Independent Third Party Review
Posted by: CQL on 12/29/2006
Filed under: Kentucky
Kentucky Department for Medicaid Services (DMS)
The Situation
Kentucky’s Department for Medicaid Services had a need for a qualified organization to provide an independent third party assessment of the federally funded providers of Home and Community Based Services.
What CQL Did
For six years (during the 1990s), CQL contracted with the Commonwealth of Kentucky’s Department for Medicaid Services (DMS) to conduct independent third party reviews to assure that only qualified providers of services were participating in the program. We conducted on-site surveys of providers in the Kentucky Alternative Intermediate Services for People with Mental Retardation (AIS/MR). These surveys used standards developed by Kentucky for providers under the Home and Community Based Waiver.
CQL survey teams visited residential, day, single and multi-service programs, and reviewed providers prior to the initiation of services. The following services were provided:
- Initial on-site visits and reviews of providers who had no previous experience as an approved provider
- Follow-up on-site reviews and surveys of providers with temporary/pending certification
- On-site reviews and surveys of all participating providers (for re-certification)
- Follow-up on-site reviews and surveys of participating providers and new providers whose initial review resulted in plans of correction
- On-site surveys of all residential settings and certify that residential providers meet criteria for individual certification
- Review of plans of corrections submitted by providers and submit letter recommending approval/disapproval to DMS
- Follow-up and investigation of complaints or critical incidents (such as reports of abuse, neglect, mistreatment, or exploitation) involving an AIS provider
- Expert witness testimony in appeals of decisions to de-certify and AIS provider
- Review of justifications of the designation of high-intensity services for individuals served by an AIS provider
In the final year of this contract CQL provided transition services, as state employees were trained in the procedures for conducting reviews. The responsibility for monitoring the Kentucky Waiver program was transferred to the Kentucky Office of Mental Retardation.