c768 task 2 rfp response.pdf - The State of West Virginia Bureau for Medical Services Response to Request for Proposal for External Quality Review

c768 task 2 rfp response.pdf - The State of West Virginia...

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Unformatted text preview: The State of West Virginia Bureau for Medical Services Response to Request for Proposal for External Quality Review Organization RFP #MED12009 Technical Proposal Original March 6, 2012 Health Services Advisory Group, Inc. 3133 East Camelback Road, Suite 300 Phoenix, Arizona 85016 Phone: 602.264.6382 Fax: 602.241.0757 SERVICES HSAG HEALTH ADVISORY GROUP March 2,2012 Donna D. Smith Senior Buyer Office of Purchasing West Virginia Department of Health and Human Resources One Davis Square, Suite 100 Charleston, WV 25301 RE: Response to Request for Proposals for External Quality Review Organization, RFP #MED 12009 Dear Ms. Smith: Health Services Advisory Group, Inc. (HSAG) is pleased to submit this response to the West Virginia Department of Health and Human Resources, Bureau for Medical Services External Quality Review Organization RFP. HSAG is eminently qualified to fulfill the External Quality Review Organization (EQRO) contract sought by the Bureau for Medical Services (BMS). HSAG brings more than 25 years of health care quality improvement experience for Medicaid, Medicare, and private health care organizations. As the provider of external quality review services in 14 states, HSAG’s track record speaks for itself. HSAG has built a reputation as an innovative and collaborative partner. Moreover, HSAG is the CMS-designated Medicare Quality Improvement Organization for Arizona, California, and Florida, and holds multiple other research and review contracts in the public and private sectors. With this considerable experience, we know we can provide excellent quality review services, economically, for BMS. Consequently, we are enthusiastic to do so. We believe our attached Technical Proposal demonstrates our skill, resources, experience and commitment to serve BMS in providing external quality review services for the West Virginia Mountain Health Trust. Please do not hesitate to contact me if you have any questions or require clarification. I can he reached at 602.801.6701 or [email protected] Sincerely, v ’ 7 Mary Ellen Dalton, PhD, MBA, RN Chief Executive Officer MED:hh Information for Health Care Improvement 3133 East Camelback Road. Suite 300, Phoenix, Arizona 850164501 • Phone 602.264.6382, Fax 602.241.0757 • vw.hsag.com — SERVICES AI)VISUAY 580SF HSAG HEAlTH Title Page RFP subject: External Quality Review Organization Number: MED 12009 Vendor’s Name: Health Services Advisory Group, Inc. Business address: 3133 East Carnelback Road, Suite 300 Phoenix, AZ 850 16-4501 Telephone number: 602.264.6382 Fax number: 602.241.0757 Name of contact person: Mary Ellen Dalton, PhD, MBA, RN E-mail address: [email protected] Mary Elle on, Chief Executive Officer Date West Virginia Department of Health and Human Resources Response to RFP #MED1 2009 for External Quality Review Organization Table of Contents Attachment A: Vendor Response Sheet 2.4.1 2.4.2 2.4.3 2.4.4 2.4.5 2.4.6 2.4.7 2.4.8 2.4.9 2.4.10 2.4.11 2.4.12 2.4.13 2.4.14 HSAG’s Plan to Evaluate the Quality of MCOs ....................................................... 1 HSAG’s Plan to Validate and Review Performance Improvement Projects .......... 13 HSAG’s Plan to Validate Performance Measures .................................................. 24 HSAG’s Plan to Conduct an Annual Compliance Review ..................................... 35 HSAG’s Plan to Monitor Medicare and Private Standards and Processes for Review and Make Recommendations to BMS ...................................................... 54 HSAG’s Plan to Review Unique MCO Activities .................................................. 63 HSAG’s Plan to Accurately and Reliably Summarize the Performance of each MCO .............................................................................................................. 72 HSAG’s Plan to Develop a Detailed Technical Report .......................................... 80 HSAG’s Plan to Develop Annual Plan-Specific Reports ....................................... 91 HSAG’s Plan to Develop a Comparative MCO Report........................................ 100 Yearly Operations Plan ......................................................................................... 109 HSAG’s Expertise with Federal Statutes, Regulations, and Guidance ................. 110 HSAG’s Knowledge of “Best Practices” .............................................................. 112 Vendor References ................................................................................................ 115 HSAG’s EQRO and QIO Contract Experience .................................................... 120 Attachment B: Mandatory Specification Checklist 2.5.1 2.5.2 2.5.3 2.5.4 2.5.5 2.5.6 2.5.7 2.5.8 Compliance with requirements in Attachment D...................................................... 1 Lead point of contact ................................................................................................ 1 Training and technical assistance.............................................................................. 2 Compliance with federal regulations ........................................................................ 3 Prepare and submit draft work plan ........................................................................ 22 Project manager attendance of quarterly meetings ................................................. 22 Quarterly written status reports ............................................................................... 22 Providing additional services .................................................................................. 22 West Virginia Department of Health and Human Resources Response to RFP #MED12009 for External Quality Review Organization 1 Attachment C: Cost Sheet Attachment D: Special Terms and Conditions Appendix Required Forms Corporate Licenses and Certifications Sample Report Vendor Registration West Virginia Department of Health and Human Resources Response to RFP #MED12009 for External Quality Review Organization 2 Attachment A: Vendor Response Sheet Provide the following: firm and staff qualifications and experience in completing similar projects; references; copies of any staff certifications or degrees applicable to this project; proposed staffing plan; descriptions of past projects completed entailing the location of the project, project manager name and contact information, type of project, and what the project goals and objectives were and how they were met. Also, describe the approach and methodology proposed for this project. This should include how each of the goals and objectives listed is to be met. The Vendor should address within their proposal how they are able to: • Identify any issues or problems regarding access, quality, and utilization; • Verify MCO compliance with program systems and clinical requirements, as outlined in the MCO contract; • Identify “best practices” and work with MCOs to improve results; • Provide BMS with a comprehensive report that can be used as part of the Bureaus’ overall quality strategy; and • Prepare BMS and the MCOs for fall review activities that will take place during the year. This approach should include an onsite orientation meeting with the MCOs and BMS. 2.4.1 HSAG’s Plan to Evaluate the Quality of MCOs 2.4.1 Vendor should propose an organized, integrated plan to evaluate the quality of MCOs participating in the West Virginia MHT program. The work plan should specifically address how the Vendor conducts all EQR activities and reporting requirements in the most efficient way for both State and MCO staff. The work plan should establish time estimates for each significant segment of work that demonstrates the Vendor’s ability to comply with expected timeframes in Section 2.5.5 of this RFP. Experience With Similar Projects Since 1983, Health Services Advisory Group, Inc. (HSAG), has been actively engaged in evaluating the quality of care that Medicaid recipients receive. Currently, HSAG provides external quality review (EQR) services in California, Arizona, Arkansas, Colorado, Florida, Georgia, Hawaii, Illinois, Michigan, Nevada, Ohio, Tennessee, Vermont, and Washington, which together include more than 30 million Medicaid recipients. HSAG performs its external quality review organization (EQRO) functions in accordance with federal and state laws, regulations, and policies regarding Medicaid—including standards and procedures pertaining to the terms and conditions of the applicable waiver programs. West Virginia Department of Health and Human Resources Response to RFP #MED12009 for External Quality Review Organization 1 With more than 25 years of experience managing multiple large-scale contracts for state and federal agencies, HSAG has refined its project management processes. HSAG’s successful track record in managing these contracts has been made possible by HSAG’s: Focused approach to managing projects that emphasizes efficient and cost-effective achievement of specific outcomes Exceptionally high-caliber professionals and support staff Systems, relationships, and resources that support all work efforts In-depth experience over the years Successful collaboration with carefully selected subcontractors HSAG focuses on collaboratively developing project plans that incorporate input from key stakeholders, beginning with the state Medicaid agency. The project approach and methodology are carefully thought out to ensure that all tasks, subtasks, and resources are necessary for the achievement of the desired outcomes and the timely completion of quality deliverables. Problems and issues are identified during HSAG project team meetings, which include state Medicaid agency staff members. Such issues are assigned to a team member for resolution, tracked, and reported at future meetings. HSAG is confident in our ability to implement and manage contracts. We have done so successfully in multiple settings—to the ultimate satisfaction of our clients. HSAG believes there are four major elements to the project management plan: Implementation—establishing our project staff and the development of a partnering relationship with the Medicaid agency staff Structure—establishing the appropriate organization, using subcontractors as appropriate, with the direction to act for the betterment of the EQRO project Support—ongoing access to subject matter experts, including HSAG senior staff members as well as subcontractor experts Reporting—keeping the state Medicaid agency informed on implementation status, operational status, and issues on an ongoing basis HSAG uses a project quality management approach that includes the processes required to ensure that the project satisfies the needs of the state Medicaid agency. It includes all activities of the overall management function that determine the project quality, objectives, and responsibilities, and implements them by quality planning, quality control, quality assurance, and quality improvement within the system. The following is an overview of the major project quality management processes: Project quality planning—In conjunction with the state Medicaid agency, HSAG identifies and implements applicable quality standards for this project. In this phase, quality checklists play a vital role and are used to verify that the required steps in any one or a number of tasks have been performed. West Virginia Department of Health and Human Resources Response to RFP #MED12009 for External Quality Review Organization 2 Project quality assurance—Planned and systematic activities are implemented throughout the project to ensure the state Medicaid agency’s quality standards are met. Project quality control—HSAG monitors specific project results to determine if they comply with relevant quality standards and identifies ways to eliminate causes of unsatisfactory results. Project results include deliverables and management results such as cost and schedule performance. Quality controls are used to track the status of the project through quality checkpoints and monitoring. Project quality improvement—Actions are implemented to increase the effectiveness and efficiency of the project and to provide added benefits to the state Medicaid agency. HSAG believes that the benefits of meeting quality requirements include higher productivity, improved relationships, and increased state Medicaid agency satisfaction. HSAG’s goal in building upon its quality control procedures is to improve HSAG responsiveness, accountability, and outcomes. Team Approach to Project Management HSAG recognizes the importance of having a well-qualified staff along with a commitment to proactive communications with each state Medicaid agency. HSAG’s experience with its EQRO contracts has demonstrated that timely and frequent communication with each state Medicaid agency increases HSAG’s understanding of the project and significantly contributes to the success of the project. The HSAG project team represents a management team structured to provide innovative and efficient direction for EQRO project activities. HSAG has organized this team to meet contractual requirements and to best utilize the professional skills of its members. In addition to possessing an optimum blend of skills and experience, team members are strong in individual capabilities and flexibility that assist the smooth flow of work, communication, and success in meeting each agency’s objectives. The multi-functional capacity of the team is the key strength for this project. Staff/Team Experience and Qualifications Bonnie Marsh, RN, BSN, MA is Executive Director, State & Corporate Services Division for HSAG’s EQRO contracts. For the West Virginia EQRO project, Ms. Marsh will provide executive oversight and expertise, and will have oversight of HSAG’s West Virginia Project Lead, Debbie Chotkevys. In her role as Executive Director, she has day-to-day oversight responsibility of all scopes of work, contract deliverables, and is the primary contact for state Medicaid agencies. Ms. Marsh is responsible for the quality of all work performed by project staff members and for client satisfaction with the work product provided. She coordinates projects through various stages using internal and external resources to achieve project goals and West Virginia Department of Health and Human Resources Response to RFP #MED12009 for External Quality Review Organization 3 objectives. She develops collaborative partnerships with state Medicaid managed care agencies to address the individual needs of the state’s Quality Strategy. Ms. Marsh is a Registered Nurse with more than 30 years of health care and behavioral health experience. She has provided professional leadership and management in both the public and private sectors. Ms. Marsh’s experience includes behavioral health clinical supervision; quality and utilization management; grievance, appeal, and risk management; and member services and advocacy. Prior to joining HSAG, she managed the behavioral health benefit program for the Arizona Health Care Cost Containment System (AHCCCS), Arizona’s Medicaid agency, and was responsible for monitoring the delivery of behavioral health services by contracted managed care organizations and prepaid inpatient health plans, using the CMS Protocols for Determining Compliance with Balanced Budget Act of 1997 (BBA) requirements. She also participated in CMS’ Performance Measurement Partnership Project for development of standardized performance measures for states’ Medicaid and CHIP programs. Ms. Marsh received her RN diploma from St. Vincent Hospital School of Nursing, as well as a Bachelor of Science Degree in Nursing and a Master of Arts Degree in Organizational Management from the University of Phoenix. Debra Chotkevys, DHA, MBA, is a Project Director for the State & Corporate Services Division at HSAG. Dr. Chotkevys will serve as the West Virginia Project Lead and as such will have day-to-day responsibility for all contract activities, deliverables, and be the primary contact between BMS and HSAG. She will be available between 8 a.m. and 5 p.m. Eastern Time, Monday through Friday, and will attend all quarterly meetings of the MHT Task Force. Dr. Chotkevys has more than 25 years of health care experience in physician credentialing and site reviews, medical record abstraction, and accreditation standards. She has been involved with external quality reviews for Medicaid managed care for the past 11 years, during which time she reviewed quality and operational standards. Currently, Dr. Chotkevys is involved in the external quality review activities in Nevada, Tennessee, and Florida. Her responsibilities include leading cross-functional teams, creating automated compliance evaluation tools to assess MCOs’ performance, conducting compliance reviews of managed care compliance with state and federal standards, and writing reports for various state activities. Before joining HSAG, Dr. Chotkevys was responsible for operational oversight of external quality review contracts in the three states. Dr. Chotkevys worked with MCOs and providers to assess and monitor care and provided direction for medical record abstraction for quality studies, on-site reviews, and technical assistance to the state bureaus. Her responsibilities included reviewing quality and operational standards of the MCOs to ensure compliance with provider contracts, state requirements, and federal requirements during annual on-site audits; assisting in implementation of a waiver program to include medical record reviews for quality audits, provider site visits, credentialing, and working with the waiver clients to assist with customer service issues; designing and developing quality studies to monitor care; and working with scientists, statisticians, and health analysts to interpret data. Dr. Chotkevys holds a Master of Business Administration Degree from Baldwin-Wallace College and a Doctor of Health Administration Degree from the University of Phoenix. She West Virginia Department of Health and Human Resources Response to RFP #MED12009 for External Quality Review Organization 4 currently teaches health administration courses at local and on-line universities as an adjunct professor (part-time). Wendy Talbot, MPH, CHCA, is an Associate Director of Audits at HSAG and is responsible for the oversight and management of HSAG’s NCQA Healthcare Effectiveness Data and Information Set (HEDIS®)1 Compliance Audit program as well as the Validation of Performance Measures activities for its EQRO contracts. Prior to her appointment to her current position, Ms. Talbot served as the Arkansas project manager, overseeing the day-to-day contract activities for HSAG’s Arkansas data mining and program evaluation contract. She was also a project manager within the Audit Department, where she was responsible for support of the HEDIS audit program and all performance measure validation activities, including communicating with health plans, preparing agendas and scheduling and conducting site visits, reviewing the systems capabilities tools completed by the health plans, reviewing programming logic and output files, and compiling audit results into a final audit report. Ms. Talbot is an NCQA-Certified HEDIS Compliance Auditor, and she is skilled in primary source verification of eligible population and numerator files, ensuring algorithmic compliance, and assessing bias using NCQA and CMS techniques and protocols. Her previous roles at HSAG included project coordinator for performance improvement projects, performing validation of physical and behavioral health PIPs, and participating on external quality review and compliance audits of Michigan mental health plans. She also served as a health care analyst with HSAG’s Federal Division, providing analytic support for the CMS 7th Scope of Work quality improvement organization (QIO) contract and analyzing and reporting on ambulatory care and inpatient data, including mammography, diabetes, and i...
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