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  • External Quality Review of Indiana’s

    Hoosier Healthwise Program and

    Healthy Indiana Plan for the

    Review Year Calendar 2013

    3030 North Third Street, Suite 200 Phoenix, AZ 85012 (602) 241-8520 www.burnshealthpolicy.com

  • FINAL REPORT 2014 External Quality Review of Indiana’s Hoosier Healthwise Program and Healthy Indiana Plan 

    Burns & Associates, Inc. April 30, 2015  

    ACKNOWLEDGMENTS

    The CY 2014 External Quality Review Team included the following individuals who served as reviewers and/or report contributors:

    Burns & Associates Staff Mark Podrazik, Principal

    Brian Kehoe, Senior Consultant Rachel Chappell, Senior Consultant James Maedke, SAS Programmer

    Barry Smith, Analyst

    Additional Staff Linda Gunn, Ph.D., Subcontractor, A.G.S. Consulting, Inc.

    Kristy Lawrance, Subcontractor, Lawrance Policy Consulting

    Burns & Associates, Inc. would like to thank the staff at Anthem, MDwise and Managed Health Services for their assistance in providing documentation and assistance in planning for the onsite portion of this review. We would also like to thank Vickie Trout at the Office of Medicaid Policy and Planning for her assistance during the course of this study.

    This report is available at our website at

    www.burnshealthpolicy.com

    Inquiries may be sent to mpodrazik@burnshealthpolicy.com

    3030 NORTH THIRD STREET, SUITE 200 PHOENIX, AZ 85012 (602) 241-8520

  • FINAL REPORT 2014 External Quality Review of Indiana’s Hoosier Healthwise Program and Healthy Indiana Plan 

    Burns & Associates, Inc. April 30, 2015  

    TABLE OF CONTENTS

    Abbreviations List Executive Summary Section I: Overview of Indiana’s Medicaid Managed Care Programs Introduction ....................................................................................................................................I-1 MCEs Contracted in the Hoosier Healthwise Program and Healthy Indiana Plan ........................I-3 Benefit Package .............................................................................................................................I-5 Section II: Approach to this Year’s External Quality Review Background .................................................................................................................................. II-1 EQR Activities in CY 2014 ......................................................................................................... II-2 The EQR Review Team ............................................................................................................... II-3 Section III: Validation of Performance Measures Introduction ................................................................................................................................. III-1 Activity 1: Pre-Onsite Visit Activities ........................................................................................ III-1 Activity 2: Onsite Visit Activities ............................................................................................... III-2 Activity 3: Post-Onsite Visit Activities ...................................................................................... III-3 Recommendations to the MCEs and the OMPP Related to Validation of Performance Measures ......................................................................................................... III-11 Section IV: Validation of Performance Improvement Projects Introduction ................................................................................................................................. IV-1 Development of the New QIP Report ......................................................................................... IV-2 Review of Performance Improvement Projects .......................................................................... IV-4 Anthem QIP Findings ................................................................................................................. IV-5 MHS QIP Findings ................................................................................................................... IV-10 MDwise QIP Findings .............................................................................................................. IV-13 Recommendations to the MCEs and the OMPP Related to Validation of Quality Improvement Projects .............................................................................................. IV-16 Section V: Focus Study on Non-Emergency Medical Transportation Introduction .................................................................................................................................. V-1 Indiana’s NEMT Benefit Compared to Neighboring States ........................................................ V-1 MCE Oversight of Transportation Vendors ................................................................................. V-2 NEMT Utilization Trends ............................................................................................................ V-5 Recommendations to the MCEs and the OMPP Related to NEMT ........................................... V-15 Section VI: Focus Study on New Member Activities Introduction ................................................................................................................................. VI-1 Methodology Related to PMP Assignments ............................................................................... VI-1 Findings Related to PMP Assignments ....................................................................................... VI-2 Methodology Related to Health Risk Assessment Screening ..................................................... VI-4 Findings Related to Health Risk Assessment Screening ............................................................ VI-5 Recommendations to the MCEs and the OMPP Related to New Member Activities ................ VI-6

  • FINAL REPORT 2014 External Quality Review of Indiana’s Hoosier Healthwise Program and Healthy Indiana Plan 

    Burns & Associates, Inc. April 30, 2015  

    Section VII: Focus Study on Provider Services Staff and Communication with Providers Introduction ............................................................................................................................... VII-1 Methodology Related to MCE Interviews and Document Review ........................................... VII-1 Interview and Document Review Findings ............................................................................... VII-2 Methodology Related to Provider Phone Interviews .............................................................. VII-10 Findings Related to Provider Phone Interviews ...................................................................... VII-10 Topics Discussed as a Follow-up to the CY 2013 EQR Report ............................................. VII-13 Recommendations to the MCEs and the OMPP Related to Provider Services Staff and Communication with Providers .............................................................................................. VII-18 Section VIII: Focus Study on Third Party Liability Introduction .............................................................................................................................. VIII-1 Methodology for Reviewing Third Party Liability .................................................................. VIII-1 Interview and Document Review Findings .............................................................................. VIII-2 Comparison of MCE and State’s Data Warehouse TPL Carrier Information Findings ........... VIII-7 Recommendations to the MCEs and the OMPP Related to Third Party Liability ................... VIII-8 Appendix A: EQR Guide Appendix B: Validation of Performance Measurement Worksheets Appendix C: Revised Quality Improvement Project Worksheet Template Appendix D: Validation of Performance Improvement Project Worksheets Appendix E: Calculation of Non-Emergency Medical Transportation by Defined Cohorts Appendix F: Provider Interview Protocol

  • FINAL REPORT 2014 External Quality Review of Indiana’s Hoosier Healthwise Program and Healthy Indiana Plan 

    Burns & Associates, Inc. April 30, 2015  

    ABBREVIATIONS LIST

    Abbreviation Meaning ABD Aged, Blind, or Disabled B&A Burns & Associates, Inc. BH Behavioral Health

    CAHPS Consumer Assessment of Healthcare Providers and Systems CHIP Children's Health Insurance Program

    CMHC Community Mental Health Center CMS Centers for Medicare and Medicaid Services COB Coordination of Benefits CY Calendar Year

    DM/CM Disease Management/Care Management/Case Management EOB Explanation of Benefits EQR External Quality Review

    EQRO External Quality Review Organization FPL Federal Poverty Level

    FQHC Federally Qualified Health Center FSSA Family and Social Services Administration

    HEDIS Healthcare Effectiveness Data and Information Set HHW Hoosier Healthwise HIP Healthy Indiana Plan

    HRA Health Risk Assessment HRS Health Risk Screening IEP Individualized Education Plans

    IHCP Indiana Health Coverage Programs (Indiana's Medicaid Programs) IRU Internal Resolution Unit

    ISMA Indiana State Medical Association MCE Managed Care Entity MCO Managed Care Organization MHS Managed Health Solutions

    NEMT Non-emergency Medical Transportation NOP Notification of Pregnancy

    OMPP Office of Medicaid Policy and Planning

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