provider operations. 2 provider relations & network development provider accountability
TRANSCRIPT
Provider Operations
2
Provider Operations
Provider Relations &
Network Development
Provider Accountability
3
Credential and recredential providers (includes ongoing monitoring between credentialing cycles)
Establish Medicaid and State Funded contracts with providers (includes maintaining providers in the Alpha system)
Complete contract amendments as necessary Conduct initial site reviews for the contract process Serve as primary contact for providers who need consultation
regarding contract compliance and other contract issues (each contracted provider is assigned to a Provider Relations Specialist)
Capacity Studies and Community Needs Assessments Conduct RFPs for new services and service gaps
Provider Relations and Network Development
4
Charles Hill, M.Ed., LPC Provider Relations and Network Development DirectorProvider Operations Division
Provider Relations and Network Development
Provider Relations Specialist Adrianne Lewis, MSW, MPA Amy Rudisill, BSAngela Scott, MBA Cynthia Benjamin, BARosalind Barksdale, BSW
Credentialing CoordinatorNakia Alexander, MBA
Administrative SupportDenise Onativia, BA
5
Conduct routine monitoring of all public MH/DD/SA providers in the network
Conduct Program Post Payment reviews Respond to provider complaints Conduct focused monitoring reviews Conduct Follow Up reviews for POCs Serve as primary contact for providers who need
consultation or technical assistance regarding monitoring issues.(Do not have provider assignments)
Provider Accountability
6
Kimberly Alexander, MBA Angela Jackson, MS Provider Accountability Manager Provider Accountability ManagerProvider Operations Division Provider Operations Division
Regulatory Compliance Analysts
Denise Polk, MS - Team Lead Dana Frakes, LPC - Team LeadMelanie Cannon, LCSW Kellie Anderson, MBAKathy Cunningham, BS Melissa, Freedman, MSWCarnice Essex, MS Donde Jones, MBASharisse Johnson, MBA Synovia Pettice, MHDL, LCASCelena Thaggard, MBA Miguel Sabillon, BA Lakisha Suber, MAGwen Drayton, Administrative Support
Provider Accountability Team
7
Effective July 1, 2012 – DHHS eliminated the use of the Provider Monitoring Tool (PMT) and the Frequency and Extent Monitoring Tool (FEM)
Tools were adopted from Cardinal Innovations Healthcare Solutions formerly known as Piedmont Behavioral Healthcare (PBH).
Legislation clearly states LME/MCOs will adhere to the PBH model.
Gold Star Monitoring
8
DHHS has worked with Cardinal Innovations to modify and enhance Gold Star Monitoring for Statewide implementation.
Representatives from various LME/MCOs provided feedback by participating in an independent peer review of the tools or by participation in special focus groups to help fine-tune the tools to facilitate replication statewide.
Coordination between DHSR and LME/MCOs
Gold Star Monitoring
9
Surveys conducted by DHSR in the previous 15 months will serve in lieu of the LME/MCO conducting Initial or Routine Monitoring on licensed facilities◦The LME/MCO will only conduct the post payment
review portion of the Gold Star Monitoring tool for these facilities
Effective April 1, 2013 use of revised Gold Star Monitoring Tools
Gold Star Monitoring
10
There are some policies and provider expectations cited within the review tools that help to directly address a number of qualitative measures that are not necessarily found in rule per se, but nevertheless reflect best practice/evidence-based practice standards and guidelines. Some of these policies are grounded in rule and may even reference some of the specific rules or statutes, while some items monitored during the Gold Star process assess compliance with LME/MCO provider contract requirements, the American with Disabilities Act, specific Centers for Medicare and Medicaid Services requirements, national accreditation standards, clinical coverage policies [CCP 8A through 8O], the Records Management and Documentation Manual [APSM 45-2], and DMA/DMH/DD/SAS Implementation Updates.
Gold Star Monitoring Guidelines
11
Applies to Two Types of Contracted Providers
Provider Agencies
Licensed Independent Practitioners (LIPs)
Gold Star Monitoring
12
Regulatory Compliance
Quality Performance
Documentation
Integrity of Billing
Focus of Monitoring Tools
13
Request to Enter the Network (initial enrollment) Initial (Implementation) Reviews
All contracted providers of direct services will have an initial review with the exception of ICF-IDD services (DHSR-Mental Health Licensure), Hospital services (DHSR- Acute and Home Care) and Assertive Community Treatment Team (DHHS).
Routine Reviews Advanced Placement on the Provider Performance
Profile• Preferred, Exceptional, Gold Star Status (PEGS)
Request to Expand the Provider’s Service Array
The Phases of Gold Star Monitoring
14
Initial Monitoring (Year 1) Occurs 90 days after the first reimbursement
has been made on claims submitted by the provider (Starting March 1, 2013)
Sample Size = 10 dates of service Look Back Period = Previous 6 months (or March 1, 2013 to present) Successful completion of review >= 85%
=Routine Status
Implementation Review
15
Occurs annually (starting Year 2)
Sample Size = 30 dates of service
Look Back Period = Previous 6 months
Successful completion of review >= 85% Provider Agencies - Routine Status
- Request Advanced Placement
Routine Review
16
Rights Notification and Funds Management* Record Review* Personnel Review* Medication Review Health, Safety and Compliance Review AFL Health & Safety Review Cultural Competency Review (after 1st year in network) Post-Payment Review* Each review tool has an accompanying guide which outlines
the requirements to meet the standard. * Check Sheets will be used for all reviews
Monitoring Tools for Initial/Routine Reviews
17
Post-Payment Reviews (PPR) are used to assure that payments are made for services delivered to beneficiaries. Any overpayments identified by this review are required to be recouped or collected.
PPR involve examination of claims, payment data, medical record documentation, financial records, administrative research,
application of Medicaid coverage policies, and any additional information to support provider's operations and processes. Post-payment reviews may be conducted via on-site visit or desk review.
PPR are about monitoring the providers to make sure they are in compliance with clinical coverage policies, state, and federal rules and regulations
Post Payment Reviews
18
PPR tools shall be used when LME-MCO conduct special audits or investigations related to program integrity activities in accordance
with DHHS/ LME-MCO Contract, 42 CFR 438.608, 42 CFR 455.14, and 42 CFR 456.23.
Post Payment Reviews
19
Child and Adolescent Day Treatment Diagnostic Assessment Innovations LIP Outpatient Opioid Treatment PRTF Residential Services- Child MH Level II, III & IV Generic
Post Payment Review Tools
20
Ambulatory Detoxification Assertive Community Treatment Team- PPR only Community Support Team ICF-IDD- PPR only Intensive In-Home Services Medically Supervised or ADATC Detoxification/Crisis Stabilization Mobile Crisis Management
Generic PPR Tool
21
Multisystemic Therapy (MST) Non-Hospital Medical Detoxification Outpatient (Agencies) Partial Hospitalization Peer Support Services Professional Treatment Services in Facility- Based
Crisis Program Psychosocial Rehabilitation
Generic PPR Tool
22
Substance Abuse Comprehensive Outpatient Treatment Program
Substance Abuse Intensive Outpatient Program Substance Abuse Non-Medical Community
Residential Program Substance Abuse Medically Monitored Community
Residential State funded services (i.e. CAET, Group Living)
Generic PPR Tool
23
Staffing ratios- Specific to Child Residential Treatment (except TFC)
Staff Qualificationso Ambulatory Detoxificationo Assertive Community Treatment Teamo Community Support Teamo Facility Based Crisiso Intensive In-Home Serviceso Innovations Waiver Serviceso Medically Supervised or ADATC Detoxification/Crisis Stabilization
Post Payment Review Worksheets
24
Staff Qualifications (continued)o Mobile Crisis Managemento Multisystemic Therapy (MST)o Non-Hospital Medical Detoxification o Partial Hospitalizationo Peer Support Serviceso Professional Treatment Services in Facility- Based Crisis Programo Psychosocial Rehabilitationo Substance Abuse Comprehensive Outpatient Treatment Programo Substance Abuse Intensive Outpatient Programo Substance Abuse Non-Medical Community Residential Program
Post Payment Review Worksheets
25
Voluntary – request initiated by the provider
There are minimum prerequisites for length of time in the public MH/DD/SA system:
Preferred Status - 1 yearExceptional Status – 2 yearsGold Star Status – 3 years
Advanced Placement
26
The years of credit are not confined exclusively to the provider’s tenure in the LME/MCO network to which the provider is applying for advanced placement.
Other creditable years of service (e.g., provider contracted with other LME/MCOs in the past or the length of time enrolled as a Medicaid provider) would need to be verified.
Advanced Placement
27
It is possible to apply for advanced standing upon enrollment in the network, however the following must occur first:o Regardless of the number of years in the public service
system, an Implementation Review must be conductedo The provider does not “skip” ahead to a higher level – in
applying for advanced standing, the provider must also demonstrate that the agency meets the requirements of all other intervening levels. (This includes successful completion of all Advanced Placement Tools for the provider)
Advanced Placement
28
Frequency of Monitoringo Preferred Status – Every 2 yearso Exceptional Status – Every 3 yearso Gold Star Status – Every 3 years
Subsequent Review Toolso Domain Review Tool (Replaces the Initial and
Routine Monitoring Tools)o Cultural Competency Toolo Post-Payment Review Tool
Advanced Placement Benefits
29
Phaseso Self-Assessment – Completed by the
providero Desk Review – Conducted by the LME/MCOo On-Site Verification – Conducted by the
LME/MCO
The LME/MCO will provide more information on this process once revised and finalized tools are posted by DHHS.
Advanced Placement
30
Provider notification 4 weeks prior to review
Records notification 1 week prior to review
Reviews will begin the week of June 10, 2013oProviders have already been notified
Gold Star Monitoring Scheduling
31
What’s New? (handout)
Helpful Reminders (handout)
MeckLINK Q&A and Power Point Presentation http://charmeck.org/mecklenburg/county/AreaMentalHealth/Pages/default.aspx
Gold Star Monitoring Tools and FAQ - http://www.ncdhhs.gov/mhddsas/providers/providermonitoring/tools.html
Gold Star Monitoring Resources
32
Please send any questions or comments concerning the Gold Star Monitoring process to:
[email protected] [email protected]
Questions or Comments