Provider OrientationContract Management

Highlights

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This document revised April 2016.

Contract Requirements

This is a general overview of some contractual requirements and does not supplant the provider’s responsibility of doing a thorough review of the Provider Agreement (Contract) with the Network.

Providers are held contractually responsible for adhering to the information contained in the contracts – it is important the provider be familiar with the material contained therein.

Compliance

Compliance with Terms of Network’s Detroit Wayne Mental Health Authority Contract

• The Provider’s Agreement with the Network is subject to the terms in the Network’s contract with DWMHA.

• This includes any manuals and policies referenced in the Network’s contract with the Authority.

Provider Manual

• The contract refers to the Network provider manual.

• Providers are contractually required to follow the directives and protocols contained in the Network’s provider manual as from time to time may be amended.

• The Provider Manual is posted to the Network’s website.

• Provider manual updates are also posted. Therefore, it is important for providers to check the website weekly for updates.

Eligibility and Coverage

• Providers cannot be reimbursed for a non-covered service.

• It is important for Providers to check the person’s eligibility prior to the service delivery.

Staffing and Training

• Providers are required to ensure their staff meets all minimum training requirements required by the Network and Detroit Wayne Mental Health Authority.

• Provider must notify the Network whenever contracted services and/or sufficient staffing of such services are not or cannot be provided.

Credentialing

• Provider’s responsibility to ensure credentialing of all appropriate staff.

• Provider’s responsibility to keep all required documents of credentialing on file.

• Provider shall comply with the Network’s and DWMHA credentialing and re-credentialing process.

• Provider is required to maintain all current licenses, insurance and accreditation documents as required for credentialing.

Credentialing Continued

• Provider cannot bill for a service if the staff that provided the service does not meet the minimum credentialing requirements to provide the service.

• Provider must immediately send written notice to the Network of any legal, governmental or other action involving Provider which could materially impair the ability of Provider to carry out the duties and obligations of the Agreement including but not limited to suspension, termination or revocation of license or licensee, insurance and accreditation, any material change in ownership or legal status or provider’s ability to continue to provide all contracted provider services.

Credentialing Continued

• Provider must notify the Network and DWMHA within 3 days it receives notice that any action is being taken against Provider which could result in exclusion, debarment, or suspension of the Provider from the Medicare or Medicaid programs, or any other governmental health care program.

• Provider must disclose of any staff member, director, manager or individual beneficial ownership, contractor, consultant, etc. if they have been convicted of a criminal offense described within the Agreement.

• Providers must check OIG and EPLS websites monthly for all staff, employees, contractors, subcontractors, etc. and maintain documentation of such checks.

Coordination of Benefits

• Provider is required to coordinate benefits including coordination with Qualified Health Plans, Medicaid, Medicare, the Network and the DWMHA.

• Provider shall make ability to pay determinations and billing determinations as to first and third parties in accordance with contract requirements.

• Provider is to ensure the DWMHA funds are those of last resort.

Utilization Management

• Services provided must be included in the person’s Individual Plan of Service (IPOS).

• Cannot bill for an outpatient service if it is not included in the person’s IPOS.

• Provider is required to abide by the Network’s utilization management protocols as from time to time may be amended.

Claims Submission Protocols

• Claims must be submitted in accordance with contract requirements including timely filing.

• Provider attests that the service was provided upon submission of the claim.

• Denied claims can be appealed utilizing the Network’s claim appeal process.

Contract Remedies and Sanctions

• Providers must be familiar with the contract remedies and sanctions part of the contract.

• Remedial actions can range from a simple correction or deficiency, a directed plan of correction, withholding payments, suspension of referrals up to and including termination of the Agreement.

Term and Termination

• Typically most contracts contain an automatic renewal clause whereby the contract is automatically renewed October 1st of each year if termination actions have not been taken by either party.

• Termination without cause requires a 90 day notice.

• Termination with cause (for default) can typically be done with a 30 day notice.

Term and Termination Continued

The following events shall result in the immediate termination or suspension of the Agreement upon notice to Provider at the Network’s discretion:

• the withdrawal, expiration or non-renewal of Authority required impaneling of Provider;

• the bankruptcy or receivership of Provider, or an assignment by Provider for the benefit of creditors;

• the loss or limitation of Provider's liability insurance;

• a reasonable determination by Authority or the Network that Provider's continued management and delivery of the services could result in harm to Consumers;

Term and Termination Continued

• the debarment or suspension of Provider from participation in any governmental sponsored program, including, but not limited to, Medicare or Medicaid;

• the indictment or conviction of Provider for any crime;

• change of control of Provider to an entity not acceptable to Authority or the Network.

• disapproval of the Provider by the Centers for Medicare and Medicaid Services (“CMS”), or any other governmental entity, to the extent such approval is required in connection with the funding for services delivered hereunder.

Provider shall provide immediate notice to the Network and Authority, upon Provider's actual knowledge of any of the aforesaid events.

Adult Foster Care Facilities

For Adult Foster Care Facilities, the Provider agrees that the Provider’s state license to provide foster care services, state certification to provide specialized residential services and continuing certification and enrollment under the Title XIX Medicaid program (if applicable) are dependent covenants of this contract. Failure to maintain such licensure and/or certification shall cause this contract to be immediately canceled.

Confidentiality

• Provider agrees to maintain and safeguard the confidentiality of all records, reports, information, and confidential communication of the persons served.

• Provider agrees to abide by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH), the Michigan Mental Health Code.

• Provider shall meet privacy and security conditions regarding health information.

Confidentiality Continued

• Provider must ensure client files are maintained in a safe and secure environment in accordance all applicable laws and regulations.

• Provider shall ensure all staff maintain appropriate confidentiality training.

• Provider ensures all staff is aware that email is not a secure form of transmission and that Protected Health Information cannot be sent via e-mail unless the email system complies with HIPAA.

Confidentiality Continued

• Provider must comply with the Network’s and DWMHA’s confidentiality policies.

• Provider must maintain a current Notice of Privacy Practices in accordance with HIPAA.

• Provider must ensure that access to DASH is limited to those required for the functions of their job and takes appropriate steps to timely end access to DASH after staff leaves the organization.

• Provider must ensure staff do not share passwords and logons. They are unique to the individual- not the organization

 

Liability Insurance

• Provider must maintain (and provide the network) all appropriate general and professional liability insurance in accordance with contract requirements.

• Failure to maintain appropriate insurance can lead to contract sanctions up to and including termination.

Ability to Pay

• Provider is required to ensure the Network and DWMHA funds are those of last resort.

• Provider is required to ensure every non-Medicaid person has ability to pay forms completed at least annually.

• Provider cannot serve those who have Medicare insurance unless provider is appropriately enrolled with Medicare (excludes AFC providers).

Impaneling and Privileging

• Provider is required to meet DWMHA’s impaneling requirements.

• Provider is required to notify the Network of any impending change to ensure the change meets with the DWMHA’s impaneling requirements including but not limited to site additions, site relocations, service additions and deletions, etc.

Fraud and Abuse

• Provider acknowledges that the DWMHA has the responsibility and authority to make fraud and/or abuse referrals to the Office of the Michigan Attorney General, Health Care Fraud Division and MDHHS.

• Provider must report suspicion of fraud and/or abuse to DWMHA and the Network.

Independent Audit

• Providers who receive more than $100,000 annually for services shall annually obtain an independent financial audit by a certified public accountant.

• Providers must track the amount of funds being paid by the contract to ensure compliance with this standard.

Criminal Background Checks

• Provider shall maintain effective methodologies to perform, and shall perform, criminal background checks on potential employees in order to avoid employment of those who do not pass such check in accordance with Federal and State law and Authority policy and annual background checks on current employees.

Provider Meetings

• PROVIDER must attend all provider meetings by the PAYER. PROVIDER is solely responsible for the information disseminated at the provider meetings.

• If PROVIDER is not able to attend a provider meeting, it is the PROVIDER’S responsibility to follow up with PAYER regarding information distributed.

• If PROVIDER fails to consistently attend provider meetings, this will become a plan of correction for the provider and subject to the network’s scope and severity protocol.

• Provider meeting notices are posted to the Network’s website. The Network will also complete an email notice of the meeting, if possible.

Contract Management

For questions, contact Denise NormanDirector, Network Management