Embed Size (px)
Citation preview
Provider Town Hall Meeting Community Mental Health and Other Behavioral Health Provider Review Services
August 2009
2
Agenda for Town Hall Meeting
• Introduction of HMS Team • Town Hall Meeting Objectives • HMS Background• DMAS Program Objectives • RFP Background • Overview of Review Process• Review of FAQs/ Additional Questions
3
Introduction of HMS Team• Project Management
– Pamela Willard, MS, CRC, LPC• Project Manager
– Kathy Lippman, MBA, MPH• Regional Director
• Data Analysis and Mining – Michael Hostetler
• Vice President of Program Integrity
4
Introduction of HMS Team • Clinical Review Team
– Maureen Riley, RN, BSN, CPHQ – Pamela Willard, MS, CRC, LPC – Sam Toney, M.D.
• Review Team – Michelle Comeaux, MSW– Chris Counihan, MSW – Patrick Kubovic, B.A. Psychology
5
Town Hall Meeting Objectives • Facilitate providers to feel “informed” and
“prepared” for the upcoming reviews • Enhance provider understanding of the review
process – Who is conducting the reviews?– How will providers/ claims be selected? – What documentation will be reviewed during the process? – What can I expect during the review process?
• Review of FAQs – Opportunity for additional provider questions
6
HMS Background• Leading healthcare cost containment firm
serving 40 Medicaid agencies – 23 years serving Medicaid community, staff of 750 across 23
office nationwide, with strong Medicaid policy and operational experience
• Have been a contractor to VA DMAS since 1987
• Worked with various providers in Virginia since 1994
• Detailed understanding of First Health MMIS data
7
Review of DMAS Program Goals • Ensure that Virginia Medicaid recipients
receive: – appropriate behavioral and community mental health
services – in the appropriate setting
• Ensure that services received by Virginia Medicaid recipients are performed in accordance with:
– Federal and state guidelines – Guidelines set forth in the Medicaid Manual
8
RFP Background
• VA DMAS has contracted with HMS to review five behavioral and community mental health service levels
– Intensive In-Home Services – Therapeutic Day Treatment – Mental Health Support Services – Outpatient Psychotherapy – Outpatient Substance Abuse Services
• Ensure Medicaid dollars used toward provision of appropriate services to this population
• Assist DMAS to identify providers who may benefit from additional provider training
9
Review Objectives • Reviews performed within established DMAS
guidelines – “Mimic” existing DMAS review process procedures, as much as
possible
• Notify the provider and DMAS if review findings identify overpayments that require recovery efforts by DMAS.
• Report review findings to facilitate provider education/ training
– Provider education to change behavior and avoid errors going forward
– Review of specific provider errors • Corrective action plan, if warranted
1010
Overview of HMS Review Process
ProcessImprovement
Conduct Reviews
“Town Hall” meetings
Provider Survey ProviderOutreach
Conference Calls
Webinars
Notification of Review
On-site Review
Clinical Review
Determination of Overpayments
Review Report
Notification of Preliminary Findings
Appeals and Recovery
Overpayment Letter
Appeal ProcessRecovery Process
Review Reports
Trend Analysis
Provider Education
Program Recommendations
Data Analysis/ Data Mining
Service/Provider Metrics
Billing Error Targets
Abuse Indicators
Outlier Patterns
Survey Results
COB Issues
11
Provider Outreach • Provider Town Hall Meetings
– Scheduled in four locations across the Commonwealth – Objective: To further provider understanding of the review
process
• Provider Town Hall Webinars – August 26 and 27 (11 am)– For providers unable to attend in person – No limit on number of attendees per provider– Registration requested [email protected]– http://anywhereconference.com
• Login reference 130255191• PIN code 5385887• Audio: (866) 200-8957 PIN code: 5385887
• Posted on DMAS Learning Network – www.dmas.virginia.gov
12
Provider Outreach • Provider Survey
– Survey Goals/Objectives: • To allow DMAS and Review Team to better understand the providers
who provide these services to the Medicaid population • To provide a mechanism to allow providers to submit feedback about
upcoming reviews, concerns
– Provider’s Role• Fill/ return out brief, easy-to-fill out survey• Participation encouraged
– Content of Survey • Demographic questions • Open-ended questions intended to solicit provider feedback, review
preferences
13
Data Analysis/ Data Mining• Service/Provider Metrics
– Billings per patient– Patients per provider
• Outlier Utilization – Units/month vs. peers– Patients/month vs. peers – Units/patients/month vs. peers
• Billing Patterns – Excess unit claims– Billing for dates of service in facility/deceased– Medicare COB opportunities– Referral targeting
14
Selection of Providers for Review• Any licensed participating provider enrolled with
Virginia Medicaid may be reviewed for any of the five service levels
– Intensive In-Home – Therapeutic Day Treatment – Mental Health Support Services – Outpatient Psychotherapy – Substance Abuse Providers
• Total of at least 70 providers selected for review from September 2009 – June 2010
15
Selection of Cases/ Claims for Review• Targeted review of claims for period DOS SFY
2008 (for providers selected)
• Review 10% of Medicaid recipients who have received services within the respective service levels
• Caps on corresponding records reviewed
16
Conducting Reviews• Provider Notification for Desk Reviews
– Certified mail to specific individual – Letter will request specific recipient and claim information– Specific return instructions provided – Provider is responsible for submitting requested
documentation within 14 business days of receipt of the medical record request
• Provider Notification for Onsite Reviews– Certified mail to specific individual – Review will occur no sooner than 14 business days from
date of letter– List of recipients/ claims selected for review available when
team arrives on-site
17
Conducting Reviews (continued)
• Process entails review of following documentation: – Provider credentials and licensure– Medical necessity– Progress notes– Services Rendered– Actual time spent with patient
• Review process is driven by Review Protocols/Error Matrix defined for each service level
– Consistent audit approach– Standardized data-gathering approach– Review Team approach
18
Conducting On-site Reviews (continued)• Provider Communication while on-site
– Entrance Conference• Scope of review• Identify specific cases/ claims to be reviewed • Discussion of review process, timing• Opportunity for Provider Questions
– Exit Conference • Discuss/ share preliminary findings• Requests for additional information• Make recommendations for improvement in documentation • Opportunity for provider questions
19
Areas for review: • Staffing Guidelines
– Review of service level staffing guidelines • provision of services, supervision of non-licensed staff as required
and setting
• Clinical Records – Review of Assessment, ISP or POC and Progress Notes
• support the initial need for services– Review that clinical criteria in the above documentation
continue to be met
• The provision of services in accordance with: – Federal and state guidelines/regulations – DMAS Policies and Procedures– Medicaid Provider Bulletins/ Medicaid Memos
20
Review Team
• Reviewer Experience/ Qualifications – Reviewers have clinical experience with the
respective community mental health service levels
• Reviewer Training – Detailed reviewer training including information
on: • Virginia Medicaid regulations• covered services • specific service limits
Clinical Review
• HMS/DMAS Review– HMS Clinical Review (review team)– Reviews are overseen by a VA Licensed
Professional Counselor (LPC), Pamela Willard– Physician Review
• All claims identified for denial subject to repayments by the review team, are subsequently reviewed by a VA Licensed Psychiatrist
– Experienced in all service levels– HMS Management Review – DMAS review of results/ approval
22
Determination/ Issuance of Preliminary Findings Letter • Issuance of Preliminary Findings letter/Review
report – Documents review findings – Sent to provider via certified letter – Listing of potential overpayments issues (does not include
dollar amount)
• Submission of additional documentation for review
– Provider may submit 30 days from date of receipt of preliminary findings letter
– Any additional documentation submitted will be reviewed
23
Issuance of Final Findings Letter• Issuance of Final Findings Letter/Review
Report – At conclusion of the review – If provider disagrees with outcome, next step is to request
an informal appeal – Letters outline all relevant appeals provisions
24
DMAS Appeals Process • All Appeals follow regular DMAS appeal
process– conducted in accordance with the Code of Virginia
• Informal Appeals – Informal Fact-Finding Conference (IFFC)– Scheduled at the request of the provider, within 30 days of
receipt of preliminary findings letter
• Formal Appeals – If provider does not agree with IFFC decision – Provider to issue request for formal administrative appeal
within 30 days of receipt of IFFC decision
25
Errors that may result in Recoupment of Medicaid Payments • Services provided not documented in accordance with
service level guidelines• Billing for services w/o documentation supporting level
of service billed• Lack of documentation in the medical record to support
the service billed • Missing Progress Notes• Initial Assessments not within specified time frames• The ISP or POC is not signed and dated by the required
LMHP or Physician
26
Additional errors that may result in Recoupment of Medicaid Payments • Billing for services that are medically
unnecessary • Billing for an inappropriate number of units• Billing of an incorrect code • Services are duplicated and billed separately• Billing for services not rendered• Failure to submit requested medical records/
allow for on-site review
27
Potential Implementation of Corrective Action Plan (CAP)• Contingent on level of errors identified, a
corrective action plan may be required
• If CAP is required: – Provider will have 30 days from receipt of the review report
to submit the plan for DMAS review/ approval– A follow up review will be scheduled within next year
28
Review Findings for Quality of Care and Compliance Findings• If Review Findings indicate serious problem
with regulatory compliance or serious quality of care issues
– Provider will be reviewed within 6 months – 1 year for follow up
29
Recovery of Medicaid Funds • DMAS will initiate recovery of Medicaid funds
• The Fiscal Department at DMAS coordinates all repayments
• If you choose not to appeal the said findings and are unable to submit payment in full within 30 days of this letter, you should immediately request an extended repayment plan. If a provider does not respond to this letter by repaying the amount in full, by requesting an extended repayment schedule, or by filing a notice of appeal, DMAS must take further action to collect.
• To discuss repayment options available to you, please call the Fiscal Accounts Receivable Unit at 804-786-5433.
30
Provider Education • Provider-Specific Outreach/Education
– Findings letters: Opportunity to educate providers on errors made and methods to avoid them
– Entrance and exit conferences – Requests for additional DMAS training – One-on-one provider phone calls
• General Outreach/Education – HMS Provider Newsletter – DMAS Provider Bulletins – Ongoing Town Hall Webinars
• Goal: To improve provider practices going forward
31
FAQS• How are the Providers selected for review?
• What time frame will be reviewed?
• How many recipient records will be reviewed?
32
FAQS (continued)• Will claims be reviewed for Medical Necessity?
• Are cases that have been prior authorized reviewed?
• What experience has HMS had with reviewing mental and behavioral health services?
33
Additional Provider Questions and Answers
Thank you for attending the Provider Town Hall Meeting
34
Contact InformationPamela Willard, MS, CRC, LPCHMS Project Manager • HMS e-mail (for all questions/inquiries):
DMAS Contract Information• DMAS website www.dmas.virginia.gov• DMAS e-mail (new for audit questions):
