An Update on Routine Provider Monitoring NC Health Information Management Association - PowerPoint Presentation

An Update on Routine Provider MonitoringNC Health Information Management Association Behavioral Health Conference Mary T. Tripp, Policy Unit LeaderAccountability Team June 11, 2014 Division of Mental Health, Developmental Disabilities and Substance Abuse Services

Focus of this WorkshopThe Impetus for Streamlining Provider MonitoringWhat’s New or Different? Overview of the ProcessInternal Quality Assurance and the Records Professional Accomplishments to DateContinued Collaboration 2

Streamlining Provider Monitoring 3

Streamlining Provider MonitoringWhat happened to Gold Star Monitoring? Waiver ExpansionContinuous Quality ImprovementReduce Administrative Burden on Providers and LME-MCOs per SL 2009-451 (SB 202)Business Practices Subcommittee of the LME-MCO & Provider Standardization Committee 4

We heard you!! 5

DHHS-LME/MCO-Provider Collaboration WorkgroupDHHS Division of Health Service Regulation (DHSR) Division of Medical Assistance (DMA) Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMH/DD/SAS) 6

DHHS-LME/MCO-Provider Collaboration WorkgroupStakeholder Groups NC Council of Community ProgramsLME/MCOsBusiness Practices Subcommittee of the LME-MCO & Provider Standardization Committee Benchmarks NC Providers Council (NCPC) Professional Association Council (PAC) 7

DHHS-LME/MCO-Provider Collaboration Workgroup8 Professional Association Council (PAC) Addiction Professionals of NC NC Counseling Association Licensed Professional Counselors of NC NC Nurses Association National Association of Social Workers – NC Chapter NC Psychiatric Association NC Association for Marriage and Family Therapy NC Psychological Association NC Society for Clinical Social Work

LME-MCOs NC Council DMH/DD/SAS DMA DHSR Benchmarks NC Prov. Council PAC Individuals & Families 9

Best Possible Outcomes for Individuals and Families ↑Quality Providers → Quality Services 10

What’s New or Different?NC Provider Monitoring Process Gold Star Provider Monitoring 11

What’s New or Different?Frequency of Routine Monitoring Routine monitoring occurs on a 2-year cycle rather than annually. 12

What’s New or Different?Scoring and Weighting There have been changes in the scoring and weighting of some of the items on the review tools. 13

What’s New or Different?Multiple Sample Sizes and Sample Selection ProcessesIncident Reporting Restrictive InterventionsComplaintsFunds ManagementMedication Management 14

What’s New or Different?Plans of Correction Plans of correction are designed to address systemic issues and trends rather than isolated non-compliance issues. 15

What’s New or Different?Frequency of Unlicensed AFL Review Annual reviews for Unlicensed AFLs under the Innovations WaiverUnlicensed AFLs that are not under the Innovations Waiver are reviewed every 2 years. 16

What’s New or Different?Threshold for Passing the Routine Review The overall passing score has been increased from 75% to 85%.Thresholds have been set for passing each section of the routine review for agencies. 17

What’s New or Different?Health, Safety & Compliance Review This site review is done when the service is first initiated (at implementation) or when the program moves to a new location.This review is not required if the service is located at a site that is licensed by DHSR. 18

What’s New or Different?Names of Tools Simplified Health & Safety Review Tool for Unlicensed AFLs → Unlicensed AFL Review ToolHealth, Safety & Compliance Review Tool → Health, Safety and Compliance Review Tool for Initial Reviews 19

Overview of Routine MonitoringIncludes:Routine Review Post-payment ReviewState-funded and Medicaid-funded services 20

Overview of Routine MonitoringSample Selection Random Sampling 21

Overview of Routine MonitoringVersatility of the Review Tools Any of the tools can be used in whole or in part to conduct program integrity activities or for targeted monitoring or investigations of incidents, complaints, or quality of care concerns. 22

Overview of Routine MonitoringThe routine review tools are used with two provider types :Licensed Independent PractitionersProvider Agencies 23

Overview of Routine MonitoringLicensed Independent Practitioners LIP Office Site Review Tool Service Plan ChecklistLIP Routine Review ToolLIP Post-Payment Review Tool 24

Overview of Routine MonitoringLicensed Independent Practitioners LIP Office Site Review Tool Service Plan ChecklistAn on-site review is conducted before the LME-MCO contracts with the provider to assess compliance with state and federal requirements (e.g., confidentiality HIPAA and ADA).A mock record review is conducted to determine the extent to which technical assistance is needed in order for the LIP to meet the records and documentation requirements for publicly-funded services.   The is used with Licensed Independent Practitioners (LIPs) in a solo practice or with LIPs in a group practice who bill under the same provider number. 2)        The sample size for a LIP in a solo practice or for LIPs who share the same office space where each LIP has their own contract and provider number with the LME-MCO is ten (10) service events. 3)        The sample size for LIPs in a group practice who bill under the same provider number is thirty (30) service events. 4)        The Routine Agency Tool and the generic post-payment review tool are used to monitor LIPs who are employed by an agency that provides other services besides basic benefit/outpatient services (e.g., CABHAs).   25

Overview of Routine MonitoringLIP Routine Review Tool This tool is used with LIPs who provide outpatient treatment services or basic benefit services only: in a solo practice or in a group practice who bill under the same provider number. 26

Overview of Routine MonitoringLIP Routine Review ToolAreas Reviewed: Rights NotificationCoordination of CareService AvailabilityStorage of Records 27

Overview of Routine MonitoringLicensed Independent Practitioners Routine Review Tool and Post-Payment Review ToolThe sample for both the routine review tool and the post-payment tool for LIPs is based on paid claims (i.e., service events for which the LIP has billed and been reimbursed). 28

Overview of Routine MonitoringSample Size for LIP Review* Solo practice: N = 10 service eventsGroup practice billing under the same provider number: N = 30 service events * Applies to the Routine Review and the Post-Payment Review 29

Overview of Routine MonitoringProvider Agencies Routine Review ToolPost-Payment Review ToolsUnlicensed AFL Review ToolHealth, Safety & Compliance Review Tool 30

Overview of Routine MonitoringRoutine Review Tool for AgenciesThis tool is used to monitor unlicensed services and services licensed under GS §122C that are not surveyed by DHSR-MHL on an annual basis. This tool is used to monitor LIPs who are employed by an agency that provides other services besides basic benefit/outpatient services (e.g., CABHAs). 31

Overview of Routine MonitoringProvider Agency Review Tool Basic Areas Reviewed:Rights NotificationIncidentsRestrictive InterventionsComplaints Coordination of CareService Availability 32

Overview of Routine MonitoringProvider Agency Review Tool The following areas are reviewed based when the agency provides either of the following services to the individuals in their program:Protection of PropertyManagement of FundsMedication Administration 33

Overview of Routine MonitoringPost-Payment Review Tools for Provider AgenciesInnovations Waiver Opiod TreatmentDiagnostic AssessmentResidential ServicesDay Treatment Psychiatric Residential Treatment Facilities (PRTF)Generic PPR Tool 34

Overview of Routine MonitoringPost-Payment Review Tools for Provider Agencies The selection of the PPR tool is determined by the specific service(s) included in the review sample.Staff qualifications worksheets are provided to assist the reviewer in determining whether the person who provided the services meets the training or educational requirements according to the service definition. 35

Overview of Routine MonitoringPost-Payment Review Tools for Provider Agencies The generic post-payment review tool is used to monitor LIPs employed by an agency that provides other services besides basic benefit/outpatient services (e.g., CABHAs).The qualifications of the LIP is determined on the basis of the LIP’s licensure unless the service provided by the LIP has specific training or educational requirements. 36

Overview of Routine MonitoringSample Selection for the Agency Review The sample is randomly selected from:Paid claimsLevel I incidentsLevel II & III incidentsRestrictive Interventions ComplaintsFunds ManagementMedication Administration 37

Overview of Routine MonitoringSample Size for the Routine Agency Review Rights Notification; Coordination of Care; Service Availability; Post-Payment Review: N = 30Incidents; Restrictive Interventions; Complaints: N = 10Funds Management; Medication Administration: N = 5 38

Some Monitoring Process Points 39

Selection of the Review Period How is the timeframe from which the sample is drawn determined? 40

Selection of the Review Period When the service event is based on paid claims:Start 6 months before the scheduled on-site visit through the next 3 months (~ 90 days) to ensure claims have been fully adjudicated.Example: The on-site is scheduled for May 1. The sample is drawn from randomly selected claims paid between December 1 – February 28. 41

Selection of the Review PeriodThe sample selected for the following items can go back up to 1 year in order to obtain an adequate sample: IncidentsRestrictive InterventionsComplaintsFunds ManagementMedication Review 42

Scheduling the On-Site Review Providers will be notified in writing 21-28 calendar days prior to the date of the review. 43

The Records Needed for the Review No less than 5 business days prior to the date of the review, providers will be notified of the specific service records needed during the review. 44

Internal Quality Assurance Make sure all the documentation that is needed to score the items on the tools are organized and easily accessible. 45

Internal Quality Assurance Implement a system for routinely monitoring staff knowledge of and compliance with the requirements for service provision and documentation. 46

Internal Quality Assurance The tools can be used to conduct periodic self-assessments to identify and remediate compliance issues . 47

Internal Quality AssuranceMake sure incidents are classified appropriately. Keep all documentation of administrative reviews and follow-up activities in response to incidents, complaints, and investigations are kept in the same file for easy retrieval during an audit. 48

Internal Quality Assurance49 When requirements change, make sure all staff are informed of the change.

Internal Quality Assurance Make sure new procedures and requirements are being instituted promptly and consistently as of the effective date of the policy change. 50

Internal Quality Assurance Do you have the systems in place that assures audit-readiness at all times? 51

Internal Quality Assurance See the webinar “Organizing and Preparing for the Review” for more tips on being audit-ready. http://www.ncdhhs.gov/MHDDSAS/providers/providermonitoring/webinars.htm 52

Internal Quality Assurance A good offense is a good defense. 53

Internal Quality AssuranceThis a transparent process. http ://www.ncdhhs.gov/MHDDSAS/providers/providermonitoring/index.htm 54

Internal Quality Assurance 55

Accomplishments to DateStreamlining the Tools 88% reduction in the # of items on the tool used for the Routine Agency Review22% reduction in the # of items on the LIP Review Tools (office site review, routine review, post-payment review) 25% reduction on the average # of items on the post-payment reviews for agencies 56

Accomplishments to DateStreamlining the tools took into account the maturity of the provider network by reducing redundancy Elimination of duplication by using existing data such as review of IRIS reports, review of provider policies, submitted reports to profile provider performance across multiple areas of accountability 57

Accomplishments to DateFocus on providing assurance that: individual’s rights are being protected; some of the key elements of quality service provision are in place; and documentation supports the integrity of billing and reimbursement 58

Accomplishments to DateWebinarsWebinars have been taped as a follow-up to the workshops introducing the new tools and process. These webinars, which cover a variety of topics, provide an opportunity to expound upon important nuances about the routine monitoring process.The webinars are presented in modules to facilitate independent study and in-service training. http://www.ncdhhs.gov/MHDDSAS/providers/providermonitoring/webinars.htm 59

Accomplishments to DateFrequently Asked Questions (FAQs) Questions from participants at trainings or submissions to the provider monitoring mailbox are posted on the Provider Monitoring web page for dissemination.Subject matter experts are consulted for input in responding to some questions to ensure accuracy. 60

Accomplishments to DateProvider Monitoring Survey A confidential survey tool has been developed to obtain feedback from providers about the monitoring experience.The survey is designed to be completed after the provider receives their monitoring report. 61

Accomplishments to DateProvider Monitoring SurveyLME-MCO Compliance with Notification Guidelines Professionalism of Review TeamResults of the Review/Provider Performance 62

Continued CollaborationParking Lot Issues 63

Continued Collaboration“We’ve Only Just Begun” --- There’s More to Do Determine lead LME-MCOIncrease consistency and inter-rater reliability among reviewersDevelop tools for advanced levels of provider statusDetermine the role of national accreditationDetermine ability to do PPRs on TFC providers 64

Continued Collaboration 65

Continued CollaborationTransparency The Key to Positive Outcomes and Accountability 66

Additional Information and UpdatesTool revisions, updates, or new material are posted on the Provider Monitoring web page. http://www.ncdhhs.gov/MHDDSAS/providers/providermonitoring/index.htm Check the Announcements page of the DMH/DD/SAS website for a brief description of what’s new on the Provider Monitoring web page and the most important revisions/updates made for each posting. http://www.ncdhhs.gov/mhddsas/Whatisnew/index.htm 67

Questions/FeedbackPlease send any questions or concerns about the Provider Monitoring Tools or process to the following mailbox: provider.monitoring@dhhs.nc.gov Identifying the nature of your question or feedback in the subject line facilitates the processing of your e-mail. 68