Medicaid External Quality Review
For more than 30 years, IPRO has been working with state Medicaid agencies to enhance the value of healthcare services provided to the Medicaid managed care population. Our service as an External Quality Review Organization (EQRO), started in 1989 in New York State, which has the second largest Medicaid managed care population in the country. Our experience predates the issuance of the federal external quality review protocols by 15 years, making IPRO among the most experienced and qualified EQROs in the nation.
IPRO serves as prime EQRO in 10 states and territories: Alabama (since 2019), Kentucky (since 2005), Louisiana (since 2011), Minnesota (since 2013), New Jersey (since 2011), New Mexico (since 2018), New York (since 1989), Ohio (since 2019), Pennsylvania (since 1999), and Rhode Island (since 2003). We also conduct EQR activities under subcontract in North Carolina (since 2016).
IPRO works with more than 150 managed care plans (MCPs) across the country, performing the full breadth of mandatory and optional EQR activities and providing innovative solutions and best practices to help our state clients monitor and improve MCP performance. These services include the newest mandatory activity – validation of network adequacy, and the optional activity of assisting states with their quality rating systems.
We have helped several states establish their EQR programs and have worked with them throughout their transitions to new managed care models by conducting readiness reviews and providing technical assistance and program guidance.
Other services we provide include:
- MCP report cards
- case reviews
- validation of ESPDT services
- pharmacy program review
- state quality strategy development and evaluation
- program guide development
- review of medical-loss ratio calculation
- development and calculation of metrics supporting and evaluating value-based purchasing programs
- care/case management audit and review
- PCP ratio survey
- functional assessment measurement data validation
- program evaluation/independent assessment
IPRO is also NCQA-licensed to conduct Healthcare Effectiveness Data and Information Set (HEDIS®) Compliance Audits. IPRO’s HEDIS services are delivered through our in-house Certified HEDIS Compliance AuditorsTM (CHCAs), augmented by a network of IPRO-trained independent consultants.
Despite the use of standard protocols in conducting EQR, we know that each state has unique demographics, issues, interests, and ways of working that drive its EQR program goals. IPRO avoids taking the “cookie cutter” approach to EQRO. Instead, we work with each state to understand its particular Medicaid population and objectives, and we tailor our solutions to reflect our insight.
Focus on special populations
We work with diverse populations and plan types (physical health, behavioral health, pharmacy, dental, MLTC/MLTSS, QHP, dual-eligible, and special needs).
IPRO’s extensive experience with analyzing demographically diverse populations has helped us address the needs of rural populations, the underserved, ethnic and racial minorities, the chronically ill, persons with diabetes, persons with AIDS, those with mental illness, children with special healthcare needs, the aged, individuals with long-term care needs, the developmentally disabled, and others
Center for Program Evaluation
As states test new, innovative models for delivering high quality care, they require independent evaluation to assess the impact of the changes. In response to customers’ requests for support evaluating health care delivery system transformation programs, in 2021 IPRO established the Center for Program Evaluation. Staffed with quantitative and qualitative researchers and clinician-researchers, IPRO designs and implements applied research studies to help clients assess the impact of their programs and modify them for greater impact.
Contact Virginia Hill, RN, MPA, Vice President, Managed Care, 516-209-5567 or GHill@ipro.org
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).