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MetaStar conducts this mandatory external quality review activity, to evaluate policies, procedures, and practices which affect the quality and timeliness of care and services provided to Managed Care Organization(MCO)/Health Maintenance Organization (HMO) members, as well as members’ access to services. MetaStar develops the methodology and tools for conducting and reporting results of quality compliance and comprehensive reviews, in collaboration with the Wisconsin Department of Health Services (DHS) and in accordance with Federal Regulation 438, Subpart E, using the Centers for Medicare & Medicaid Services (CMS) guide, External Quality Review Protocol 1: Assessment of Compliance with Medicaid Managed Care Regulations (2012).
MetaStar’s independent reviews cover three main focus areas:
For each MCO/HMO, the review process consists of a review of the organization’s contract with DHS; a review of requested and submitted documents; interviews with staff from numerous departments and functions, members and providers (upon direction of DHS); verification and validation activities; an analysis and compilation of findings; and a report of the results to DHS and the MCO/HMO.