Month: November 2017

3. (40 points) Use the sample managed care contract of the Illinois Department of Healthcare and Family Services (the Illinois Medicaid agency) in the following link to answer the following questions:
 https://www.illinois.gov/hfs/SiteCollectionDocuments/201824001MCOModelContractRev3RedLine.pdf .
A. (2 points) Identify the section of the contract that names the parties to the contract.
i. Who are the parties to the contract?
ii. Which party is the Medicaid agency and which party is the managed care plan?
B. (2 points) Which party is paying for the services in the contract?
C. (6 points) Identify the sections of the contract which describe the following payment methodologies and describe the payment methodologies:
i. the base payment methodology
ii. sanction methodology
iii. bonus methodology
D. (30 points) Chapters 8, 10 and 11, respectively, discuss improving patient safety, utilization management, and organizing for quality.
i. (9 points) Organizing for Quality
a. Identify the section(s) of the contract that mandate that the managed care plan has a quality management system in place
b. Describe the quality management system that the contractor is required to implement
c. Identify the stakeholders involved and give an opinion as to why you think there is a mandate in the contract to include these stakeholders
d. Identify the topics selected for performance measure and improvement activities
ii. (9 points) Patient Safety Management
a. Identify the sections and describe two topic areas where patient safety is required
b. Describe the patient safety quality requirements
c. Identify the stakeholders involved and give an opinion as to why you think there is a mandate in the contract to include these stakeholders
d. Identify the sections where performance improvement tools are recommended for the patient safety guidelines and describe the tools
e. Identify the sections where data sources are recommended for the patient safety guidelines and describe the sources
f. Identify the sections and describe two performance measures used
iii. (9 points) Utilization Management
a. Identify the section(s) and describe the utilization review guidelines
b. Identify the sections and describe 2 of the following:
– the performance measures and standards used
– benchmarks used
– tools used
c. Identify the section and definition of the utilization management program
d. Identify one section where continuous improvement is required and describe the improvement
e. How and where is medical necessity defined?

f. Identify and describe one section of the contract that mandates

– prospective medical necessity review

– concurrent medical necessity review

– retrospective medical necessity review

g. Identify the section and describe the medical conditions for which clinical practice guidelines and best practices are required

h. Identify the section and describe the organizations and committees used to establish the basis for the clinical practice guidelines

iv. (1 point) Identify the sections of the contract where the Medicaid agency is demanding that the contractor address issues in Medicaid recipients access transportation and use of telemedicine. Describe the contractual requirements.

v. (1 point) Identify two sections of the contract where there are environmental requirements of the contractor related to state and federal environmental protection agencies. Give an opinion as to why these requirements exist.

vi. (1 point) Identify the section of the contract and the organization(s) responsible for accrediting the managed care plans.

4. Conduct an internet search for the following quality models for improving patient safety: Failure Mode and Effects Analysis (FMEA) and Root Cause Analysis (RCA).

a. Find an example of each model. For each model, identify the internet site and the date.

b. (9 points) For the FMEA model, identify:

i. The process that is being reviewed

ii. Process steps

iii. Potential failure mode for each step

iv. Potential effect of each step

v. The criticality score of each step

vi. The critical failure of each step

vii. The root cause of the critical failure for each step

viii. The actions intended to eliminate or reduce failure or mitigate effects of critical failure of each step

ix. The measures of success used for each step

x. Identify the quantitative and qualitative performance improvement tools that were discussed, respectively, in chapters 3 and 6 that were utilized in the FMEA models and give an opinion whether they were appropriate

xi. Identify the members of the performance improvement team and give an opinion if they are appropriate for the project (use Chapter 7 and 8 criteria)

xii. Why was the FMEA model chosen, e.g. the process that is being reviewed to prevent an adverse event, and given an opinion if FMEA is the appropriate model to utilize

c. For the RCA model

i. Identify the team members and give an opinion if they are appropriate for the project (use Chapter 7 and 8 criteria),

ii. Identify the adverse event

iii. Identify the causal factor(s)

iv. Identify the root cause(s)

v. Identify the action category (ies)

vi. Identify the risk reduction strategy (ies) implemented

vii. Identify the quantitative and qualitative performance improvement tools that were discussed, respectively, in chapters 3 and 6 that were utilized in the root cause models and give an opinion whether they were appropriate

viii. Why was the RCA model chosen and given an opinion if the RCA is the appropriate model to utilize