Client Spotlight: The State of New Mexico’s MES Quality Assurance Module — Benefits and Best Practices

April 28, 2021

The Medicaid Management Information System (MMIS) is critically important as state Medicaid programs process claims and information. Over time, the Centers for Medicare and Medicaid Services (CMS) has issued new MMIS-related standards and states have modernized their IT infrastructures to conform with them.

Medicaid Enterprise Systems (MES), for example, is part of the Medicaid Information Technology Architecture Guidance – Version 3.0 (MITA 3.0). The goal of MES is to create a seamless, integrated system with interoperability and common standards that maintain flexibility and rapid response. MES’ modular capabilities enable services or vendors to plug and play without replacing the entire enterprise system. Each state has the freedom to structure and develop MES modules to meet their unique needs.

When states update their systems to support Medicaid requirements, CMS allows them to use contractual services to design, develop, install or enhance their mechanized claims processing and information retrieval systems. This is exactly how the state of New Mexico decided to proceed when modernizing its MMIS Quality Assurance module.

The Benefits of a Modular Approach to MMIS Updates

New Mexico’s chose MES’ modular, enterprise-wide approach for its Quality Assurance module because it is more flexible, interoperable and person-centric for multiple state agency partners. Following CMS’ direction, New Mexico tailored the MES modules to fit its needs. For the Quality Assurance module, for example, the team combined various industry-accepted MES modules into a Business Process Outsource (BPO) service solution. The benefits of BPO services include reduced costs and increased productivity.

The New Mexico Human Services Department signed an agreement with HMS to manage the MMIS Quality Assurance (QA) module. The use of contractual services enabled the state to manage the HMS’ work in terms of functionality, efficiency, performance and outcomes, rather than requiring the enabling technology itself.

New Mexico’s MES QA module includes program integrity; third-party liability (TPL) detection, avoidance, and recovery; fraud abuse detection and reporting services; audit and hearing coordination; and quality reporting and recovery audit contracting (RAC). By combining all payment accuracy services into the QA module and integrating all payment integrity services, New Mexico can now better coordinate and identify fraud, waste and abuse (FWA).

Six Best Practices for Medicaid Enterprise Systems Projects

New Mexico’s MES Quality Assurance module project highlights six best practices that other states may want to adopt when launching similar initiatives:

  1. Solicit feedback from business owners and MES work groups. This enabled the state of New Mexico to understand current constraints impacting their practice, as well as current and future needs.
  2. Engage vendors early in the module creation discussions. In this way, New Mexico harnessed best-in-class concepts to shape the QA module, based on innovative solutions supported in the marketplace. The result was strategic procurement that reflected both the state’s needs and marketplace realities.
  3. Combine similar services into one module. This approach provides better visibility into state programs and improves recoveries. Results can be shared across the module to improve functionality. In addition, implementation is faster, since features don’t need to be developed from the ground up.
  4. Contract with a single vendor. A single point of contact maintains consistency for providers and carriers that interact with MES. In addition, other vendors receive information from one source.
  5. Adopt an Agile implementation methodology. By using Agile for its QA module, New Mexico was able to implement real-time services sooner. Simultaneously implementing alongside other modules ensures continuity of savings and recoveries during the design, develop and implement phase.
  6. Apply service level agreements (SLAs) explicitly related to the services provided. SLAs ensure oversight and state recourse options, facilitate consistency and maintain flexibility.

By using these best practices, New Mexico attracted best-in-class bidders that offered innovative, high-value solutions at competitive rates. The state now has better visibility and oversight of managed care organization performance and state audits, insight into claims data trends that point to potential FWA and better cost avoidance for COVID-19 claims for the New Mexico Department of Health.

To learn more about the benefits that the State of New Mexico has derived from its MES QA module, contact us today!

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