DHS/DMH/The CollaborativeDHS/DMH/The CollaborativeContractual Overview Contractual Overview

PresentationPresentation

February 13, 2013February 14, 2013

Scott Permentier, LSW, MBA, CCEPChief Executive Officer

Introductions

About the DHS/DMH, Administrative Service Organization and the Illinois Mental Health Collaborative for Access and Choice (The Collaborative)

Recovery and Resilience

Clinical Services/Medical

Compliance/Quality

Provider Relations

Scott Permentier, Chief Executive Officer

Bryce Goff, Director of Recovery and Resilience

Pat Palmer, Director of Clinical Services

Todd Kasdan, MD, Director of Medical Services

Shawn Wilson, Director of Compliance

Aissa Bell, Director of Provider Relations

As the state mental health authority, DHS/DMH is responsible for ensuring that those most in need have access to appropriate mental health services that comply with federal and state statutes and regulations

Ensure access for those most in need of mental health service

Ensure that services meet standards of quality relative to mental health services

Ensure prudent stewardship of taxpayer dollars

Establish all policies and procedures for the system of care

The Illinois Mental Health Collaborative for Access and Choice is:

◦ A partnership between the DHS/DMH and ValueOptions to improve and advance mental health services

◦ An ASO created to help DMH make the best use of limited resources to serve people in need of mental health assistance

◦ Committed to the Recovery and Resilience of children and adults with mental illnesses

A health solutions company designed to ensure that:

◦ The right services are provided

◦ In the right amount

◦ To the right person

◦ At the right time

ValueOptions is the company contracted by DHS/DMH to provide ASO services

These services are provided under the name “Illinois Mental Health Collaborative for Access and Choice”

The contract is set to expire June 30, 2015

There are two (2), one (1) year contract extensions that may be exercised by DHS/DMH that could continue the contract until June 30, 2017

The Collaborative operates two (2) offices in IL:

◦ Chicago

◦ Springfield

Clinical

Finance

Management Information Systems

Provider Relations

Quality Management

Recovery and Resilience

Patricia Palmer, LCSW, CADC, Clinical Director

Callie R. Lacy, LCPC, Clinical Supervisor

Sue Kapas, LCPC, Clinical Quality Assurance Advisor

Todd H. Kasdan, MD, Medical Director

Clinical OverviewClinical Overview

The Utilization Management (UM) Program is the vehicle through which DHS/DMH ensures that individuals being served receive:

◦ The services best suited to support their recovery needs and preferences

◦ Cost effective services in the most appropriate treatment setting

◦ Services consistent with medical necessity criteria and evidence-based practices

By implementing the UM Program, DHS/DMH strives to achieve a balance between:

◦ The needs, preferences, and well-being of persons in need of mental health services

◦ Demonstrated medical necessity

◦ The availability of resources

UM is dynamic and evolutionary

UM must be based on data

Individuals accessing services should meet a consistent threshold of medical necessity statewide

Authorization must be clinically focused and conducted by qualified staff

The Medical Necessity Criteria (MNC) are published by IL DHS/DMH

These criteria should be used by providers to guide them in making consistent admission, continuing service, and termination of service decisions for each consumer

Providers must use these criteria consistently, regardless of whether or not DHS/DMH or its designee externally authorizes the service

Provider adherence to these criteria may be subject to post- payment review

Assertive Community Treatment (ACT)

Community Support Team (CST)

Community Support Group (CSG)

Psychosocial Rehabilitation (PSR)

Therapy Counseling

Individual Care Grant (ICG)

Permanent Supportive Housing (PSH) Including Williams Class members

Region 1 Crisis Care Inpatient CHIPS Mental Health Crisis Residential Substance Abuse Crisis Residential Acute Community Care

Northwest Crisis Care Inpatient CHIPS Mental Health Crisis Residential Acute Community Care

Provider will contact the Collaborative to request services

Collaborative clinical care managers (CCMs) review submitted documents for adherence to Medical Necessity Criteria (MNC) via:

◦ Treatment Plan Goals

◦ Status Updates and Progress

◦ A rating scale LOCUS Scoring for adults Ohio Scales for Children/Adolescents

If the MNC are met for the service(s), the Collaborative CCM will enter an authorization

If medical necessity IS established, request is authorized by CCM and communicated to the provider

If medical necessity is NOT established, the CCM contacts the provider to seek clarification and offer education/consultation regarding authorization criteria◦ The Collaborative and the provider will reach

mutual agreement with respect to next steps (e.g., additional information will be submitted for review, alternative service will be considered, etc.)

◦ If mutual agreement has NOT occurred and provider believes medical necessity is present, the CCM will forward information to a Collaborative Physician Advisor (PA) reviewer

PA reviews and either authorizes OR denies authorization

In the case of a Clinical denial of authorization, a Reconsideration Request or Appeal (depending on the service/level of care) may be initiated

This review will be conducted by a Physician Advisor (PA – a physician licensed in the State of Illinois and board-certified in the specialty of psychiatry)

• Not the same PA who issued the original denial

• Not a subordinate of the PA who issued the original denial

◦ Review outcome Either: Overturn of the original denial decision Upholding of the original denial decision

Reconsideration Requests and/or Appeals can be Clinical or Administrative in natureClinical

◦ Related to Medical Necessity Criteria

Administrative◦ Administrative = based on reasons other than lack of medical

necessity

◦ Examples of administrative denials Consumer not eligible due to geographic residency Diagnosis not present in eligible population universe Service requested is not covered Request is outside of timeframe

Bryce GoffDirector, Recovery and Resilience

Focus on Persons Focus on Persons Served and RecoveryServed and Recovery

Concept of recovery includes:– Individuals with serious mental illnesses or serious

emotional disorders can create a life of meaning and purpose• Person-centered care - Focus on helping individuals

achieve personal goals as opposed to merely managing symptoms

• Family support and involvement• Providing hope as the cornerstone of recovery

People who have mental illnesses:– Form a partnership with their providers– Have a voice in their care– Guide their treatment planning process– Use their strengths to achieve goals

The Collaborative builds upon and works with the established DHS/DMH Recovery Services Development Group

The Collaborative draws on ValueOptions’ extensive experience in empowering consumers

On the national level:

◦ Clarence Jordan – ValueOptions’ Vice President for Recovery and Wellness

National recovery and consumer movement leader

Training and consultation for providers, service center employees, persons served

Facilitating integration of recovery and wellness principles throughout ValueOptions

Certified Recovery Support Specialists (CRSS) at the Service Center level

◦ Director of Recovery in senior level position on management team

◦ Peer and Family Support Specialists Facilitate consumer communications and education Consultation and support to community and providers

Community training on recovery

◦ Providers

◦ Persons Served

◦ Family Members

Involvement of persons with lived recovery experience in development and implementation of initiatives

Certified Recovery Support Specialists employed throughout the organization

Community education about mental illness and recovery

Warm Line Recovery and Empowerment Statewide Calls Recovery Services Development Snapshots CRSS Trainings and Provider Forums Recovery and Empowerment Handbooks Wellness Recovery Action Plan Training

Support Recovery Oriented Consultation to all

Collaborative Departments

Compliance/Quality ManagementCompliance/Quality Management

Shawn Wilson, CCEPCompliance/QA Departmental Director Bobbie FracassiQM Specialist/Resolution Coordinator

Maintain several QM functions to ensure quality of operations and regulation compliance

QM functions ensure VO contractual obligations are performed satisfactorily

Compliance function ensures operations meet all legal requirements (HIPAA/HITECH/mandated reporting, etc.)

The Collaborative receives and processes consumer- and family-generated complaints regarding DMH service providers

Formalized process between ValueOptions and DMH

Process ensures all allegations are:◦ Taken seriously

◦ Reviewed in an objective and timely manner

◦ Results are communicated to necessary entities

Call: (866) 359 - 7953 and file your complaint or grievance with our Resolution Coordinator

Write to: Illinois Mental Health CollaborativeAttn: Resolution Coordinator

P.O. Box 06559 Chicago, IL 60606

Aissa BellDirector, Provider Relations

Provider Relations (PR)Provider Relations (PR)

A. Training and Technical Assistance

B. Provider Monitoring

C. Management of the Collaborative Web Site

D. Support of Provider Database Verification Maintenance

Via webinar on a variety of subjects

On-site at the time of monitoring reviews in an effort to assist and guide providers with improving documentation practices

Individually as requested by the provider

This contract year, the Collaborative is responsible for 5 different types of reviews:

PPR (Post-Payment Review)

Two Types: Standard Post-Payment Review, ICG Post Payment Review

Evaluates provider’s compliance with 11 specific Rule 132 items

Length of Review is 1-2 days depending on the number of claims reviewed

The number of claims depends upon the number of post-payment reviews the provider is receiving and the number of claims the provider has submitted during the billing period

Billing period if reviewed last year: 60 days after last review up to date claims pulled.

Billing period if not reviewed last year: 12 months back and up to the date claims pulled.

DMH Contract Managers follow through on Plans of Improvement

Note: Same tools are used for both PPR and ICG PPR. If provider is receiving both types of Post-Payment Reviews, separate reports are left with provider for each type of review.

ACT (Assertive Community Treatment)

Measures a provider’s delivery of ACT services to the fidelity model

Typical length is one full day per team being reviewed

With a few minor modifications, this scale is the Dartmouth Assertive Community Treatment Scale (DACTS) developed by Teague, Bond, and Drake (1998)

CST (Community Support Team)

Measure a provider’s delivery of CST services according to the definition and intent of the service

Typical length is one full day per team being reviewed

The review is conducted using a tool developed by a workgroup of DMH and the IL PR team

Certification Evaluates compliance of Rule 132 (a much broader review

than PPR)

Typical length of review is three days.

Reviewers use DHS/BALC established tools

DHS/BALC office follows through with providers post-review

ICG Documentation Reviews Reviews service documentation and focuses on the

rehabilitative nature of services provided and coordination with other entities and includes a review of the provider’s policies and procedures related to elopement

Typically length is one day

The review is conducted using a tool developed by a workgroup of DMH, DHS C and A office and the IL Collaborative PR team

DHS/C and A office follows through with providers post-review

In partnership with DHS/DMH and DHS/DORS, assistance with supported employment fidelity monitoring

Up to 33 provider programs

The purpose of provider database verification is to ensure that data in our system is accurate and up-to-date

Providers who are receiving a monitoring visit:

Receive an encrypted email with an attached pre-populated PDV form documenting the provider’s information that is currently in our system. Providers make any corrections or changes and give to reviewers at the time of the monitoring visit

Providers who are NOT receiving a monitoring visit:

The Contract Manager will be contacting you to verify the information

Today’s presentation will be available online at:www.illinoismentalhealthcollaborative.com

You can follow these steps:

Step 1: Go to www.illinoismentalhealthcollaborative.com

Step 2: Click on “Providers”

Step 3: Click on “Provider Information”

Step 4: Under Provider Trainings, click on this PowerPoint

Questions?