Validation of Performance Measures for PMHPs. Health Services Advisory Group. January 17, 2008 10:00 a.m. –12:00 p.m. Presenter: Peggy Ketterer, RN, BSN, CHCA Executive Director, EQRO Services. Balanced Budget Act (BBA) of 1997. Balanced Budget Act (BBA) of 1997. 42CFR438.240
Health Services Advisory Group
January 17, 2008
10:00 a.m.–12:00 p.m.
Peggy Ketterer, RN, BSN, CHCAExecutive Director, EQRO Services
States must require each managed care organization (MCO) and pre-paid inpatient health plan (PIHP) to annually measure and report performance to the state using standardized measures.
The BBA also requires that states contract with an EQRO for an annual independent review of each MCO and PIHP to evaluate the quality and timeliness of, and access to, health care services provided to Medicaid enrollees.
States must ensure that the performance measures are validated annually through the external quality review process.
Performance Measure Characteristics:
Performance Measure Calculation:
A Brief Overview
Step 1: Identify necessary data sources and data elements for reporting the selected measures
Step 2: Prepare data set
Step 3: Produce source code to calculate measures
Step 4: Calculate measures administratively
Step 5: Validate results
Step 9:Submit Performance Measure reports to the state
The percent of enrollees who were hospitalized for a mental health diagnosis and were discharged to the community from an acute care facility and were seen on an outpatient basis by a mental health practitioner and/or case manager within seven days.
Three calculations will be generated:
Specifies any age, continuous enrollment (CE), and event/diagnosis requirements
Specifies any exclusions
Specifies any exclusions (cont’d)
An outpatient follow-up encounter with a mental health practitioner up to seven days after hospital discharge
Three Main Phases:
Pre-On-Site Activities (cont):
On-Site Activities (for each PMHP):
Receive PMHP documentation
Request ISCAT Documentation
05/19/08 – 05/30/08
Conduct Onsite Visits
06/09/08 – 07/11/08
Prepare ReportValidation ActivitiesProposed Timeline
Questions and Answers