Medicaid Managed Care Oversight

Partner with IPRO to ensure that your state’s Medicaid managed care beneficiaries receive high-quality, efficiently administered care.

State Medicaid managed care programs cover over 57% of the more than 40 million people enrolled in Medicaid, and account for a significant share of total state spending. IPRO’s team of experts specializing in Medicaid-funded managed care programs will help you ensure that public dollars are being put to good use.

The IPRO Solution

External Quality Review

IPRO has extensive experience in all mandated and optional activities and can customize programs to meet your state’s needs. IPRO coordinates External Quality Review (EQR) activities with Medicaid managed care organizations, managed long term care plans, behavioral health MCOs and SCHIP plans. Our EQR services include:

  • Validation of performance improvement projects
  • Automated data collection tools and medical record abstraction and tracking systems
  • Quality improvement program development and administration
  • Assessment of MCO administrative processes to ensure compliance with state and federal requirements
  • Educational programs
  • Provider and member satisfaction, and access and availability surveys
  • State level and health plan-specific technical reports
  • Individual case review
  • Focused clinical studies
  • Validation of performance measures

Encounter Data Validation

Reliable encounter data is the basis of quality assessments, HEDIS® rates, risk-adjusted payments, and provider and MCO profiling. IPRO’s comprehensive encounter data review and validation program, designed to help states develop reliable and complete encounter data, includes:

  • Encounter data questionnaires
  • Assessment of accepted and rejected encounters
  • On-site review of systems and processes
  • Comparison of encounters to medical records
  • Comparison of encounters to transactional data and reports
  • Encounter data management project reports
  • Technical assistance

The IPRO Advantage

  • 15 years experience in External Quality Review in multiple states
  • Currently evaluating health care provided to more than  3 million Medicaid recipients in 100+ managed care organizations
  • Conducted numerous studies of Medicaid data accuracy, completeness and quality
  • Administered several national Medicare encounter data projects
  • Played a key role in developing the HEDIS Compliance Audit™ program, including developing the standard Baseline Assessment Tool
  • Extensive experience working with regional and national plans

Contact Virginia Hill, RN, MPA, Vice President Managed Care, 516-209-5567 or

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

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