Oregon Medicaid activities

External quality review activities

As the external quality review organization (EQRO) for Oregon’s Medicaid program, Acumentra Health conducts reviews of Coordinated Care Organizations (CCOs) and managed care organizations for the Oregon Health Authority (OHA).

Oregon Health Plan website

Acumentra Health conducts the three federally mandated activities described below.

Compliance review

Acumentra Health reviews CCO compliance with federal and state regulations and contract provisions regarding enrollee rights, access to care, structure and operation, and quality measurement and improvement.

PIP validation

Acumentra Health validates the CCOs’ Performance Improvement Projects, which are a required element of their quality improvement programs.

Performance measure validation

OHA uses statewide performance measures to assess the quality of healthcare services provided to Oregon Health Plan enrollees. As part of the validation of these measures, Acumentra Health assesses the information systems the CCOs use to calculate and report on the measures.

Mental health consumer satisfaction surveys

Since 2005, Acumentra Health has administered annual surveys of consumer satisfaction among adults (the Mental Health Statistics Improvement Project Survey for Adults) and children (the Youth Services Survey for Families) who receive managed mental health services through the Oregon Health Plan.

2011 Oregon Mental Health Statistics Improvement Project Survey for Adults (PDF)

2011 Oregon Youth Services Survey for Families

Mental health quality and utilization review

Acumentra Health conducts federally required quality and utilization review activities for all Oregon Medicaid Title XIX programs providing inpatient and residential psychiatric treatment to Medicaid recipients under 21 years of age or 65 and older. Review settings include psychiatric inpatient hospitals and psychiatric residential treatment centers.

Using criteria derived from federal and state requirements, Acumentra Health conducts preauthorization of care for children served in psychiatric residential treatment facilities, approves stays for clients age 18–21 and 65 and older in psychiatric state hospitals, and identifies quality-of-care concerns. Acumentra Health provides quality oversight of the psychiatric residential treatment facilities as negotiated with AMH.

On behalf of AMH, Acumentra Health determines whether individual Medicaid clients living in adult residential treatment facilities, foster homes, and other community-based settings are eligible for benefits under the Medicaid Home and Community-Based Services (HCBS) state plan. This demonstration program targets coordination of care for Medicaid clients with serious and persistent mental illness. Acumentra Health determines needs-based eligibility for HCBS by reviewing the client’s clinical record, including the mental health assessment, individual service plan, and other documentation. We conduct yearly re-evaluations of all people receiving services under this waiver.

In 2010, Acumentra Health conducted the first comprehensive study of Oregon’s adult residential mental health system—types of treatment provided, appropriateness of care in various settings, and barriers to independent living. AMH is using the information from our report to refine service delivery for adult residents and to strengthen clients’ ability to make a successful transition to independent living.