This performance measure is important because it gives us an independent assessment of our compliance with key Medicaid managed care laws as well as our Intra Governmental Agreement (IGA) with AHS. These auditors review Medicaid Managed Care models across the country, so their perspective and findings are very helpful to us as we continuously look for ways to improve our Medicaid system.

The External Quality Review Organization (EQRO) audit is conducted annually, but there are three different groups of standards. The audit focuses on one group of standards per year on a three-year cycle. Some audit years have more difficult standards. The audit scores demonstrate not only our compliance with standards, but also our commitment to improving our compliance program.  Close collaboration with our partners has been the most effective strategy for keeping our compliance scores high. The audit covers topics that go beyond DVHA’s direct responsibilities, so each standard requires cooperation from partnering departments and the AHS Central Office.

During this audit period, we received an overall compliance score of 81%, which is 9 points below our benchmark of 90%. If you compare this score to the 2019 score (the last time we were audited on these specific standards), you will see that we were five percentage points lower this year. This tells us that DVHA has struggled with this particular set of standards in recent years and supports the need for a more comprehensive approach to meeting these compliance requirements. In 2022, we created a Risk Assessment project to assess compliance risks across all of the departments responsible for Medicaid service delivery. This team is focusing heavily on our annual EQRO compliance audit and we anticipate much higher compliance scores starting with our July 2023 review.

When reviewing the 2022 compliance score, it is important to note that our non-compliance in one area often resulted in several findings. For example, we were found to be out of compliance with the requirement that we report on the availability of several provider types in our network. Each provider type resulted in its own finding, which had a magnifying effect on the percentage points we lost in the audit.

Narrative last updated:  04/04/23

• Department of Aging and Independent Living (DAIL)
• Vermont Department of Health (VDH)
• Department of Mental Health (DMH)
• Department for Children and Families (DCF)
• Agency of Human Services Central Office (AHS-CO)

In 2022, DVHA initiated a new Risk Assessment project designed to systematically identify and correct Medicaid compliance risks. The project team comprises subject matter experts in compliance, quality and oversight & monitoring. To date, the team has reviewed approximately half of the pertinent compliance standards and their goal for 2023 is to ensure that all EQRO findings are addressed and that we take action to reduce or eliminate future findings. The team’s approach will significantly reduce or remove future repeat findings as well.