4. managed care organization and dental maintenance ... · care coordination and disease management...

Texas Contract Year 2016 External Quality Review Organization: Summary of Activities and Trends in Health Care Quality Version: 7.0 HHS Approval Date

4. Managed Care Organization and Dental Maintenance Organization

Structure and Process

The EQRO for Texas annually conducts:

Data certification to assess the completeness and validity of claims and encounter data

maintained by Texas Medicaid and CHIP MCOs.

AIs to assess MCO compliance with state and federal regulations in addition to different

components of MCO structure and process, including data systems capabilities and

processes and disease management programs.

Evaluations of MCO QI programs.

Evaluations of MCO PIPs.1

This section presents data certification findings on key elements in claims and encounter data,

select findings from AIs with each health plan, disease management programs, and QAPI

evaluations.

The EQRO conducts EDV studies every year. Each year the EDV studies alternate being for

MCOs and DMOs.2

An addendum is provided to the report that highlights PIP topics. A PIP topic reflects the health

plan’s enrollee characteristics including the demographics, disease prevalence, and disease

consequence. The topic addresses the patterns of over or underutilization that lowers an

enrollee’s health or functional status.3The addendum covers the three-year 2014 PIPs.

4.1. Data Certification

The EQRO annually certifies key data elements in claims and encounter data maintained by

Texas Medicaid and CHIP MCOs. Annual data certification includes four types of analyses: (1)

volume analysis based on service category, (2) data validity and completeness analysis, (3)

consistency analysis between encounter data and financial summary reports, and (4) validity

and completeness analysis of provider information.

Key data elements assessed during data certification include those that are critical for proper

care coordination and quality-of-care measurement. These include place of service code,

admission date, discharge status, discharge date, primary diagnosis code, National Provider

Identifier (NPI), provider taxonomy code, procedure code, and present-on-admission code.

The EQRO developed procedures for certifying the Texas Medicaid and CHIP encounter data

using two documents: (1) Texas Government Code §533.0131, Use of Encounter Data in

Determining Premium Payment Rates; and (2) U.S. Department of Health and Human Services,

CMS – Validation of Encounter Data Reported by the MCO.4,5 Data certification is conducted

separately for STAR, STAR+PLUS, STAR Health, CHIP, CHIP Dental, Medicaid Dental, CHIP

Perinate, and NorthSTAR. For managed care programs served by multiple MCOs (e.g., STAR,


CHIP, and STAR+PLUS), analyses are conducted at the plan code level (MCO and service

area combined).

Volume analysis based on service category

For each month of state fiscal year 2015 in each program and plan code, the analysis assessed

the number of records for facility, physician, dental (where present), and total services. The

EQRO examined monthly totals to determine the extent to which the number of records for each

of the service categories and the total number of records varied from month to month. The

EQRO found the results to be consistent for all plan codes based on overall volumes.

Data validity and completeness analysis

The EQRO examined the presence and validity of critical data elements in the claims extracts

submitted by the MCOs for state fiscal year 2015. The EQRO derived data validity standards

from accepted lists from a variety of sources, including data dictionaries supplied by HHS,

Current Procedural Terminology (CPT) manuals, and International Classification of Diseases,

10th Revision (ICD-10-CM) manuals.6,7 The EQRO analyzed the final image of all state fiscal

year 2015 claims received from Texas Medicaid and Health Care Partnership through

December 2015. All critical fields were present in the data as specified in the CMS Data

Validation Protocol.

Consistency analysis between encounter data and financial summary reports provided by the

MCOs

The EQRO compared payment dollars documented in the state fiscal year 2015 claims data to

payment dollars in the MCOs’ self-reported financial summaries provided by HHS. The analysis

found that consistency between encounter data and financial summary reports met the HHS

standard that claims data and the financial summary report must agree within three percent for

the data to be certifiable.

Validity and completeness analysis of provider information

Adequate provider identification is critical to the EQRO’s efforts to calculate HEDIS® and other

administrative measures and obtain medical records to validate encounter data and calculate

hybrid HEDIS® measures. For state fiscal year 2015, a valid NPI was found in almost all

encounters. When locating records, and particularly for attributing services to providers with

identified specialties (e.g., for HEDIS® measure calculation), the individual service provider must

be identified on the encounter, with the taxonomy (specialty) code included. The EQRO

assessed the quality of provider identification in the encounter data in two ways: (1) presence of

a primary NPI identified as an individual (not an organization) in the provider table; and (2)

taxonomy for the primary NPI on professional encounter records. Primary NPI was the first filled

NPI field among rendering, pay to, and billing NPI fields. Professional encounters had

transaction type ‘P’ and included a CPT code for evaluation and management services,

excluding non-office and non-hospital facilities, and non-face-to-face services.


Overall, the primary NPI on over 90 percent of these encounters was an individual. However,

within STAR+PLUS, all five MCOs had at least one service area where less than 80 percent of

encounters had an individual NPI as the primary NPI. When the primary provider identification

number is for a group and not the individual providing the service, the taxonomy reported or

associated with the identification number may not reflect the qualifications required for

calculating quality measure defined with provider constraints.

Certain quality of care measures rely on provider specialization information, and the accuracy of

these measures suffers when MCOs and DMOs do not submit complete information about

provider specialization in their encounter data. Examples of these problems are when

professional claims are submitted in which no individual person is named as the rendering

provider or when encounter data has missing provider identification numbers or taxonomy

codes. . If valid taxonomy information was absent on more than 5 percent of the encounters, the

EQRO considered this an area of concern. Overall, the EQRO identified 72 percent of

professional encounters in STAR, 78 percent in CHIP, and 69 percent in STAR+PLUS with an

individual NPI and included the taxonomy. For STAR Health, the rate was only 54 percent.

Because the valid taxonomy was absent more than five percent of the time, the EQRO

considered this an area of concern.

4.2. Administrative Interviews

CMS protocols for external quality review of Medicaid and CHIP managed care include AIs to

assess health plan compliance with relevant state and federal regulations. The AIs entails the

completion of a web-based tool by the health plan on an annual basis. The web-based tool

includes questions that address the state and federal regulations with which the health plans

must comply. The EQRO evaluates the health plans’ web-based tool, including reviewing

health plan policy and procedures, to assess health plan compliance with the state and federal

regulations. Each health plan receives a final score and a set of recommendations informing

them what regulations have not been fully met. This happens on an annual basis. Every year,

The EQRO either calls or visits the health plan to address outstanding issues with compliance

and collect supplemental information related to other CMS-required activities, such as the QAPI

and PIPs. The site visit rotation is set up to ensure that the EQRO visits each health plan at

least once every three years, as per CMS requirements in Protocol 1.

The EQRO conducted MCO AIs in 2016 that addressed the following areas:

Organizational structure

Member enrollment and disenrollment

Children’s programs and preventive care

Care coordination and disease management programs

Member services

Member complaints and appeals

Provider network and reimbursement


Authorizations and utilization management

Information systems

Data acquisition

In addition, the NorthSTAR questionnaire included items specific to BH, while the Medicaid

Dental and CHIP Dental questionnaires included items specific to dental health.

After MCO completion of the web-based AI tool, the EQRO conducted follow-up

teleconferences and site visits to further address quality and compliance. The EQRO conducted

AI teleconferences with 17 of the health plans and site visits with the remaining five. The EQRO,

working with HHS, selected to visit the health plans participating in the Dual Demonstration,

which included all of the health plans providing coverage for the STAR+PLUS population. The

teleconferences focused on health plan care coordination efforts and strategies. The site visits

focused on care coordination efforts and strategies in addition to LTSS and the Dual

Demonstration program.

4.2.1. MCO Compliance with State and Federal Regulations

The EQRO reviewed MCO responses on the web-based AI tool to assess compliance with state

and federal regulations. These regulations fall in the following categories.

General Provisions:

o Information about enrollment, benefits and access to care the MCOs are required

to provide to members

o Type and timeframe for communication of the required information to the

members

State Responsibilities:

o Timeframe requirements for disenrollment from a MCO by the State

Member Rights and Protections:

o Members’ rights to access to care and to participate in treatment

o Required coverage and payment of emergency and post-stabilization services

QAPIs:

o Provider network requirements and member access to out-of-network providers

o Requirements for identification and assessment of members with special health

care needs and the development of treatment plans for these members

o Process and timeframes for standard and expedited authorization of services

o Provider selection and credentialing

o Requirement that the MCO ensure that accurate and complete data reported by

providers is verified for accuracy and timeliness


Grievance System:

o Establishment of a grievance system which includes the processes by which a

provider or member may file a complaint or appeal, at the MCO or State level, in

accordance with federal and/or state regulations

o Timeframes for the MCO’s response to a complaint or appeal and the information

that must be included in the MCO’s response

The MCOs were in compliance with state and federal requirements overall, although no health

plans were compliant with 100 percent of the regulations. Table 1 shows the 2016 AI Evaluation

Scores and Percent Change from 2015.


Table 1. 2016 Administrative Interview Evaluation Scores and Percent Change from 2015

2016 Administrative

Interview Evaluation Scores

Administrative Interview

Evaluations Percent Change in Scores from 2015

to 2016i

(0-100) %

Health Plan Average 93.2 7.5

Aetna Better Health 95.4 22.6

Amerigroup 95.9 -2.0

Blue Cross and Blue Shield of Texas 94.3 0.6

CHRISTUS Health Plan 86.0 4.4

Community First Health Plans 97.8 0.4

Community Health Choice 86.3 16.3

Cook Children’s Health Plan 97.3 6.0

Dell Children’s Health Plan (formerly Seton) 96.2 29.4

Driscoll Health Plan 94.7 -0.4

El Paso First Health Plans, Inc. 95.6 1.8

FirstCare 97.8 13.5

Cigna-HealthSpring 93.9 5.1

Molina Healthcare of Texas, Inc. 96.3 19.7

Parkland Community Health Plan 79.7 -0.4

RightCare from Scott & White Health Plan 95.6 6.8

Sendero Health Plans 91.0 4.5

Superior HealthPlan 93.7 -2.6

Texas Children’s Health Plan 86.6 12.6

UnitedHealthcare Community Plan 95.6 3.4

i Changes in health plan scores could be attributed to improved documentation that they submitted during the AI process and modified policies to meet state and federal requirements.


4.2.2. Disease Management Programs

HHS requires all MCOs participating in STAR, STAR+PLUS, CHIP, and STAR Health to provide

disease management services covering asthma and diabetes.8 In addition to asthma and

diabetes, HHS requires MCOs participating in STAR+PLUS to offer disease management for

chronic obstructive pulmonary disease, congestive heart failure, and coronary artery disease.

Finally, all MCOs are required by HHS to provide disease management programs for other

chronic diseases based on disease prevalence within each MCO's membership.9 In calendar

year 2015, these included programs for depression, attention deficit hyperactivity disorder, other

mental and BH, high-risk perinatal, human immunodeficiency virus / acquired immunodeficiency

syndrome, hypertension, oncology, obesity, and general disease management.

This section presents findings from calendar year 2015 MCO AIs on the structure and practice

of disease management and health promotion programs operating in Texas Medicaid and CHIP

MCOs, focusing on programs that are required by the state.


Table 2, Table 3, and Table 4 show rates of member participation in select disease-

management programs in STAR, CHIP, and STAR+PLUS, respectively, in calendar year 2015.

Active members are defined as members (or their representatives) with one or more telephonic

or face-to-face encounter with disease-management staff.

Fewer than one in five eligible members participated in asthma disease management in STAR

(18.6 percent) or CHIP (14.9 percent). Disease management participation rates were higher in

STAR+PLUS for both asthma (52.6 percent) and diabetes (48.2 percent).


Table 2. STAR – Member Participation in Disease Management Programs, 2015

Active

Members Members

Eligible Participation Rate

Depression 2,889 4,542 63.6%

General Disease Management 5,704 9,656 59.1%

High-Risk Obstetrics 6,535 27,738 23.6%

Asthma 56,054 301,063 18.6%

Attention Deficit Hyperactivity Disorder 1,510 16,124 9.4%

Mental and Behavioral Health 4,403 46,652 9.4%

Diabetes 7,955 190,613 4.2%

Table 3. CHIP – Member Participation in Disease Management Programs, 2015

Active

Members Members


Depression 225 323 69.7%

General Disease Management 236 420 56.2%

Asthma 5,358 35,891 14.9%

High-Risk Obstetrics 537 7,850 6.8%

Attention Deficit Hyperactivity Disorder 93 2,915 3.2%

Diabetes 538 23,379 2.3%

Mental and Behavioral Health 715 33,723 2.1%

Table 4. STAR+PLUS – Member Participation in Disease Management Programs, 2015

Active

Members Members


Obesity in Adults 453 453 100.0%

Chronic Obstructive Pulmonary Disease 2,903 4,934 58.8%

Congestive Heart Failure 2,264 4,153 54.5%

Coronary Artery Disease 2,266 4,156 54.5%

Asthma 3,873 7,368 52.6%

Diabetes 15,383 31,918 48.2%

Human Immunodeficiency Virus / Acquired Immunodeficiency Syndrome

774 1,719 45.0%

Mental and Behavioral Health 3,447 8,287 41.6%

Depression 1,148 3,149 36.5%

General Disease Management 4,214 12,626 33.4%


4.3. Quality Improvement

The EQRO annually reviews the Texas Medicaid MCO QI programs to evaluate aspects of

structure and process that contribute to their success, and to assess compliance specified in the

CFR. This section discusses the EQRO’s evaluation of calendar year 2016 MCO QAPI

programs as they pertain to 42 CFR §438.358 Activities Related to External Quality Review and

42 CFR §438.364 External Quality Review Results.

4.3.1. Quality Assessment and Performance Improvement Program Evaluations

Evaluations

The QAPI Program Evaluations follow CMS guidelines to evaluate both quality assurance and

QI practices of the Texas Medicaid MCOs. CMS specifies five essential elements of a quality

assessment and performance-improvement program: (1) design and scope; (2) governance and

leadership; (3) feedback, data systems, and monitoring; (4) performance-improvement projects;

and (5) systematic analysis.10 This review covers the first three elements and part of the fifth.

Using documentation submitted by the MCOs, the QAPI program evaluations review the MCOs’

performance-improvement structures and program assessments. This evaluation captures the

structure and process of the QI program through review and scoring of the following sections:

Documentation of the MCO’s work plan, QI organizational chart, performance-improvement

projects and completed quality assessment and evaluation of those projects (maximum 3.75

points).

Role of the Governing Body, covering the level and type of governance and leadership

within the organization (maximum 10 points).

Structure of QI Committee(s), including the role, structure, and function of QI committee(s),

and level of provider and member representative involvement (maximum 3.75 points).

Identification of Adequate Resources, including human and material resources available for

the QAPI program (maximum 10 points).

Identification of Improvement Opportunities, including actions taken to improve at the

system, process, and outcome levels (maximum 10 points).

Program Description, including the MCO’s statement of purpose, scope, goals and

objectives, organization-wide communication of results, methodology, and monitoring and

evaluation of progress toward accomplishing goals and objectives (maximum 10 points).

Assessment of Overall QAPI Program Effectiveness, including the method by which the

MCO addresses barriers to implementation, factors of success, and program effectiveness

(maximum 3.75 points).

Clinical Practice Guidelines, including a review of current clinical practice guidelines to

ensure they are evidence-based, relevant to member needs, and support care of members

and services for members (maximum 3.75 points).

Availability and Accessibility Indicators, including results of MCO monitoring of member

access-to-care indicators, goals for all indicators, the MCO’s actions to improve rates of


accessibility and availability of care for members, and the effectiveness of actions taken

(maximum 10 points).

Clinical Quality Indicators, including results of MCO monitoring of clinical indicators, goals

for all indicators, the MCO’s actions to improve rates of clinical indicators, and the

effectiveness of actions taken (maximum 10 points).

Service Quality Indicators, including results of MCO monitoring of service indicators, goals

for all indicators, the MCO’s actions to improve rates of service indicators, and the

effectiveness of actions taken (maximum 10 points).

Credentialing/Re-credentialing, summarizing the number of providers and facilities

credentialed or re-credentialed, the number who requested or were denied credentialing,

reasons for denials, the number who were reduced, suspended, or had privileges terminated

during calendar year 2015, and the reasons for these reductions, suspensions, or

terminations (maximum 3.75 points).

Delegation of QAPI Program Activities, including procedures for monitoring and evaluating

delegated functions, results of evaluation of delegated activities, and deployment of the

results to improve quality (maximum 3.75 points).

Corrective Action Plans, including any corrective actions required and taken following a

Texas Department of Insurance audit (maximum 3.75 points).

Previous Year’s Recommendations, including a review of whether and how the MCO

addressed the recommendations (maximum of 3.75 points).

Each section includes different components that target key elements of QI, as described above.

The overall evaluation of health plan responses focuses on whether the MCO satisfied the

requirements of a strong, comprehensive QI program and complied with specific CFR

policies.11,12


Scoring Methodology

The scoring system rates each MCO on a scale of 0-100 based on its QAPI summary report.

The QAPI program evaluation includes 15 activities. The EQRO calculated the scores for each,

then weighted them to assign more importance to those activities representing the five essential

components of a successful QI program as described above. Excluding Element 4 PIPs,

evaluated separately, the EQRO applied more weight to the following activities, together

representing 70 percent of the score. Each of these activities contributed 10 percent of the final

score:

A1: Role of Governing Body (CMS Element 2)

A3: Adequate Resources (CMS Element 2)

A4: Improvement Opportunities (CMS Elements 3 and 5)

B1: Program Description (CMS Elements 1 and 3)

B4: Availability and Access to Care Monitoring and Results (CMS Elements 3 and 5)

B5a: Clinical Indicator Monitoring (CMS Elements 3 and 5)

B5b: Service Indicator Monitoring (CMS Elements 3 and 5)

The remaining eight activities accounting for 30 percent of the final score are also important

components of the QI program. These eight capture the health plan's compliance with CFR

policies or support the above activities:

Required Documentation

A2: Structure of QI Committee(s)

B2: Overall Effectiveness

B3: Clinical Practice Guidelines

B6: Credentialing and Re-credentialing

B7: Delegation of QAPI Activities

B8: Corrective Action Plans

B9: Previous Year’s Recommendations

The EQRO divided the 30 points allotted to these activities evenly among all those applicable.

For any activity that did not apply to a plan, the EQRO scored the activity as N/A and

redistributed the points to all remaining activities. Overall, the final weighted scores allow for a

more accurate analysis of the MCOs’ QI programs. The results presented below are based on

the QAPI program evaluations reporting on data elements and occurrences during calendar

year 2016.

Table 5 shows the overall score for each health plan. The average score of all health plans was

95.6 percent. Fourteen of 22 MCOs or dental plans scored above that. All plans, with the

exception of Cook Children’s Health Plan, scored above 90 percent.


Table 5. Quality Assessment and Performance Improvement Scores by Health Plan, Measurement Year 2016

Health Plan Score

Average 95.6%

Aetna Better Health 99.4%

Parkland Community Health Plan 98.4%

UnitedHealthcare Community Plan 98.4%

Superior HealthPlan 98.1%

Driscoll Health Plan 97.6%

Dell Children’s Health Plan (formerly Seton) 97.5%

Texas Children’s Health Plan 97.5%

Blue Cross and Blue Shield of Texas 97.4%

RightCare from Scott & White Health Plan 96.9%

El Paso First Health Plans, Inc. 96.8%

FirstCare 96.8%

Amerigroup 96.7%

Community Health Choice 96.3%

DentaQuest 96.3%

Sendero Health Plans 94.6%

MCNA Dental 93.8%

ValueOptions 93.5%

Community First Health Plans 93.1%

Cigna-HealthSpring 92.8%

CHRISTUS Health Plan 91.4%

Molina Healthcare of Texas, Inc. 91.1%

Cook Children’s Health Plan 89.8%

The EQRO also evaluated the plans’ QAPI program summary reports by section to identify

areas of high performance and opportunities for both systematic and individual improvement.

Table 6 presents the average QAPI program summary report activity score, calculated as the

average weighted score across all MCOs for each activity. Overall, the MCOs scored highest in

activities related to: A1: Role of governing body; B7: Delegation of QAPI Activities; and B8:

Corrective Action Plans, with scores of 100 percent. The score for B9: Previous Year’s

Recommendations is low because one health plan received a zero, 11 health plans received a

50, and only nine received a 100.


Table 6. Quality Assessment and Performance Improvement Scores by Activity, Measurement Year 2016

Activity Score

Average 95.3%

A1: Role of Governing Body 100.0%

B7: Delegation of QAPI Program Activities 100.0%

B8: Corrective Action Plans 100.0%

A2: Structure of Quality Improvement Committee(s)

99.7%

B6: Credentialing and Re-credentialing 99.4%

B5a: Clinical Indicator Monitoring 98.9%

Required Documentation 98.9%

B5b: Service Indicator Monitoring 98.5%

B3: Clinical Practice Guidelines 97.7%

A4: Improvement Opportunities 97.3%

B4: Availability and Access to Care Monitoring and Results

96.2%

B1: Program Description 92.6%

B2: Overall Effectiveness 92.4%

A3: Adequate Resources 92.0%

B9: Previous Year’s Recommendations 65.9%

Quality Assessment and Performance Improvement Recommendations

In the 2016 QAPI program evaluations, the EQRO made a number of recommendations to each

MCO to strengthen QI practices based on activities in 2015. Table 7 provides examples of

recommendations made for each activity. Importantly the EQRO recommended that health

plans: develop long-term goals for their QI programs; evaluate and report on the effectiveness

of access to care, clinical indicator, and service indicator monitoring; and evaluate and report on

the effectiveness of the overall program.


Table 7. Examples of Recommendations Made for Quality Assessment and Performance Improvement Programs in STAR, CHIP, STAR+PLUS, and STAR Health, 2016

Activity Example Recommendation

Required Documentation Complete all sections of the Quality Assessment and Performance Improvement evaluation tool.

Role of Governing Body Describe actions taken by the governing body to modify the quality improvement program. Indicate if no actions taken.

Structure of Quality Improvement Committee(s)

Specify which committee members have clinical and non-clinical voting rights.

Adequate Resources Provide greater detail about human resources available to operate and oversee the quality improvement program.

Opportunities for Improvement

Describe the process of how non-clinical improvements were identified.

Program Description Develop long-term goals for overall and measure-specific quality improvement.

Overall Effectiveness Include an evaluation of the overall effectiveness of the quality assessment and performance-improvement program.

Clinical Practice Guidelines Detail how guidelines are relevant to member needs.

Access to Care Monitoring and Results

Evaluate and report the effectiveness of actions and provide future actions for all indicators.

Clinical Indicator Monitoring and Results

Include an analysis of the effectiveness of actions such as the percentage change in measurement from the previous year.

Service Indicator Monitoring Report change in rates from the previous year.

Credentialing and Re- credentialing

Report number of facilities credentialed during the measurement period. Indicate if none.

Delegation of Activities Describe identified improvements or corrective actions for all delegated functions as needed.

Corrective Action Plans Provide the completion date or targeted date for completion.

Previous Year’s Recommendations

Address all previous year’s recommendations, describe how each was incorporated into the QAPI program, and describe actions to meet the recommendation.


References

1 Please note, the results of the PIPs will be reported in the addendum to this report. There are four sets of PIPs discussed in this report and the addendum: 1) the 2-year, 2014 PIPs, which started in January 2014 and continued through December of 2015; 2) the 3-year, 2014 PIPs, which started in January 2014 and continued through December 2016; 3) the 2016 PIPs, which started in January 2016 and will continue through December 2017; and 4) the 2017 PIPs, which started in January 2017 and will continue through December 2019. The 2-year and staggered implementation of the PIPs and allows the opportunity to evaluate and assess outcomes over time while still being able to initiate new PIPs to address opportunities for improvement that are identified through the evaluation of performance measurement.

2 The EQRO’s encounter data validation studies were conducted on an annual basis until 2012, at which time they shifted to a biennial schedule.

3 CMS (2012). Available at: https://www.medicaid.gov/medicaid/quality-of-care/downloads/eqr-protocol-3.pdf

4 Texas Government Code § 533.0131. Available at: http://www.legis.state.tx.us/tlodocs/77R/billtext/html/HB01591F.htm.

5 CMS. 2012.

6 AMA. 2011. CPT – Current Procedural Terminology. Available at: http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt.page

7 CDC. 2009b. International Classification of Diseases, Ninth Revision (ICD-9). Available at: http://www.cdc.gov/nchs/icd/icd9.htm

8 Texas HHS. 2008. Texas Medicaid and CHIP Uniform Managed Care Manual: Disease Management. Available at: https://hhs.texas.gov/services/health/medicaid-chip/provider-information/contracts-manuals/texas-medicaid-chip-uniform-managed-care-manual.

9 Texas HHS. 2008.

10 CMS. 2012. Preview of Nursing Home Quality Assurance & Performance Improvement (QAPI) Guide – QAPI at a Glance. Available at: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-05.pdf.

11 HRSA (Health Resources and Services Administration), 2011. Developing and Implementing a QI Plan. Available at: http://www.hrsa.gov/quality/toolbox/508pdfs/developingqiplan.pdf.

12 CMS. 2012.

https://www.medicaid.gov/medicaid/quality-of-care/downloads/eqr-protocol-3.pdf

https://www.medicaid.gov/medicaid/quality-of-care/downloads/eqr-protocol-3.pdf

http://www.legis.state.tx.us/tlodocs/77R/billtext/html/HB01591F.htm

http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt.page



http://www.cdc.gov/nchs/icd/icd9.htm

http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-05.pdf



http://www.hrsa.gov/quality/toolbox/508pdfs/developingqiplan.pdf

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