IDHS, Division of Mental HealthProvider Briefing: Changes to Provider Monitoring

April 3, 2009 2-3:30pm

April 6, 2009 10-11:30am

Speakers

Jackie Manker, LCSW – Associate Director of Community Services, DHS/DMH

Lee Ann Reinert, LCSW – ASO Clinical Policy Manager, DHS/DMH

Cathy Cumpston – Chief, DHS Bureau of Accreditation, Licensure and Certification (BALC)

Aissa Bell – Director, Provider Relations, IL Mental Health Collaborative for Access and Choice

Rusty Dennison, MA, MBA – President, Parker Dennison & Associates, Ltd.

Introduction

•Beginning in FY09, DMH incorporated Post Payment Reviews (PPR) into DMH/Collaborative provider monitoring site visits

•Current DMH/Collaborative site visits include:

- Post Payment Reviews- Clinical Practice and Guidance Reviews- Fidelity Reviews (PSR in FY09)

•DHS BALC is still performing Certification reviews

IntroductionDMH reviewed and approved all policies, forms,

and training materials implemented by the Collaborative for PPR

At the time PPR was implemented, DMH instituted managerial oversight of the Collaborative’s practicesWeekly meetings with reviewers as well as the

Collaborative’s Provider Relations DirectorMade available DMH clinical staff and BALC staff to

consult with the Collaborative’s reviewers in the field Involved DMH Regional Contract Managers in reviews

Introduction•Consistent with continuous quality improvement, DMH asked Parker Dennison to evaluate our provider monitoring process in February 2009

•Parker Dennison completed this analysis and has provided DMH with recommendations

•DMH has considered these recommendations and has begun to implement changes to the process

•Find the Parker Dennison report on the DMH website at: http://www.dhs.state.il.us/page.aspx?item=43483

BALC Coordination with DMH/Collaborative PPR

Participation in development of PPR/monitoring model

Participation in Collaborative’s PPR staff and provider training

Participation in weekly PPR Collaborative/DMH coordination and problem solving calls

PPR vs. Certification: Differences?

Example~

Post Payment ReviewFinds 50% of claims reviewed have no current ITP in

recordOutcome: provider will lose value of those claims

Certification ReviewFinds 5 of 10 records reviewed (50%) have no current

ITPOutcome: provider will lose 42 points on certification As a result will have 422 of 464 points on their

certification for a total score of 91%

Parker Dennison Assessment of Post Payment Review

Assessment conducted in January/February 2009

Information sources included:Focus group with 25 providers statewideFeedback from other stakeholdersReview of policies, forms, training materials, protocolsReview of Federal OIG reports from IL and other statesReview of applicable state and Federal rulesAnalysis of audit results through 12/31/08 Included 3,070 claims and audits from 32 providers

Parker Dennison Report:Focus of Post Payment Review

All PPR elements consistent with those found in other OIG reports

Some elements found in OIG reports are not present in IL PPR

Federal OIG does identify some elements that can be deficient, need correction but not recoupmentThis is inconsistent even within different OIG audits

Recommendations include:DMH should periodically rotate in new/different

elements (annually review/update)DMH can consider a limited amount of ‘procedural’

designations, at least as a transition

Parker Dennison Report:Training & Communication

Provider training was adequate compared to other states but not best practice

Training was provided regarding Rule 132 (basis of PPR)

Training was provided regarding the PPR tool and protocolRecommendations include:Detailed interpretive guidelinesOn-going Frequently Asked Questions (FAQs)On-going feedback to providers about aggregate

results, common problems, recommendations

Parker Dennison Report:Audit Staff Resources

All Collaborative reviewers are LPHAs, including two who are also Certified Recovery SpecialistsRepresents the highest standard of practice in audits

Overall feedback was positive regarding professionalism and clinical knowledge

Recommendations include:Expand inter-rater reliability monitoring of reviewersInvolve DMH contract managers for cross training

where feasibleInclude reviewer competency training in training for

new reviewers

Parker Dennison Report:Post Payment Review Process

Unannounced reviews are problematic

Some inconsistency on provider staff involvement

Lack of public interpretive guidelines

Recommendations include:Discontinue unannounced reviews (unless there is a

provider-specific reason)Clarify provider staff involvement protocol and be

consistentInclude interpretive guidelines in provider training

materialsMore detail on PPR report to providers

Parker Dennison Report:Analysis of PPR Results (12/31/08)

Key statistics:32 providers3,070 claimsAvg. of 55% of claims unsubstantiatedValue of unsubstantiated claims (no extrapolation) =

$101,937Avg. unsubstantiated claims per provider (no

extrapolation) = $3,186

Average of two deficiencies per unsubstantiated claim

Overwhelming majority of deficiencies confined to 7 elements on PPR toolOnly these 7 fell below 95% compliance levelAll 7 elements were cited in other Federal OIG reports

Parker Dennison Report:Analysis of PPR Results (12/31/08)

Lowest compliance %:Q2 – (66.87%): MHA contains all required elementsQ10 – (81.14%): Note contains description of

interaction w/consumer including response and progress toward ITP goal(s)

All other questions had compliance of 92% or greater

Remediation of top 7 deficiencies would reduce statewide average to 12% unsubstantiated claims (from 55%)

No data demonstrating an inter-rater reliability issue

DMH ResponsePleased with the overall assessment results of the

Post Payment Review processAppears to be identifying targeted areas for

improvement in moving the system forward Identified areas for improvement can be addressed

in trainingValidates the risk and need for continued efforts for

continuous improvement in compliance

Will continue the established managerial oversight practices

DMH Changes to the ProcessAnnounce site visits (began 3/20/09)

Improve communication with providersPost interpretive guidelines to websiteProvider alerts with summaries of issues and trendsAnalyze and use provider post-review survey

feedbackCollect provider questions through the

dhsmh@dhs.state.il.us addressPost provider FAQs to website

Ensure reviewer consistencyStrengthen inter-rater reliability and monitoringContinue weekly reviewer check-ins with DMH, BALC,

and the Collaborative

DMH Changes to the Process (cont.)

Change Post Payment Review scoring Split claim status into two parts: claims disallowed and

procedural deficiencies Begin requesting plans of improvement based on

compliance (including all claims findings) Begin tracking the individual parts of the Mental Health

Assessment in the database

Allow some types of claims to be corrected

Begin scoring changes going forward and re-score those already reviewed this fiscal year

[see the separate document “Claims Guide”]

Feedback and Questions

Available to Answer Your Questions—Thanks!

Jackie Manker, LCSW – Associate Director of Community Services, DHS/DMH

Lee Ann Reinert, LCSW – ASO Clinical Policy Manager, DHS/DMH

Cathy Cumpston – Chief, DHS Bureau of Accreditation, Licensure and Certification (BALC)

Aissa Bell – Director, Provider Relations, IL Mental Health Collaborative for Access and Choice

Rusty Dennison, MA, MBA – President, Parker Dennison & Associates, Ltd.