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Provider Operations.

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Presentation on theme: "Provider Operations."— Presentation transcript:

1 Provider Operations

2 Provider Accountability
Provider Operations Provider Relations & Network Development Provider Accountability

3 Provider Relations and Network Development
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

4 Provider Relations and Network Development
Charles Hill, M.Ed., LPC Provider Relations and Network Development Director Provider Operations Division Provider Relations Specialist Adrianne Lewis, MSW, MPA Amy Rudisill, BS Angela Scott, MBA Cynthia Benjamin, BA Rosalind Barksdale, BSW Credentialing Coordinator Nakia Alexander, MBA Administrative Support Denise Onativia, BA

5 Provider Accountability
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)

6 Provider Accountability Team
Kimberly Alexander, MBA Angela Jackson, MS Provider Accountability Manager Provider Accountability Manager Provider Operations Division Provider Operations Division Regulatory Compliance Analysts Denise Polk, MS - Team Lead Dana Frakes, LPC - Team Lead Melanie Cannon, LCSW Kellie Anderson, MBA Kathy Cunningham, BS Melissa, Freedman, MSW Carnice Essex, MS Donde Jones, MBA Sharisse Johnson, MBA Synovia Pettice, MHDL, LCAS Celena Thaggard, MBA Miguel Sabillon, BA Lakisha Suber, MA Gwen Drayton, Administrative Support

7 Gold Star Monitoring 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.

8 Gold Star Monitoring 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

9 Gold Star Monitoring 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

10 Gold Star Monitoring Guidelines
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.

11 Applies to Two Types of Contracted Providers
Gold Star Monitoring Applies to Two Types of Contracted Providers Provider Agencies Licensed Independent Practitioners (LIPs)

12 Focus of Monitoring Tools
Regulatory Compliance Quality Performance Documentation Integrity of Billing

13 The Phases of Gold Star Monitoring
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

14 Implementation Review
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

15 Routine Review 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

16 Monitoring Tools for Initial/Routine Reviews
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

17 Post Payment Reviews 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

18 Post Payment Reviews 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 , 42 CFR , and 42 CFR

19 Post Payment Review Tools
Child and Adolescent Day Treatment Diagnostic Assessment Innovations LIP Outpatient Opioid Treatment PRTF Residential Services- Child MH Level II, III & IV Generic

20 Generic PPR Tool 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

21 Generic PPR Tool Multisystemic Therapy (MST)
Non-Hospital Medical Detoxification Outpatient (Agencies) Partial Hospitalization Peer Support Services Professional Treatment Services in Facility- Based Crisis Program Psychosocial Rehabilitation

22 Generic PPR Tool 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)

23 Post Payment Review Worksheets
Staffing ratios- Specific to Child Residential Treatment (except TFC) Staff Qualifications Ambulatory Detoxification Assertive Community Treatment Team Community Support Team Facility Based Crisis Intensive In-Home Services Innovations Waiver Services Medically Supervised or ADATC Detoxification/Crisis Stabilization

24 Post Payment Review Worksheets
Staff Qualifications (continued) Mobile Crisis Management Multisystemic Therapy (MST) Non-Hospital Medical Detoxification Partial Hospitalization Peer Support Services Professional Treatment Services in Facility- Based Crisis Program Psychosocial Rehabilitation Substance Abuse Comprehensive Outpatient Treatment Program Substance Abuse Intensive Outpatient Program Substance Abuse Non-Medical Community Residential Program

25 Advanced Placement Voluntary – request initiated by the provider
There are minimum prerequisites for length of time in the public MH/DD/SA system: Preferred Status - 1 year Exceptional Status – 2 years Gold Star Status – 3 years

26 Advanced Placement 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.

27 Advanced Placement It is possible to apply for advanced standing upon enrollment in the network, however the following must occur first: Regardless of the number of years in the public service system, an Implementation Review must be conducted 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)

28 Advanced Placement Benefits
Frequency of Monitoring Preferred Status – Every 2 years Exceptional Status – Every 3 years Gold Star Status – Every 3 years Subsequent Review Tools Domain Review Tool (Replaces the Initial and Routine Monitoring Tools) Cultural Competency Tool Post-Payment Review Tool

29 Advanced Placement Phases Desk Review – Conducted by the LME/MCO
Self-Assessment – Completed by the provider Desk Review – Conducted by the LME/MCO 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.

30 Gold Star Monitoring Scheduling
Provider notification 4 weeks prior to review Records notification 1 week prior to review Reviews will begin the week of June 10, 2013 Providers have already been notified

31 Gold Star Monitoring Resources
What’s New? (handout) Helpful Reminders (handout) MeckLINK Q&A and Power Point Presentation Gold Star Monitoring Tools and FAQ -

32 Questions or Comments Please send any questions or comments concerning the Gold Star Monitoring process to:


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