The Risk and Quality Management Team  is comprised of the Medicaid Compliance Unit (MCU), the Oversight & Monitoring Unit (OMU), & Quality Improvement Unit (QIU).  Like many organizations, compliance functions at DVHA often lead to quality improvement activities. The purpose of bringing these groups together under one larger team is to gain efficiencies regarding our comprehensive regulatory environment and realize greater success in our work.

The over-arching goals of that team include:

• create a culture of pro-active regulatory compliance and continuous quality improvement;
• identify, analyze, prioritize and correct compliance risks across all departments and programs responsible for Medicaid service delivery;
• take advantage of opportunities to move beyond compliance and identify ways to improve the services we deliver to Vermonters;
• coordinate the production and/or analysis of standard performance measures pertaining to all Medicaid enrollees, including the special health care needs populations (service provision delegated to IGA partners).

The Medicaid Compliance Unit (MCU) collaborates with programs responsible for delivering Medicaid services to ensure that programs are run in compliance with state and federal laws, rules and policies, as well as the terms and conditions of our Global Commitment waiver.

The Oversight & Monitoring Unit (OMU) consists of two teams; Audit & Internal Control and Healthcare Quality Control. The OMU is responsible for ensuring the effectiveness and efficiency of departmental control environments, operational processes, regulatory compliance, and financial and performance reporting in line with applicable laws and regulations.

The Quality Improvement Unit (QIU) collaborates with AHS partners to develop a culture of continuous quality improvement, maintains the Vermont Medicaid Quality Plan and Work Plan, coordinates quality initiatives including formal performance improvement projects, coordinates the production of standard performance measures, and is the DVHA lead unit for the Results Based Accountability (RBA) methodology & produces the DVHA RBA Scorecards.

The MCU coordinates with departments across AHS to ensure that Vermont Medicaid members benefit from a healthcare system that follows all required rules and policies.  Much of this work is designed ensure that the services we deliver are medically necessary and that our processes serve the medical needs of our members in accordance with statutes and rules.

The OMU serves DVHA Senior Leadership and all DVHA departments and units.

The QIU serves Vermonters enrolled in Medicaid.

The MCU provides consultation and assistance to Vermont Medicaid programs on compliance issues and assists these programs with compliance corrective actions as necessary.  This impacts our programs and members by ensuring the effectiveness and efficiency of our Medicaid service delivery system and limits the number of adverse findings we have during external audits.

The OMU Audit & Internal Control Team facilitates and consults on numerous exams, reviews and audits to establish professional working relationships between the DVHA units, examiners, regulators and auditors resulting in a better understanding of what is truly an issue versus a miscommunication, which results in reduced of findings.

The OMU Health Care Quality Control Team reviews beneficiary enrollment and eligibility determinations consistent with guidelines set forth in the Federal Payment Error Rate Measurement (PERM) regulations. This process requires a separate and distinct business area to conduct quality control reviews of eligibility determinations, based on CMS defined scopes, quantities and time frames. 

The QIU supports the Department in creating a culture of quality improvement; supporting units to strive for and demonstrate improvement.

MCU SFY23 Priorities:  

1. Continue work with the Medicaid Risk Assessment Project by reviewing additional compliance standards with Medicaid programs across AHS
2. Ensure that our subject-matter experts are prepared for the 2023 EQRO audit topics and that corrective actions from prior audits are completed or on schedule for completion
3. Once our AHS-DVHA IGA is completed, update department IGAs to include a schedule of monitoring deliverables that match the recommendations from the Risk Assessment Project
4. Update the Utilization Management Plan to match any changes that arise from the new AHS IGA
5. Continue to serve as a compliance consultation resource for Medicaid programs across AHS

OMU SFY23 Priorities:

1. PHE Unwind
2. Successfully implementing our new Data Reporting System
3. Recruitment/Retention, Succession Planning, and Professional Development

QIU SFY23 Priorities:

1. Quality Improvement Projects – PIP and Foster Care Learning Collaborative
2. Continue to coordinate DVHA’s Risk Assessment work group
3. Re-envision the DVHA Performance Accountability Scorecard