Addressing Critical Incidents in the MLTSS Environment: Research Brief. How Do States Monitoring MCO Management of Critical Incidents?


Since most states do not currently utilize an electronic reporting/management system, they rely instead on critical incident reports from the MCOs as a way to monitor how the system is working. States have adopted different approaches to MCO reporting. Several require quarterly or bi-monthly critical incident reports from the MCO. As an example, Wisconsin requires MCOs to submit quarterly reports that provide a detailed listing of each incident including the date of the incident, actions taken, and a description of any policies/practices that have been changed to prevent similar incidents in the future. The state reviews the MCO's quarterly report using a standard review tool and provides feedback to the MCO within 30 days, including any concerns about the MCO's response to an incident.

States have the option of conducting audits as a way to monitor the MCO's handling of critical incidents to augment the reports they receive from MCOs. Tennessee, for example, has a practice of conducting semi-annual audits of how the MCOs manage critical incidents. These audits address whether the MCO accurately identified critical incidents and reported them timely to the state, and whether the MCO ensured that appropriate investigations were conducted and corrective actions were implemented. Texas takes another approach to monitoring. When reviewing the MCO, they draw a sample of members whose charts they will review and who they will interview. They make a point of including in the sample members who have experienced a critical incident (as identified from critical incident data submitted by the MCO). The focus of this part of the quality review is to ensure that the MCO/provider conducted appropriate follow-up to the occurrence of an incident and the member's health and safety was protected.


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