Medicaid Quality

Ursula Keller Weiss, PhD
Bureau Chief

2727 Mahan Drive
Mail Stop #38
Tallahassee, FL 32308

Phone: (850) 412-4147

The Quality Bureau provides data-driven, focused and systematic feedback on the quality of Florida’s Medicaid program to federal and state agencies, Medicaid recipients, Medicaid managed care plans, and providers. Florida’s 2014 transition from a mix of fee-for-service and managed care to mostly managed care hastened a newly-honed focus on quality: providing more comprehensive care, improving health outcomes, and reducing costs.

The Quality Bureau is responsible for the following:

  • Quality measurement and improvement
  • Research and evaluation of Medicaid managed care plans
  • Monitoring Medicaid managed care clinical outcomes
  • Oversight of prior authorization of services
  • Management of remaining Medicaid fee-for-service programs
  • Providing clinical consultation to the entire Agency

Federal Reports

The State of Florida is required to furnish a written quality strategy to the federal Centers for Medicare and Medicaid Services (CMS) every three years.  This report must include a written quality strategy for assessing and improving the quality of health care and services furnished by the managed care organizations and other providers within Florida Medicaid.  The Medicaid Quality Bureau of the Agency for Health Care Administration (the Agency) is compiling a new Comprehensive Quality Strategy (CQS) report, outlining Florida Medicaid’s priorities and goals for continuous quality improvement, the performance improvement efforts that align with and promote these priorities/goals, and the quality metrics and performance targets to be used in measuring performance and improvements to provide “better health care for all Floridians”.

A draft of the 2017 Comprehensive Quality Strategy report was submitted to CMS on March 3, 2017 for approval.  A copy of the draft report is located at the following link: Comprehensive Quality Strategy Report.

Performance Evaluation and Research

  • Establishes performance benchmarks for Medicaid managed care plans and analyzes results.
  • Leads managed care quality improvements.
  • Monitors specific programs for improvement opportunities.
  • Produces the Medicaid Health Plan Report Card comparing Medicaid Managed Medical Assistance (MMA) plans.

Clinical Quality Review and Initiatives

  • Research, identify, and communicate evidence-based strategies to improve performance. Visit the Innovation Center.
  • Educate Medicaid recipients on the importance of oral health and promote the utilization of preventive dental benefits for children ages 0-20. To learn more about oral health and Medicaid dental benefits visit Florida Medicaid Dental Care for Your Health.
  • Compare, review and evaluate care management processes to promote quality improvement strategies.
  • Facilitate collaborations between stakeholders.
  • Provide clinical support to the Agency as clinical subject matter experts and serve as a clearinghouse to maintain quality improvement information.

Quality Performance Review and Clinical Monitoring

  • Conduct quality reviews of the Medical Foster Care Program; Prescribed Pediatric Extended Care Program; Early Intervention Services; Medicaid Certified School Match Program; Project AIDS Care Waiver; Adult Cystic Fibrosis Waiver; and the Traumatic Brain and Spinal Cord Injury Waiver.
  • Participate in interagency child staffing meetings for medical neglect, behavioral health services, and the Children’s Multidisciplinary Assessment Team (CMAT).
  • Provide clinical reviews of managed care plan reports and initiatives.
  • Perform targeted monitoring of managed care services to ensure that Medicaid enrollees receive services provided in the quantity and quality required for treatment of the enrollee’s condition, in compliance with the Statewide Medicaid Managed Care (SMMC) contract.
  • Review and analyze data submitted by the SMMC plans for the Critical Incident Report – Individual; Adverse and Critical Incident Summary Report; PCP Appointment Report; ER Visits for Enrollees without PCP Appointment Report; Healthy Behaviors Report; and the Residential Psychiatric Treatment Report.

Utilization Management Contracts

  • Ensures that Medicaid recipients not enrolled in managed care plans receive medically necessary, quality services in the most cost-effective manner.
  • Manages prior authorization and utilization management contracts.
  • Monitors and provides technical assistance to fee-for-service Medicaid components.
  • Payment Error Rate Measurement