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 necessaryConduct initial site reviews for the contract processServe 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 AssessmentsConduct RFPs for new services and service gaps
4 Provider Relations and Network Development Charles Hill, M.Ed., LPCProvider Relations and Network Development DirectorProvider Operations DivisionProvider Relations SpecialistAdrianne Lewis, MSW, MPA Amy Rudisill, BSAngela Scott, MBA Cynthia Benjamin, BARosalind Barksdale, BSWCredentialing CoordinatorNakia Alexander, MBAAdministrative SupportDenise Onativia, BA
5 Provider Accountability Conduct routine monitoring of all public MH/DD/SA providers in the networkConduct Program Post Payment reviewsRespond to provider complaintsConduct focused monitoring reviewsConduct Follow Up reviews for POCsServe 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, MSProvider Accountability Manager Provider Accountability ManagerProvider Operations Division Provider Operations DivisionRegulatory Compliance AnalystsDenise 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, BALakisha Suber, MAGwen Drayton, Administrative Support
7 Gold Star MonitoringEffective 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 MonitoringDHHS 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 MonitoringSurveys conducted by DHSR in the previous 15 months will serve in lieu of the LME/MCO conducting Initial or Routine Monitoring on licensed facilitiesThe LME/MCO will only conduct the post payment review portion of the Gold Star Monitoring tool for these facilitiesEffective 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 MonitoringApplies to Two Types of Contracted ProvidersProvider AgenciesLicensed Independent Practitioners (LIPs)
12 Focus of Monitoring Tools Regulatory ComplianceQuality PerformanceDocumentationIntegrity of Billing
13 The Phases of Gold Star Monitoring Request to Enter the Network (initial enrollment)Initial (Implementation) ReviewsAll 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 ReviewsAdvanced Placement on the Provider PerformanceProfilePreferred, 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 serviceLook 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 serviceLook Back Period = Previous 6 monthsSuccessful 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 ReviewHealth, Safety and Compliance ReviewAFL Health & Safety ReviewCultural 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 ReviewsPost-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 recorddocumentation, 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 ReviewsPPR tools shall be used when LME-MCO conduct special audits orinvestigations 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 TreatmentDiagnostic AssessmentInnovationsLIPOutpatient Opioid TreatmentPRTFResidential Services- Child MH Level II, III & IVGeneric
20 Generic PPR Tool Ambulatory Detoxification Assertive Community Treatment Team- PPR onlyCommunity Support TeamICF-IDD- PPR onlyIntensive In-Home ServicesMedically Supervised or ADATC Detoxification/CrisisStabilizationMobile Crisis Management
21 Generic PPR Tool Multisystemic Therapy (MST) Non-Hospital Medical DetoxificationOutpatient (Agencies)Partial HospitalizationPeer Support ServicesProfessional Treatment Services in Facility- Based Crisis ProgramPsychosocial Rehabilitation
22 Generic PPR ToolSubstance Abuse Comprehensive Outpatient Treatment ProgramSubstance Abuse Intensive Outpatient ProgramSubstance Abuse Non-Medical Community Residential ProgramSubstance Abuse Medically Monitored Community ResidentialState funded services (i.e. CAET, Group Living)
23 Post Payment Review Worksheets Staffing ratios- Specific to Child Residential Treatment (except TFC)Staff QualificationsAmbulatory DetoxificationAssertive Community Treatment TeamCommunity Support TeamFacility Based CrisisIntensive In-Home ServicesInnovations Waiver ServicesMedically Supervised or ADATC Detoxification/CrisisStabilization
24 Post Payment Review Worksheets Staff Qualifications (continued)Mobile Crisis ManagementMultisystemic Therapy (MST)Non-Hospital Medical DetoxificationPartial HospitalizationPeer Support ServicesProfessional Treatment Services in Facility- Based Crisis ProgramPsychosocial RehabilitationSubstance Abuse Comprehensive Outpatient Treatment ProgramSubstance Abuse Intensive Outpatient ProgramSubstance 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 yearExceptional Status – 2 yearsGold Star Status – 3 years
26 Advanced PlacementThe 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 PlacementIt 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 conductedThe 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 MonitoringPreferred Status – Every 2 yearsExceptional Status – Every 3 yearsGold Star Status – Every 3 yearsSubsequent Review ToolsDomain Review Tool (Replaces the Initial and Routine Monitoring Tools)Cultural Competency ToolPost-Payment Review Tool
29 Advanced Placement Phases Desk Review – Conducted by the LME/MCO Self-Assessment – Completed by the providerDesk Review – Conducted by the LME/MCOOn-Site Verification – Conducted by the LME/MCOThe 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 reviewRecords notification 1 week prior to reviewReviews will begin the week of June 10, 2013Providers have already been notified
31 Gold Star Monitoring Resources What’s New? (handout)Helpful Reminders (handout)MeckLINK Q&A and Power Point PresentationGold Star Monitoring Tools and FAQ -
32 Questions or CommentsPlease send any questions or comments concerning the Gold Star Monitoring process to: