Oversight and Monitoring Unit

% of cases pulled during the month that were completed within 24 business days

100.0%Dec 2019

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Notes on Methodology

Story Behind the Curve

The target for this measure is to complete all case reviews for a given month by 24 business days from the date the sample is assigned. The grid in the notes on methodology shows the number of cases that the OMU Health Care Quality Control Team (HCQC) completed every 8 business days up to the target 24 business days and beyond. This also shows the trend over time of how quickly HCQC completes cases.

The HCQC Team has recently changed the due date of Quality Control (QC) cases since for the last 3 months we have been completing prior to the 24th day. The goal is to get cases out to units in a timely manner so the eligibility units can have as close to real time reporting as possible. This measure also shows the percentage of the total sample size for the month HCQC completed.

Factors that may influence the rate include any reduction in staff due to vacations or termination of employment, sample size and/or the upcoming Medicaid Eligibility Quality Control (MEQC) audit.

Work has begun on a Case Management Database for QC, which may impact the completion rate.  The expected completion of the database is between late December 2019 and early February 2020. 

 

The QC unit went live with our new database system on 2/4/2020.  Starting in October 2019 we began intense testing of the system to ensure it would be up and running by the time the January 2020 sample was pulled.  Due to the testing, it took longer to process cases.  It was also decided to put the December 2019 sample on hold indefinitely so there will not be any data for the December 2019 sample month.  We have started fresh in the SalesForce system with the January 2020 sample.  This also marks the start of the federally mandated Medicaid Eligibility Quality Control (MEQC) audit.  The reporting year for MEQC is 1/1/2020-12/31/2020.  The results of all cases reviewed in this time period will be reported to CMS by 8/1/2021.   The sample size during the MEQC audit will drop from 95 to 81 as we only need to review a minimum of 800 cases during the reporting year.  QC has oversampled to ensure the minimum requirement is met.  MEQC requires reviews from the MCA, CHIP, MABD, LTC programs. QC will continue to review VPharm programs even though these will not be reported to CMS.

 

 

Last updated:  08/18/2020

Strategy

HCQC has set dates based on when the sample is assigned, where 25%, 50%, 75% and 100% of the auditors’ caseload is due.  This helps in meeting the target of completing all cases within 24 business days.

Scorecard Result Container Indicator Measure Action Actual Value Target Value Tag S R I P PM A m/d/yy m/d/yyyy