GUIDELINES FOR DEVELOPING STATE
MEDICAID ELIGIBILITY QUALITY CONTROL PILOT PROJECTS
OVERVIEW
Medicaid eligibility quality control (MEQC) pilots offer States the opportunity to develop innovative approaches to error reduction in their Medicaid programs. Since 1994, many States have used MEQC pilots to target error prone areas, high dollar areas, special populations and other areas to determine how best to reduce errors or improve administration of the program. Information about State MEQC pilots will be updated September of each year.
MEQC pilots are alternative ways to administer State quality control programs. As such, these pilots can not be used to determine client satisfaction, outreach efforts, the efficiency of managed care delivery systems or other program areas unless it results in a form of error prevention or reduction. Also, since surveys and questionnaires of this type generally are limited in scope, the use of such surveys and questionnaires must be combined with other error identification methods to complete the pilot. MEQC pilots can not be used to monitor the activities of Medicaid negative case actions or other programs, e.g., Temporary Assistance for Needy Families, Food Stamps, Child Health Insurance Programs under Title XXI. The goals of a pilot must focus on error prevention, a reduction in Medicaid errors or erroneous expenditures or improved program administration that results in these measures. The Medicaid error rate for a State conducting an approved MEQC pilot program is assigned as the error rate for the period ending prior to implementation of the pilot.
Listed below are guidelines to assist you in planning a pilot project. These guidelines contain questions that commonly arise when developing a MEQC pilot. We recommend that you use these guidelines, the summary pilot information available on the Internet and contact other States in the course of your planning. Your regional office can assist you with any questions.
MEQC PILOT GUIDELINES
What is the purpose of the pilot?
When planning a pilot, determine what you want to achieve. Program areas that can be targeted for a pilot are not limited to Medicaid eligibility. For example, you can review how well your State identifies third party liability (TPL) and/or how well third party payments are recouped (if your State has a pay-and-chase system). Also, you need not review the entire TPL program. You can target your study to an element of TPL, such as determining how well your State identifies insurance available through a noncustodial spouse; or how well a managed care program recoups TPL payments (if poor performance would increase the capitation rate your State pays}. Any program area that, when corrected or improved by the pilot findings, results in a prevention or reduction of errors or erroneous expenditures can be targeted for a pilot.
MEQC pilots do not have to be applied on a Statewide basis. You can target your pilot to a certain geographic area where, for example, a large percentage of the Medicaid population lives, (urban vs. rural areas) or to a certain county where a large percentage of errors are occurring. You can conduct management reviews Statewide over a period of time, e.g., half of the State during the first 6 months and the other half of the State during the last 6 months of the year. Depending on the subject of your pilot, a geographic breakdown could afford you the best results for your efforts.
What is the method used to achieve this purpose?
Approaches to implement your pilot are not limited to case reviews. Telephone surveys, management reviews, systems reviews (e.g., eligibility, payment, case information), questionnaires and interviews are some of the alternative approaches you can use in your pilot. The method is essentially the action plan that will be used to target, collect and apply information in a way that achieves the purpose of the pilot.
Evaluate your method to determine if it will generate the information needed. You should obtain enough information to enable you to determine the causes of problems and plan good corrective actions or apply the information to other means of error reduction. For example, if you develop a questionnaire targeting a certain program area, each question should be specific enough to identify weaknesses or error prone areas as well as determining the causes. This information will enable you to develop corrective actions or forward useful data to the component responsible for correcting the errors or improving program performance.
Are the pilot and proposed method cost-effective?
Evaluate if the pilot is cost-effective. For example, will the pilot cost you more than the value of the information received or the money that can be saved after corrective actions are made? If so, determine if the approach is cost-effective. You can use the CMS Home Page to determine if another State has operated a similar project. Could you apply the materials designed for that project to your pilot? Can the other State provide suggestions that will allow you to operate your pilot more efficiently? Determine if there are other sources you can contact that could save you time, effort or money in developing the pilot.
What other actions could you take to achieve the purpose of the pilot?
Are there other actions you could use that would be more efficient or cost-effective while achieving the goals of the pilot? Even if you have determined that the proposed approach is cost-effective, consider other methods that may be preferable. Are there other actions you could use to complement your action plan? For example, should you follow up caseworker interviews with a telephone survey? Again, it may be useful to talk with other States that have operated similar pilots to determine other actions that can help you achieve your goals.
What type of training will be needed?
The amount of training, if any, that will be needed depends on the scope of your pilot. For example, if you plan to do targeted case reviews, most likely there will not be a great need for training since quality control staff are familiar with reviewing Medicaid cases for errors. However, if you plan to interview caseworkers to determine weaknesses in policy application, you may need to provide training to your staff on interviewing techniques or methods of collecting and analyzing data. Who will provide the necessary training? Can the training be done in-house or will staff need to travel to the training site? How much time will be needed to train staff? These questions will help you determine start-up costs and time so you can plan a reasonable implementation date.
Will a change in forms be required?
The type of pilot proposed will dictate if a change in forms is needed. For example, you may be able to use existing forms if you plan to conduct targeted case reviews. Using telephone surveys or questionnaires most likely will require you to develop new forms to capture the data as well as develop the actual surveys or questionnaires to be used in the pilot. You may need to consider the costs of printing new or revised forms in your cost-effective analysis.
Will coding changes be required?
Meet with the systems staff to determine if coding changes will be required for your pilot. Determine if it is reasonable to make these changes. For example, if you plan to operate your pilot for only 3 months and it will require complicated or extensive coding changes; you may want to consider other methods that will meet your goals.
What other staff will need to be involved?
You must plan to maintain the same amount of quality control staff effort for the pilot that was used to operate the traditional quality control program in your State. This maintenance of effort requirement is a condition of pilot approval. You will need to demonstrate that you are maintaining quality control staff effort in your pilot proposal.
Consider other staff who can provide valuable input when planning your pilot. Consider meeting staff from other States who may have suggestions, recommendations or advice on lessons they learned when planning their pilot. Consider meeting with the corrective action staff, managers from other program areas, training staff and other staff that will assist you in implementing the pilot. However, do not include these other staff members in your demonstration of maintenance of effort.
What kinds of problems can be anticipated?
This area is where staff from other States who have conducted similar pilots can be immensely helpful to you in avoiding pitfalls. Similarly, you could keep a record of events when you are developing your pilot that could help another State. Determine if you might have budget problems, lack of travel funds, absences due to vacations, holidays and other events that may delay or disrupt implementation. Allow for these delays when estimating your implementation date and the duration of the pilot.
How long will you operate the pilot?
Most States operate MEQC pilots on an annual basis. However, depending on the nature of your pilot, you may wish to operate the pilot on a 3 month or 6 month basis. Once you have implemented your pilot, if you find that you need more or less time; notify your regional office of the change in dates and the reasons for extending or abbreviating the duration of the pilot.
