Operational and Financial Reviews

In this section:

Definitions
Purpose of Reviews
Frequency of Reviews
Notifying a Contractor About a Review
Contractor Preparation for an On-site Review
Review Team Activities During Review
Final Report to Contractor

Definitions


AHCCCSA: Arizona Health Care Cost Containment System Administration

Arizona Administrative Code: State regulations established pursuant to relevant statutes and referred to as "AHCCCS rules."

Contractor: A person, organization or entity agreeing through a direct contracting relationship with AHCCCSA to provide the goods and services specified by contract in conformance with the stated contract requirements, AHCCCSA statute and rules and federal law and regulations.

Review Team: Includes, but is not limited to, staff from the AHCCCS Office of Managed Care and the AHCCCS Office of Medical Management.

Purpose of Reviews

To ensure a contractor's operational and financial program compliance with their contract with AHCCCSA. Reviews will:

Determine if the contractor satisfactorily meets AHCCCS requirements as specified in contract, policy and rule.
Review the progress made toward implementing the recommendations made during the previous review.
Determine if the contractor is in compliance with its own policies and procedures, and evaluate the effectiveness of those policies and procedures.
Improve the agency's knowledge of the contractor's operational and financial procedures.
Provide advice and identify areas in which improvements can be made, as well as identifying areas of noteworthy performance and accomplishment.

Frequency of Reviews

As required by Arizona Administrative Code Rules R9-22-521 and R9-31-521, AHCCCSA will conduct a program compliance audit of a contractor at least every 12 months during the term of its contract with the contractor. AHCCCSA may also conduct an Operational and Financial Review in the event the contractor undergoes a merger, reorganization, change in ownership or makes changes in three or more key staff positions within a 12 month period.

Notifying a Contractor About a Review

Except in cases where advance notice is not possible or advance notice may render the review less useful, AHCCCSA will give the contractor at least three weeks advance notice of the date of the on-site review.

Contractor Preparation for an On-site Review

Contractors are to cooperate fully with AHCCCSA and the AHCCCSA Review Team by forwarding in advance policies, procedures, job descriptions, contracts, logs and other information that AHCCCSA may request. The contractor is to have all requested medical records on-site, and any documents not requested in advance by AHCCCSA should be made available upon request of the Review Team during the course of the review. The contractor's personnel identified in advance should be available to the Review Team at all times during AHCCCSA's on-site review activities.

While on-site, the contractor shall provide the Review Team with:

Workspace
Access to a telephone
Electrical outlets
Privacy for conferences

Review Team Activities During Review

The Review Team may perform any or all of the following procedures:

Conduct private interviews and group conferences with members, physicians, and other health professionals and members of the contractor's administrative staff including, but not limited to, the contractor's principal management persons;
Examine records, books, reports, and papers of the contractor and any management company, and all providers or subcontractors providing health care and other services to the contractor. The examination may include, but not limited to:

Minutes of medical staff meetings

Peer review and quality of care review records

Duty rosters of medical personnel

Appointment records

Written procedures for the internal operation of the contractor

Contracts and correspondence with members and providers of health care services and other services to the plan

Additional documentation deemed necessary by AHCCCSA to review the quality of medical care

Final Report to Contractor

The contractor will be furnished a copy of the Operational and Financial Review Report and given the opportunity to comment about any review findings prior to AHCCCSA publishing the final report. Recommendations made by the Review Team to bring the contractor into compliance with federal, State, AHCCCSA and/or contract requirements must be implemented by the contractor.

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