External Quality Review Organization Services (EQRO)
PTM operates an External Quality Review Organization (EQRO) that partners with State Medicaid Agencies to analyze and evaluate quality, timeliness, and access to health care services provided by managed care organizations (MCO), Children’s Health Insurance Programs (CHIP), Prepaid inpatient health plans (PIHP), prepaid ambulatory health plans (PAHP) and/or primary care case management (PCCM) entities and/or their contracted providers furnish to Medicaid recipients with medical care.
PTM has more than ten years performing external quality reviews for state government. Qualified and experienced, nurses, physicians, statisticians, and other healthcare professionals perform EQR-related activities and is guided by an EQR Advisory Board.
External Quality Review (EQR) related activities are the mandatory and optional activities defined by CMS which produce the data and information that the EQRO analyzes. CMS issues the protocols that set the guidelines for all the EQR-related activities.
PTM’s EQR-related activities improve state’s ability to oversee and manage the managed care plans that they are contracted with for services; and help managed care plans improve their performance with respect to quality, timeliness, and access to care.
PTM EQR Services
• HEDIS Compliance Certified Auditors to validate the Healthcare Effectiveness Data and Information Set (HEDIS) reporting that is required by most managed care plans. In addition, nurses, physicians, statisticians and other healthcare professionals perform EQR-related activities.
• EQR-related activities without duplication allows, under certain conditions, a state to use information from a Medicare or private accreditation review of a MCO in place of generating that information through one or more mandatory EQR activities. These efforts save state and MCO dollars and ensure a more robust approach to optimize managed care quality oversight.
• EQRO experienced staff brings extensive, professional health care experience to our contracts. Their expertise assures for accurate and appropriate analysis, perspectives, and guidance in health care quality for contracted MCOs as well as their related State Agencies.
• Technical assistance to states and MCOs on all mandatory activities and optional activities.
• Quality review technical assistance to states that do not operate managed care programs, but desire to monitor the delivery of healthcare services and outcomes to their Medicaid recipients.
• Customized IT technical assistance to support states in achieving their strategic and programmatic goals.
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