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N ETWORK A DEQUACY R EPORT Council on Medical Assistance Program Oversight Presented by Rep. Abercrombie, Rep Ritter, and Olivia Puckett.

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Presentation on theme: "N ETWORK A DEQUACY R EPORT Council on Medical Assistance Program Oversight Presented by Rep. Abercrombie, Rep Ritter, and Olivia Puckett."— Presentation transcript:

1 N ETWORK A DEQUACY R EPORT Council on Medical Assistance Program Oversight Presented by Rep. Abercrombie, Rep Ritter, and Olivia Puckett

2 L EGISLATORS, PROVIDERS, AND STAKEHOLDERS PARTICIPATED IN THE PROCESS Rep. Ritter, Rep. Abercrombie, and Sen. Slossberg chaired the committee. As part of the process, the network adequacy committee invited providers who serve the Medicaid population. The concerns and recommendations are from the provider community.

3 A GENCIES P ARTICIPATED IN THE P ROCESS Office of Policy and Management and Department of Social Services were involved in the process to discuss their responses to key areas of concern and recommendations.

4 A UDIT R EQUIREMENTS AND P ROCEDURES WERE KEY A REAS OF C ONCERN Audit-Requirements and Procedures Ordering Prescribing and Referring Requirements-Procedures for Non-Medicaid enrolled physicians Rates and Rate Setting Capacity-Provision of Services to Medicaid Beneficiaries

5 A UDIT C ONCERNS : R ULES, E XTRAPOLATION, AND P ROCESS Presumption of fraud and abuse in cases which may have resulted from clerical error Rules are not transparently shared with providers Extrapolation method currently used is not precise enough Obsolete codes and manual intervention methods cause audit errors Court as first option for providers makes process unduly adversarial

6 A UDIT R ECOMMENDATIONS : E XTRAPOLATION AND T HIRD P ARTY L IABILITY Extrapolation across like claims Past audit results should dictate intensiveness of audit Provider responsibility for Third Party Liability (TPL) results in administrative burden on providers. TPL Process that initially identifies appropriate payers

7 A UDIT R ECOMMENDATIONS : I NDEPENDENT A PPEALS P ROCESS, P ROSPECTIVE R EVIEW P ROCESS, AND F REE A UDIT P ROCESS T RAINING Establish independent appeals process DSS Assurance Dept. should develop more prospective review DSS should provide information and free training about audit process to providers

8 O RDER, PRESCRIBING AND R EFERRING C ONCERNS : A CCESS TO C ARE, C ONFUSION ABOUT PROCESS Potential for significant access to care issues Potential for decrease in quality of care Physicians still unaware or confused about requirement and enrollment Only enrolled providers are searchable via website’s provider look-up Lack of one clear document that explains enrollment process

9 OPR R ECOMMENDATIONS : D EVELOP C OMMON M ESSAGE AND I MPROVE C OMMUNICATION Develop common message for clients to follow- up with own physician Develop communication with physicians clarifying the requirement Improve communication with agencies and stakeholders Improve DSS website, provider look-up and provider bulletin formats

10 R ATES AND R EIMBURSEMENTS C ONCERNS : R ATE S ETTING P ROCESS AND R ATES TOO L OW Medicaid rates are too low to cover provider costs and to attract new providers Rates do not adequately cover care for persons with disabilities Lack of transparency in rate-setting process and lack of provider feedback Some rates haven’t changed since rates should be adjusted annually for inflation

11 R EVIEW PAYMENT STRUCTURE, EXPEDITE PAYMENTS, AND DEVELOPMENT REIMBURSEMENT METHODOLOGIES Rates and Reimbursement Recommendations: Review payment structure and adopt fair and transparent compensation models Expedite provider payments and prior authorizations Increase payment rate, especially for specialists Develop reimbursement methodologies that reflect time spent and complexity of services

12 R EVIEW CMS G UIDELINES, I DENTIFY ACTIVITIES NOT REIMBURSED, R ATE S CHEDULE Review CMS guidelines for behavioral health and disability services reimbursement Identify activities not reimbursed under current rate methodology Adjust Medicaid rate schedule to include all services coverable under the federal guidelines

13 C APACITY C ONCERNS : L ACK OF PROVIDERS AND S PECIALISTS Lack of providers and specialists Health care systems and programs difficult to understand and navigate Providers lack capacity and infrastructure to implement comprehensive PCMH

14 C APACITY R ECOMMENDATIONS : I NCENTIVES TO EXPAND WORKFORCE AND MAPOC R EVIEW ASO N ETWORK AND R ECRUITMENT E FFORTS Provide incentives to expand workforce MAPOC to review ASO’s current provider network and recruitment efforts on a quarterly basis Develop PSA about benefits of PCMH Increase patient navigation services and education Develop strong patient-provider relationships

15 C APACITY R ECOMMENDATIONS : FREE TELEPHONIC TRANSLATION SERVICES AND RESEARCH OTHER PATIENT MODELS OF CARE Provide free telephonic translation services and on-call translation services for Medicaid providers and beneficiaries Research other patient models of care for individuals with complex needs

16 DSS R ESPONSE : M EETING WITH ASSOCIATIONS, ROLLOUT OF ACA REQUIREMENTS, SEMINAR FOR PROVIDERS ABOUT RATE - SETTING PROCESS, AND NEED FOR COMPLIANCE IN AUDIT PROCESS DSS is working with Connecticut Association of Healthcare at Home to address administrative burden on providers Stressed need for compliance in audit process Rollout of ACA’s OPR requirements were successful Open to having seminar for providers about rate- setting process

17 DSS R ESPONSE : D IVERSE STRATEGIES TO IMPROVE HEALTH OUTCOMES AND P RIOR AUTHORIZATION NUMBER Providers can receive prior authorization online or through centralized number CT is comparably well situated to other states in Medicaid-to-Medicare fee index Employing diverse strategies to achieve improved health outcomes (see report for full details)

18 DSS R ESPONSE : A T & T LINE, CHNCT AND ASO ROLE TO SUPPORT PROVIDERS CHNCT and ASO support to enroll providers AT&T Language Line services are free to providers and Culture Vision is free to PCMH practices CHNCT links Medicaid beneficiaries to primary care through an attribution process

19 B EST P RACTICES IN DSS I NITIATIVES : PCMH, OB P4P, AND DHP PCMH Obstetric Pay for Performance Dental Health Partnership

20 T HANK YOU. Questions?


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