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documentation in the medical record will be compared to specific criteria and standards developed by the Wisconsin Medicaid medical consultants with provider input.

• Medical consultants who are specialists in the area under review will conduct a number of on-site administrative and clinical audits.

• Grievance audits and reviews of grievances received from recipients and providers will assure that the contracted managed care organizations are complying with the rules of BadgerCare Plus.

• The Wisconsin Medicaid contract will continue to require each HMO to employ at least one full-time internal advocate for recipients to help ensure that the HMO remains responsive to recipients' concerns.

KEY ELEMENTS:

Performance-based contract

Defines roles, structure and process

Includes QAPI program, access and other requirements

Includes data system, encounter data and reporting requirements

Enforcement tools-intermediate sanctions up to termination To view the HMO contract, go to: http://www.dhfs.state.wi.us/medicaid7/providers/pdfs/mc10051.pdf

Automated performance measures:

Wisconsin monitors MCO performance using automated clinical performance measures called MEDDIC-MS (Medicaid Encounter Data Driven Improvement Core Measure Set). The measure set has been evaluated by AHRQ (the Agency for Healthcare Research and Quality) and approved for inclusion in the National Quality Measures Clearinghouse. Using the system, the state can monitor 59 indicators, including private accreditation status. Wisconsin publicly reports the clinical indicator data on its Medicaid managed care website. Reporting is done annually.

Non-clinical performance indicators: Wisconsin reports non-clinical performance data based on enrollee satisfaction surveys which are done by the DHFS bi-annually on a state-wide basis. In addition, the DHFS monitors grievance and complaint data. Other non-clinical data sources include:

WISCONSIN

Effective Date:

Approval Date: 35