EXTERNAL QUALITY REVIEW ORGANIZATION

• Primaris owns and 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 beneficiaries.

Primaris has more than ten years performing external quality reviews.  In fact, Primaris is Missouri division of Medicaid’s first EQRO, performing external quality review of the state’s first contracted managed care organizations, in the 1990s.

• External Quality Review (EQR) related activities are the mandatory and optional activities, as set forth in 42 CFR §438.358, which produce the data and information that the EQRO analyzes when performing the EQR. The Centers for Medicare and medica Services (CMS) issues the protocols that set forth guidelines, for the EQR-related activities.
  • Primaris 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.
  • Primaris has staff who are certified as HEDIS Compliance 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.

Primaris EQRO strives to perform EQR-related activities without duplication.  Nonduplication allows, under certain conditions, a state to use information from a Medicare or private accreditation review of a plan in place of generating that information through one or more mandatory EQR activities.  These efforts save state dollars and ensure a more robust approach to optimize managed care quality oversite.

Primaris EQRO provides Technical Assistance to states and managed care plans on all mandatory activities, as well as optional activities.  In addition, Primaris can provide 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 beneficiaries.  Primaris will customize it technical assistance to support states in achieving their strategic and programmatic goals.