Quality in Managed Long-Term Services and Supports Programs. G. External Quality Review Organization Responsibilities


Our interest in the EQRO pertains to activities they perform above and beyond those required under the Medicaid managed care regulations (compliance review, validation of encounter data, performance measures and PIPs). In particular, we were focused on additional quality management activities for which states employ EQROs in their MLTSS programs.

Four of the study states maintain a more traditional relationship with their EQRO (Arizona, Michigan, Minnesota, and Pennsylvania). But in Wisconsin, the EQRO takes on the added task of conducting the care management review in the MCOs. The EQRO assumes multiple additional tasks in Tennessee; rather than just validating PIPs they are involved in assisting the MCOs with PIP implementation, as well as responsibilities for training the MCOs and state staff on quality-related issues. The Tennessee EQRO also reviews all MCO corrective action plans from its annual compliance review and conducts a legislatively-mandated network adequacy review. The EQRO's scope of work in Texas includes focused studies, an annual satisfaction survey of members, validating encounter data as well as developing data for the program's performance dashboard and planned MCO report cards.

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