State Managed Care Oversight and Quality Review

The Medicare Parts C and D Oversight and Enforcement Group (MOEG) at the Centers for Medicare & Medicaid Services (CMS) develops and directs the audit strategies to oversee the Part C and Part D programs. These program audits evaluate the compliance of a sponsoring organization with the terms of its contract with CMS. The audits place particular emphasis on requirements for access to medical services, drugs, and other beneficiary protections required by Medicare.[1]

An External Quality Review Organization (EQRO) performs the analysis and evaluation of quality, timeliness, and access to health care services provided by state Medicaid managed care plans. Each state’s EQRO reviews aspects of the state’s contractual requirements, with a primary focus on the policies and procedures of its managed care organizations. However, these reviews do not necessarily address the effectiveness of those procedures. When procedures are not effective, members are at risk, and access to care can become compromised.

How We Can Help

As a national leader in audit services for federal and state Medicaid agencies, Myers and Stauffer offers:

• A team with expertise across the entire spectrum of audit and reimbursement consulting issues.
• A demonstrated multi-state performance in the management and execution of audit contractor duties for a variety of providers.
• A blend of qualifications and value-added competencies in institutional and non-institutional provider reimbursement, analysis of health care costs and utilization, and investigation of fraud and abuse in cost reimbursed programs.

Focused Federal Experience

Our comprehensive work supporting MOEG represents a specialized type and level of experience performing audit, oversight, and technical/operational support of Medicare Advantage (Part C), Prescription Drug Plan (Part D), and related organizations. For more than a decade, our team has reviewed Medicare Advantage Organizations’ (MAOs) operations across the nation. We have established operational plans, underpinned by best practices, to implement audit processes and ensure correct and timely completion. Our technical resources and applications can evaluate and analyze large data sets and facilitate reporting processes. And we know our time-tested processes work: we continue to identify instances in which MAOs are not ensuring members have access to necessary and contractually required services and medications.

The Right Partner Performing Federal Audits for States

We offer state agency clients in-depth reviews that provide critical insight into members’ access to care and prescription drugs. In fact, the audits we perform identify – and help correct – significant access-to-care concerns in each of these high-risk areas:

• Inappropriate clinical decisions related to authorization requests/services on appeal.
• Inappropriate adjudications of requests for drugs. 
• Untimely processing of requests for authorizations of services/drugs or requests for appeals. 
• Questionable denials related to clinical provider payments.
• Unrecognized or unprocessed service authorization requests, requests for drugs or complaints/grievances. These issues often relate to significant access-to-care concerns.

[1] https://www.cms.gov/files/document/2020-program-audit-process-overview.pdf