Performance Improvement 2009. Do States Operating Medicaid Managed Care Programs Arrange for External Quality Reviews?


This study assessed ways in which States utilized external quality reviews of Medicaid managed care. Federal statute requires States that operate Medicaid managed care programs to arrange for external quality reviews which States may conduct or contract with an independent external quality review organization (EQRO). States receive matching Federal funds for the costs of the review. Regulations include three mandatory and five optional activities for the review. These regulations specify five deliverables that EQROs must produce based on the review activities.

Most States were using the results of EQRO reviews. Of the 37 States that implemented external quality reviews, 33 required their managed care plans to make changes based on EQRO reports, such as improving how plans conduct performance improvements. Some EQRO reports did not include all required information, despite the States’ oversight. Reports for 15 States were missing at least one of the deliverables. All States reported regular monitoring of their EQROs, through communication, status reports, and contract provisions. More than half of the States cited concerns with the external quality review process regarding staffing issues, EQRO report quality, and redundancy with other monitoring efforts.

Report Title: External Quality Reviews in Medicaid Managed Care
Agency Sponsor: OS-OIG, Office of Inspector General
Federal Contact: Erin Lemire, 202-205-9523
Performer: Staff; Office of Inspector General
PIC ID: 8977

View full report


"PerformanceImprovement2009.pdf" (pdf, 1.26Mb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®