model of caremar 10, 2014 · model of care course summary a model of care creates the foundation...

Model Of Care

Virginia Premier Health Plan • 03/10/2014

Virginia Commonwealth University Health System Health Plan Division

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Model Of Care

Course Summary

A Model of Care creates the foundation for providing the best possible care

for the dually eligible population which includes individuals with:

• Intellectual and/or developmental disabilities

• Physical or sensory disabilities

• Serious and/or persistent mental illness

• Anticipated long-term support needs.

Within this session we introduced Member Rights. Four key rights the Model

of Care protects include:

• Timely access to a provider

• Treatment with quality, respect and dignity,

• Not to be treated against their will and

• Have prescriptions filled in a reasonable period of time.


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Model Of Care

Course Summary

Through the Model of Care, goals for the dually eligible

population include:

• Access to essential services

• Access to affordable care

• Coordination of care through an identified point of contact

• Seamless transitions of care across healthcare settings

• Access to preventive health care services

• Assuring appropriate utilization of services


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Model Of Care

Course Summary: Cultural & Disability Sensitivity

Understanding and delivering effective health communication is the charge

of all health care professionals. Effective communication can lead to

positive health outcomes, such as better use of the health care system,

better medical outcomes, and improved patient-provider relationships.

Cultural competence is the understanding of those values, beliefs, and

needs that are associated with member's age, gender identity, sexual

orientation, and/or racial/ethnic heritage, or religious background. Disability

competence is the understanding of the disability, attitudes, barriers,

abilities, and mental and physical challenges faced by this population.

Competence also includes a set of skills required to ensure appropriate,

sensitive health care to persons of varying cultures and beliefs and/or with

congenital or acquired disabilities.


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Model Of Care


Culture is central to health care. A person’s culture can affect:

• How health care information is received

• How rights are exercised

• What is considered to be a health problem

• How symptoms and concerns about the problem are expressed

• How they view and therefore follow instructions

• And the relationship boundaries deemed appropriate

• Effective communication in health care can only occur with a unified approach that takes

into consideration health care literacy, culture & disability sensitivity, and English

proficiency.

• A unified approach looks at communication from a member-centered perspective. A

member-centered perspective reflects the realities of people’s everyday lives and their

current practices, attitudes, beliefs, and lifestyles.


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Model Of Care


Health Plan literacy refers to an individual’s ability to read and understand

medical or health plan text and to follow instructions. Someone with low

health literacy may have difficulty navigating the health care system,

sharing health information, participating in managing his/her health care.

The third component of a unified approach to cultural sensitivity is English

proficiency. Limited English Proficiency (LEP) is defined as a limited ability

to read, write, speak or understand English. When members have trouble

communicating, the consequences can result in mistrust, dissatisfaction,

medical errors and changing plans.

Reducing health care disparity requires workforce training and

development, linguistic competency, and improving quality of care.


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Model Of Care


When members have trouble communicating with health care providers, the

consequences can result in a)mistrust, b)dissatisfaction, and c)medical

errors.

Finally the most important component of cultural & disability competency is

recognizing and acknowledging your own biases.

Be sure to examine personal biases, prejudices and filters. Talk with your

staff about the importance of never making assumptions based on

someone’s appearance, cultural background, English proficiency or

perceived abilities or disabilities.


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Model Of Care

Course Summary: Fraud & Abuse

The laws surrounding Fraud, Waste & Abuse include:

False Claims Act (FCA)

Anti-Kickback Statute

Physician Self-Referral Law (Stark Law)

Social Security Act

U.S. Criminal Code

Government agencies enforce these laws, including the…

Department of Justice (DOJ)

Department of Health & Human Services

Office of Inspector General (OIG)

Centers for Medicare & Medicaid Services (CMS)


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Model Of Care


The False Claims Act protects the federal government from

being overcharged or sold substandard goods or services.

The Anti-kickback Statute makes it a criminal offense to

knowingly and willfully offer, pay, solicit, or receive any

remuneration to induce or reward referrals of items or services

reimbursable by a Federal health care program.

Violation of these laws may result in nonpayment of claims, Civil

Monetary Penalties, exclusion from the Medicare program, and

criminal and civil liability.


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Model Of Care


The OIG is required to impose exclusions from participation in all

Federal health care programs on health care providers and

suppliers who have been convicted of:

Medicare fraud

Patient abuse or neglect

Felony convictions for other health care-related

fraud, theft, or other financial misconduct; or

Felony convictions for unlawful manufacture, distribution,

prescription, or dispensing of controlled substances.


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Model Of Care


Keeping clear documentation is important! Claims submitted should be

supported by documentation. Good documentation practice helps ensure

that your patients receive appropriate care from you and other medical

providers who may rely on your records.

When submitting Medicare claims, you are filing a claim with the Federal

Government. This session provided examples of improper claims billing

practices along with the rules of balanced billing. If you have questions

about these rules, review the Fraud & Abuse chapter. Also, remember that

when billing Medicaid, federal guidelines always take precedent over state

guidelines.

The Affordable Care Act requires drug, device, and biologic companies to

publically report nearly all gifts or payments they make to physicians in

2013.

model of caremar 10, 2014 · model of care course summary a model of care creates the foundation...

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