define network adequacy indicators
Questions to define provider types:
Examples:
Identify the state's network adequacy standards
Which provider types does the state consider primary care providers?
Are travel times measured separately for private vehicles, public transit, or other means of transportation?
Step 1
Are there circumstances in which providers who primarily see adult patients count toward network adequacy standards for the pediatric population?
Should distance be measured “as the crow flies” or using driving distances?
Planning
Protocol 4
Review of Protocol 4
Activity 2: Identify Data Sources for Validation
In Activity 2, the EQRO identifies all data sources needed for the network adequacy validation
Examples:
Step 1
Identify data sources
Identify the state's network adequacy standards
Are travel times measured separately for private vehicles, public transit, or other means of transportation?
Step 1
Are there circumstances in which providers who primarily see adult patients count toward network adequacy standards for the pediatric population?
Should distance be measured “as the crow flies” or using driving distances?
Planning
Step 2
Answer additional questions about state sources
Protocol 4
Review of Protocol 4
Activity 2: Identify Data Sources for Validation
Examples of potential data sources
Example questions:
Examples:
Identify the state's network adequacy standards
- Which variables are necessary for network adequacy validation?
- Beneficiary datasets
- Provider datasets
- Does the state set standards for completeness and accuracy of the data
- What challenges could the EQRO encounter in accessing and using the data?
- Beneficiary enrollment files
- Provider network data files/online provider directories
- Claims and encounter data
- Grievance and appeals data
- Survey Data (CAHPS, National Core Indicators)
- Primary data collected by the EQRO by telephone, mail or in-person visit
Step 1
Planning
Protocol 4
Review of Protocol 4
Activity 3: Review Information Systems Underlying Network Adequacy Monitoring
In Activity 3, the EQRO determines if the MCP's information systems are able to collect and report high quality network adequacy data
Examples:
Step 1
Assess processes for collecting data not addressed in the ISCA
Step 2
Review the MCP’s most recently completed ISCA
Identify the state's network adequacy standards
Are travel times measured separately for private vehicles, public transit, or other means of transportation?
Step 1
Are there circumstances in which providers who primarily see adult patients count toward network adequacy standards for the pediatric population?
Should distance be measured “as the crow flies” or using driving distances?
Planning
Step 3
Interview MCP or other personnel to clarify findings
Protocol 4
Review of Protocol 4
Activity 3: ISCA
The ISCA is a mandatory element for the validation of network adequacy
Examples:
- If the MCP has completed an ISCA within the previous two years, the EQRO should review the findings
- If the MCP has not conducted an ISCA within the previous two years, the EQRO must conduct one consistent with the processes discussed in Appendix A of the EQR protocols
Identify the state's network adequacy standards
Are travel times measured separately for private vehicles, public transit, or other means of transportation?
Step 1
Are there circumstances in which providers who primarily see adult patients count toward network adequacy standards for the pediatric population?
Should distance be measured “as the crow flies” or using driving distances?
Planning
Step 1
Protocol 4
Review of Protocol 4
Activity 4: Validate Network Adequacy Assessment Data, Methods, and Results
In Activity 4, the EQRO will validate the MCP's assessment of its network adequacy
Examples:
Step 1
Assess the reliability and validity of MCP network adequacy data
Assess the methods used by the MCP to assess network adequacy
Step 2
Identify the state's network adequacy standards
Are travel times measured separately for private vehicles, public transit, or other means of transportation?
Step 1
Are there circumstances in which providers who primarily see adult patients count toward network adequacy standards for the pediatric population?
Should distance be measured “as the crow flies” or using driving distances?
Planning
Step 3
Step 4
Validate network adequacy results submitted by the MCP
Summarize network adequacy validation findings
Protocol 4
Review of Protocol 4
Activity 4: Validate Network Adequacy Assessment Data, Methods, and Results
Examples:
High confidence
The EQRO summarizes all validation findings, and gives the MCP a validation rating and comments for each network adequacy indicator
Step 1
Moderate confidence
Low confidence
No confidence
Planning
Step 1
Could not be validated
Protocol 4
Review of Protocol 4
Activity 5: Communicate Preliminary Findings to Each MCP
In Activity 5, the EQRO shares preliminary network adequacy validation findings with each MCP. The EQRO should prepare a preliminary validation report for each MCP. The report should:
Examples:
Step 1
Document the EQRO's findings
Make suggestions for improvement
Provide validation ratings
Identify areas of concern
Planning
Step 1
Protocol 4
Review of Protocol 4
Activity 5: Communicate Preliminary Findings to Each MCP
Examples:
The MCP may provide documentation to correct errors and omissions in the preliminary report. As needed, the EQRO may discuss the documentation with each MCP.
Step 1
Planning
Step 1
Protocol 4
Review of Protocol 4
Activity 6: Submit Findings to the State
In Activity 6, the EQRO will compile the results for each MCP into the annual EQR Technical Report. In the report, the EQRO will assess each MCP's ability to:
Examples:
Step 1
Produce accurate results to support MCP and state network adequacy efforts
Use sound methods to assess the adequacy of its managed care networks
Collect reliable and valid network adequacy monitoring data
Planning
Step 1
Protocol 4
Review of Protocol 4
Activity 6: Submit Findings to the State
A list of the data and documentation validated by the EQRO
The EQRO's technical report to the state should include:
A description of the state’s network adequacy standards, and the network adequacy indicators that were validated for each MCP
Worksheets, tools, and other supporting documentation
Examples:
Step 1
Recommendations for improving the reliability and validity of each MCP’s process for monitoring network adequacy
Analyses and conclusions for each network adequacy validation activity for each MCP
Findings on the MCP’s information systems capabilities and data integration
A description of the EQRO’s validation activities
"Diam nonummy nibh euismod tincidunt ut laoreet dolore"
Planning
Step 1
Knowledge Check
Knowledge Check
Knowledge Check
Knowledge Check
Knowledge Check
Knowledge Check
Protocol 4
Congratulations!
Congratulations!
You have completed Protocol 4!
- Now you are ready to proceed to
Protocol 5: Validation of Encounter Data Reported by the Medicaid and CHIP Managed Care Plan.
- If you have any questions or comments about this lesson please reach out to your Program Manager, Course Instructor or leave a message in the Chat Boards.
📌 Course Instructor: Michelle Hoover
📌 email: mhoover@qsource.org
Protocol 4: Validation of Network Adequacy Activities 5 and 6
Michelle Hoover
Created on April 28, 2023
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Transcript
Protocol 4:Validation of Network Adequacy
Activities 5 and 6
Start
Protocol 4
Activity 5: Communicate Preliminary Findings to Each MCP
Activity 5: Communicate Preliminary Findings to Each MCP
Protocol 4
Activity 5: Communicate Preliminary Findings to Each MCP
Activity 5: Communicate Preliminary Findings to Each MCP
In the report, the EQRO should:
Provide validation ratings
Document findings
Identify areas of concern
Make suggestions for improvement
Protocol 4
Activity 6: Submit Findings to the State
Activity 6: Submit Findings to the State
Protocol 4
Activity 6: Submit Findings to the State
Activity 6: Submit Findings to the State
In the annual EQR Technical Report, the EQRO will provide its assessment of each MCP's ability to:
Use sound methods to assess the adequacy of their managed care networks
Produce accurate results to support MCP and state network monitoring efforts
Collect reliable and vaild network adequacy monitoring data
Protocol 4: Activity 3
Step 1: Review the MCP's ISCA
Activity 6: Submit Findings to the State
The EQRO’s technical report to the state should follow the state’s required format, and include the following elements
Element 1
Element 4
Element 5
Element 2
Element 3
Element 6
08
Protocol 4
Review of Protocol 4
Review of Protocol 4
Now that we have discussed the activities that are involved in Protocol 4, let's take a few minutes to review the material we have covered.
Protocol 4
Review of Protocol 4
Review of Protocol 4
To ensure provider networks are sufficient to provide timely and accessible care to Medicaid and CHIP beneficiaries across the continuum of services, states must develop and enforce network adequacy standards.
Protocol 4
Review of Protocol 4
Review of Protocol 4: Quick Facts
Click on the pencil icon for some quick facts about Protocol 4
step 1
#2
#4
#3
#1
Duis autem vel eum iriure dolor in hendrerit in
+info
Protocol 4
Review of Protocol 4
Review of Protocol 4
The state could set different network adequacy standards for urban, rural, and frontier regions of the state.
States must set network adequacy standards for all geographic areas covered by by their MCP contracts
To ensure provider networks are sufficient to provide timely and accessible care to Medicaid and CHIP beneficiaries across the continuum of services, states must develop and enforce network adequacy standards.
These standards may vary by geographic area for the same provider type
Protocol 4
Review of Protocol 4
Review of Protocol 4
States must set quantitative network adequacy standards for provider types covered under their managed care contracts. Some examples include:
Minimum provider-to-enrollee ratios
Maximum wait times for an appointment
These standards may vary by geographic area for the same provider type
Maximum travel time or distance to providers
Hours of operation
Protocol 4
Review of Protocol 4
Review of Protocol 4
Other considerations include:
Protocol 4
Review of Protocol 4
Review of Protocol 4
Examples:
Protocol 4
Review of Protocol 4
The 1, 2 and 3 of Protocol 4
There are three basic steps for EQROs completing Protocol 4. EQROs are required to:
Examples:
Validate the results submitted by the MCPs and generate a validation rating for each network adequacy indicator
Validate the data and methods that MCPs use to assess the adequacy of their networks.
The EQRO will report the validation findings in the annual EQR technical report
Protocol 4
Review of Protocol 4
Protocol 4 Phases
Protocol 4 consists of three phases:
Reporting
Analysis
Planning
Examples:
Protocol 4
Review of Protocol 4
Protocol 4 Phases and Activities
There are six activites in Protocol 4, organized into the three phases:
Examples:
Reporting
Planning
Analysis
Protocol 4
Review of Protocol 4
Activity 1 : Define the Scope of the Validation
In Activity 1, the EQRO will work with the state to obtain all of the information needed for the validation.
Examples:
Identify methods used by the state and MCPs to monitor network adequacy
Identify the state's network adequacy standards
Reporting
Planning
Establish an approach for network adequacy validation
Protocol 4
Review of Protocol 4
Activity 1: Define the Scope of the Validation
There are four steps for an EQRO to complete to meet the objectives for Activity 1
Examples:
Identify and define network adequacy indicators for validation
Step 2
Step 1
Identify methods used by the state and MCPs to monitor network adequacy
Obtain needed information from the state
Identify the state's network adequacy standards
Establish network adequacy validation activities and timeline
Planning
stablish an approach for network adequacy validation
Step 4
Step 3
Identify and define provider types
Protocol 4
Review of Protocol 4
Activity 1: Define the Scope of the Validation
What is the difference between network adequacy standards and indicators?
Examples:
Network Adequacy Standard
Network Adequacy Indicator
Identify methods used by the state and MCPs to monitor network adequacy
Identify the state's network adequacy standards
Step 1
A quantitative parameter that states establish to set expectations for contracted managed care plans’ provider networks
A metric used to measure adherence to network adequacy standards and to determine plan compliance with state network adequacy standards
Reporting
Planning
Example: All enrollees have access to a primary care provider (PCP) within 30 miles or 30 minutes of their home
Example: The proportion of enrollees who have access to a PCP within 30 miles or 30 minutes of their home
Protocol 4
Review of Protocol 4
Activity 1: Identify Network Adequacy Standards
Examples:
Identify the state's network adequacy standards
Step 1
Planning
Protocol 4
Review of Protocol 4
Activity 1: Identify Network Adequacy Indicators
Examples:
Identify the state's network adequacy standards
Step 1
Planning
Protocol 4
Review of Protocol 4
Protocol 4: Define the Scope of the Validation
Questions to define network adequacy indicators
Questions to define provider types:
Examples:
Identify the state's network adequacy standards
Which provider types does the state consider primary care providers?
Are travel times measured separately for private vehicles, public transit, or other means of transportation?
Step 1
Are there circumstances in which providers who primarily see adult patients count toward network adequacy standards for the pediatric population?
Should distance be measured “as the crow flies” or using driving distances?
Planning
Protocol 4
Review of Protocol 4
Activity 2: Identify Data Sources for Validation
In Activity 2, the EQRO identifies all data sources needed for the network adequacy validation
Examples:
Step 1
Identify data sources
Identify the state's network adequacy standards
Are travel times measured separately for private vehicles, public transit, or other means of transportation?
Step 1
Are there circumstances in which providers who primarily see adult patients count toward network adequacy standards for the pediatric population?
Should distance be measured “as the crow flies” or using driving distances?
Planning
Step 2
Answer additional questions about state sources
Protocol 4
Review of Protocol 4
Activity 2: Identify Data Sources for Validation
Examples of potential data sources
Example questions:
Examples:
Identify the state's network adequacy standards
Step 1
Planning
Protocol 4
Review of Protocol 4
Activity 3: Review Information Systems Underlying Network Adequacy Monitoring
In Activity 3, the EQRO determines if the MCP's information systems are able to collect and report high quality network adequacy data
Examples:
Step 1
Assess processes for collecting data not addressed in the ISCA
Step 2
Review the MCP’s most recently completed ISCA
Identify the state's network adequacy standards
Are travel times measured separately for private vehicles, public transit, or other means of transportation?
Step 1
Are there circumstances in which providers who primarily see adult patients count toward network adequacy standards for the pediatric population?
Should distance be measured “as the crow flies” or using driving distances?
Planning
Step 3
Interview MCP or other personnel to clarify findings
Protocol 4
Review of Protocol 4
Activity 3: ISCA
The ISCA is a mandatory element for the validation of network adequacy
Examples:
Identify the state's network adequacy standards
Are travel times measured separately for private vehicles, public transit, or other means of transportation?
Step 1
Are there circumstances in which providers who primarily see adult patients count toward network adequacy standards for the pediatric population?
Should distance be measured “as the crow flies” or using driving distances?
Planning
Step 1
Protocol 4
Review of Protocol 4
Activity 4: Validate Network Adequacy Assessment Data, Methods, and Results
In Activity 4, the EQRO will validate the MCP's assessment of its network adequacy
Examples:
Step 1
Assess the reliability and validity of MCP network adequacy data
Assess the methods used by the MCP to assess network adequacy
Step 2
Identify the state's network adequacy standards
Are travel times measured separately for private vehicles, public transit, or other means of transportation?
Step 1
Are there circumstances in which providers who primarily see adult patients count toward network adequacy standards for the pediatric population?
Should distance be measured “as the crow flies” or using driving distances?
Planning
Step 3
Step 4
Validate network adequacy results submitted by the MCP
Summarize network adequacy validation findings
Protocol 4
Review of Protocol 4
Activity 4: Validate Network Adequacy Assessment Data, Methods, and Results
Examples:
High confidence
The EQRO summarizes all validation findings, and gives the MCP a validation rating and comments for each network adequacy indicator
Step 1
Moderate confidence
Low confidence
No confidence
Planning
Step 1
Could not be validated
Protocol 4
Review of Protocol 4
Activity 5: Communicate Preliminary Findings to Each MCP
In Activity 5, the EQRO shares preliminary network adequacy validation findings with each MCP. The EQRO should prepare a preliminary validation report for each MCP. The report should:
Examples:
Step 1
Document the EQRO's findings
Make suggestions for improvement
Provide validation ratings
Identify areas of concern
Planning
Step 1
Protocol 4
Review of Protocol 4
Activity 5: Communicate Preliminary Findings to Each MCP
Examples:
The MCP may provide documentation to correct errors and omissions in the preliminary report. As needed, the EQRO may discuss the documentation with each MCP.
Step 1
Planning
Step 1
Protocol 4
Review of Protocol 4
Activity 6: Submit Findings to the State
In Activity 6, the EQRO will compile the results for each MCP into the annual EQR Technical Report. In the report, the EQRO will assess each MCP's ability to:
Examples:
Step 1
Produce accurate results to support MCP and state network adequacy efforts
Use sound methods to assess the adequacy of its managed care networks
Collect reliable and valid network adequacy monitoring data
Planning
Step 1
Protocol 4
Review of Protocol 4
Activity 6: Submit Findings to the State
A list of the data and documentation validated by the EQRO
The EQRO's technical report to the state should include:
A description of the state’s network adequacy standards, and the network adequacy indicators that were validated for each MCP
Worksheets, tools, and other supporting documentation
Examples:
Step 1
Recommendations for improving the reliability and validity of each MCP’s process for monitoring network adequacy
Analyses and conclusions for each network adequacy validation activity for each MCP
Findings on the MCP’s information systems capabilities and data integration
A description of the EQRO’s validation activities
"Diam nonummy nibh euismod tincidunt ut laoreet dolore"
Planning
Step 1
Knowledge Check
Knowledge Check
Knowledge Check
Knowledge Check
Knowledge Check
Knowledge Check
Protocol 4
Congratulations!
Congratulations!
You have completed Protocol 4!
- Now you are ready to proceed to
Protocol 5: Validation of Encounter Data Reported by the Medicaid and CHIP Managed Care Plan.📌 Course Instructor: Michelle Hoover
📌 email: mhoover@qsource.org