External Quality Review Organization

External quality review organizations (EQROs) examine health plans to determine compliance with Centers for Medicare and Medicaid Services (CMS) requirements and provide quality assurance oversight. APS Healthcare works with state Medicaid programs to conduct administrative, clinical and information technology reviews to assure that Medicaid recipients are receiving appropriate services.

APS Healthcare provides quality improvement, external review and other services for more than five million public sector behavioral and physical health beneficiaries throughout the United States.

APS’ external quality review process involves a comprehensive office-based and on-site review of documentation, technology and data, including medical records, to determine a health plan’s compliance with performance measures in areas such as:

• Utilization management
• Medical director, case management and care coordination
• Information systems
• Provider and contractor services
• Enrollee rights and protections
• Grievance systems
• Certifications and program integrity

APS’ EQRO professionals, including assessment and audit experts, provide states and health plans with a written assessment of the review process. In conjunction with the review process, APS offers innovative clinical recommendations based on the review findings to improve the quality of services for Medicaid beneficiaries.

APS’ EQRO approach proactively guides states to make improvements by comparing the performance of health plans across the state, highlighting best practices within the health plans and sharing these recommendations across the industry to promote improvements in the healthcare delivery system.

Each EQRO program is customized based on the needs of the state. APS’ primary EQRO activities include:

• Performance measure validation and performance improvement plan development and execution
• Field-based audits on clinical and administrative procedures
• Detailed review of IT analysis and system administration capabilities and practices
• Extensive consumer and stakeholder involvement and educational processes
• Comprehensive data collection, analysis and reporting
• Education and technical assistance
• Provider service reviews
• Continuous quality improvement and outcomes management