302 behavioralhealthpanel...participant guide 1 compliance in behavioral health for mcos and...

1/28/2014

Participant Guide 1

COMPLIANCE IN BEHAVIORAL

HEALT H FOR MCOS AND

PROVIDERS

Tuesday, February 11, 2014

2:45pm - 4:15pm

Gregory W. Moore

Peter J. Domas

Lesa Yawn

Mary Thornton

12

PANEL

D ISCUSSION

AGENDA

� Understanding current

environment and the implications

for MCOs and providers – 15 mins

� Assessing and determining risk for

MCOs and providers – 30-35 mins

� Implementing strategies to

mitigate and manage risk for MCOs

and providers – 30- 35 mins

� Questions and Answers – 10 mins

23

C O M P L I A N C E F R O N T A N D C E N T E R - R EQ U I R E M E N T S A N D E X P EC TAT I O N S

� MCO

– Compliance program, plan and activities in place

– Staffing and expertise of program in house

– Expectations for participating providers

� Providers

– Compliance program

– Reduction of Provider and MCO risk

– Expectations of guidance from MCOs and the government and on-going assessment of risk

3

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Participant Guide 2

T HE ENVIRONMENT

Constant Change Models

45

T H E E N V I R O N M E N T: A C A , PA R I T Y, C H R O N I C H E A LT H H O M E S ,

I N T E G R AT I O N , E T C .

� What does it mean for BH member/provider/services

management by MCO and Provider

– Inclusion

– Expectations of waste management

– Impact on MCO-provider relationship

6

ENVIRONMENTAL SCAN

� Compliance front and center - requirements and expectations

� Affordable Care Act - content and implications for both MCO and Provider

� Limited dollars - more for less

� Inclusion of eligible members with significant needs, lack of resources and barriers for engagement

� Inclusion of private and public sector providers with varying business and clinical models, resources and expertise

6

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Participant Guide 3

7

IMPACT OF

ELIGIBLE

MEMBERS ON

MCO AND

PROVIDERS

� Changes in eligibility due to

political climate and budgets -

moving target

� Increased penetration rates,

increased access and access

standards

� Changes in reimbursement

� More for less

7

Opportunit ies for

Behavioral Heal th Providers (and Payors) in

the Era of Heal thcare Reform

89

W H AT D O E S T H E G OV E R N M E N T S AY A B O U T T H E A C A

A N D B E H AV I O R A L H E A LT H?

� Fundamentally change what services will be available to individuals that have mental health and addiction disorders.

� Expand access to prevention services, including annual wellness visits, and include outreach and education campaigns. In addition, grants will be available to implement, evaluate, and disseminate community prevention activities.

� Create incentives to coordinate primary care, mental health, and addiction services, including the creation of health homes for individuals with chronic health conditions, including mental illness and substance use disorders.

� Enhance community-based service options for individuals with a mental health and/or substance use condition. Medicaid state plan changes and demonstration grants will expand these services for individuals who have long-term care needs (e.g., dual-eligibles, high-risk Medicare beneficiaries, 1915i changes, Money Follows the Person).

� Develop capacity to provide services in an effective and modern mental health and substance use system through various workforce initiatives, including education and training grants, loan repayment programs, and primary care residency training.

http://www.samhsa.gov/samhsanewsletter/Volume_18_Number_3/AffordableHealthCareAct.aspx

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Participant Guide 4

10

OPPORTUNITIES

AS A RESULT OF

THE ACA

� Opportunities unique to

behavioral health care providers,

MCOs and other third party

payors.

� Impact of Essential Health

Benefits on relationships

between providers and payors.

11

AUTHORITY

� ACA gives states authority to work with providers and payers:

– To establish and fund alternative health care delivery models

– To develop innovative payment methods

– To promote federal, state and local collaboration by forming model of integrated care delivery for a better value

12

M ORE OF T HE M ANY C HANGES U NDER T HE AC A

� Integrated primary care and behavioral health models –treatment, case management, key service coordination

� Medicaid expansion

� Accountable Care Organization (ACO) model

� Community Health Centers (CHC)

� Patient Centered Medical Home Pilots

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Participant Guide 5

Impact of Health Reform• Research findings published

in a report entitled, “Impact of National Health Reform on Adults With Severe Mental Disorders,” by Garfield, Zuvekas, Lave and Donohue

• Medicaid enrollments are expected to increase 137.9% - 9 million to 21.5 million; about 4.1 million beneficiaries in 2019 will have severe mental health disorders

19%

81%

Medicaid Beneficiaries in 2019

(21.5 Million)

Severementalhealthdisorders

14

IMPACT OF HEALTH REFORM (CON’T. )

� Private insurance enrollment expected to increase by 16%

� Uninsured for a full or partial year expected to decrease by 59%

� Projected change in mental health service users:

– Up 107% among Medicaid beneficiaries overall; up 86.8% for severe disorders

– Up 12.3% among adults with private insurance; up 22.4% for severe disorders

15

M AN AGE D C ARE M UST L EARN TO M AN AGE

B EHAVIOR A L H EALTH

� Section 1302(b) – “Essential Health Benefits” includes:

– “Mental health and substance use disorder services, including behavioral health treatment.”

� Mental Health Parity Addiction Equity Act (“MHPAEA”)– Final Regulations Issued November 8, 2013.

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Participant Guide 6

16

ESSENTIAL

HEALTH

BENEFITS

(CON’T.)

� Under the MHPAEA, cost-sharing (e.g., deductibles and copayments) and treatment limitations (e.g., visit or day limits) applicable to mental health or substance use disorder benefits can be no more restrictive than the cost-sharing and treatment limitations applicable to medical and surgical benefits covered by the plan

� the ACA will require all small group and individual market plans created after March 23, 2010 to comply with federal parity requirements.

MCO PROVIDER BH

NET WORKS

MCO Evaluations of Organizational Risk in their Provider Networks

1718

CONDUCTING

MCO R ISK

ASSESSMENT

� Tools: environmental scan

� Methodology

� Sources and Resources

� Results

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Participant Guide 7

19

MCOS� Opportunities for contracting with

managed care health plans

– Sophistication on the private side or “cash and carry only”

– Most public providers cannot exist with just SPMI models – but they are wary of MCO interference OR are unaware of MCO requirements

• Their “deficit funding” is going away

� New population of providers: “Medicaiding” mental health and substance abuse services

20

M C O C O N S I D E R AT I O N O F VA RY I N G B U S I N E S S A N D C L I N I C A L M O D E L S ,

R E S O U R C E S A N D E X P E R T I S E

� Who are the providers?

– Private

• CMHCs: big focus of OIG and other oversight

• Minimal experience with insurances – small private practices (most psychiatrists not participating)

• Experts – single case contracting

• Encouraged to not document

– Public

• Substance abuse and mental health may not be integrated –separate bureaucracies and regs

• Varying degree of management expertise

• Policy-based bureaus fighting for their existence

• Lots of regs and costs associated with licensing and accreditation

• Access to “quality” psychiatry

– Primary health – integration models

� What does this mean for the MCO?

– Contracting is complex

– Various levels of risk and hand-holding

21

MCO

CONSIDERATIONS

IN

IMPLEMENTATION

OF BEST OR EBPS

� Uneven

� Academic models

� Expense associated with fidelity

� MCO coverage:

– reluctance to choose for the

providers

– Incorporation into utilization

management

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Participant Guide 8

22

MCO

CONSIDERATIONS

IN INTEGRATION

� Regs have not caught up with

policy in many cases

� 4 quadrant model – accepted but

not easily implemented

23

MCO

CONSIDERATIONS

CARE

COORDINATION

� Usually called case management on provider side

– In some states no longer funded –MCO responsibility?

– In some cases still provided by state workers

� Community-based model is most prevalent

� Usually lower credentials

� National certification - not used

� High productivity models fight “recovery”

24

MCO

CONSIDERATIONS

IN

CREDENTIALING

� Private practitioners: licensed; varying degrees of experience; specialty providers

� Public providers: limited access to licensed practitioners – many are in supervisory, not practice positions

– Many MA level, no license

– BS and other BA providers –some allowed to do psychotherapy

– Below BA – case management; supports coordination; residential techs; rehab workers

– Peers: various credentials

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Participant Guide 9

25

CREDENTIALS

(CONT)

� Psychiatrists:

– Must be convinced to see insured individuals –payment issues primarily

– Child psychiatrists: rare and very expensive

– Public system: older; foreign; and difficult to find; patchwork of hours and coverage; medical directors given limited time to direct; quality issues can be overlooked because of replacement difficulty

� NPPs: CNS and nurse practitioners: difficult to find; do not want to just do medication management; PA’s often do not have appropriate credentials for psych

– State variation in how they may practice

� Primary care: will tolerate limited complexity –single meds; often (even with CM and other supports) will not take on the SPMI population even if stabilized.

26

EXPERIENCE

WITH MCO’S

� What experience with managed

care? If any?

� Internal UM required? How

significant was this to operations?

� Use of level of care tools for

assignment

ROLE OF BEHAVIORAL HEALT H

PROVIDERS

Experiences Unique to Behavioral Health Providers Create a Significant Opportunity for Contracting

27

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Participant Guide 10

28

O PPOR TUNITIES BH – R EAD M ISSION P EN ALTY

S AGA

� If exceed 30 day readmit average for heart failure, heart attack or pneumonia

� In 2012, 2,217 hospitals penalized

� 307 cut full 1%

� In 2014, the penalty for readmission will increase to 2%

� In 2015, the penalties rise to 3%

29

MEDICARE

READMISSION

PENALTY

IMPACT

U.S. Total = $17.5 Billion a year

Source: Greene, Jay – Hospitals face reimbursement penalties over readmission rates

30

WHAT

HOSPITALS

SAY ABOUT

THE ISSUE

� “The process is out of our control”

� “We have found there is not a direct cause and effect as to why patients are readmitted”

� “There was no lack of coordination”

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31

THE CASE FOR BH INVOLVEMENT

Identifying Potentially Preventable Readmissions, Norbert I. Goldfield, MD, et al, Health Care

Financing Review, Fall 2008.

The Revolving Door: A report on U.S. Hospital

Readmissions, Robert Wood Johnson Foundation – An Analysis of Medicare Data by

the Dartmouth Atlas Project, February 2013

32

THE CASE

FOR BH

INVOLVEME

NT

33

THE CASE

FOR BH

INVOLVEMENT

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34 35 36

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37 38

THE CASE

FOR BH

INVOLVEMENT

39

OTHER

OPPORTUNITIES

� Post Discharge Transitional Care Management

� New HCPCS code

� All non face-to-face services related to the transitional care management furnished by physician or qualified non-physician practitioner w/in 30 days following discharge from inpatient acute care hospital, psychiatric hospital, LTC, SNF, inpatient rehab. facility

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BEHAVIORAL HEALT H

PROVIDERS

Risks Associated with Expanded Relationships with Behavioral Health Providers.

41

COMPLIANCE IS

NOT OPTIONAL

–

CONTRACTUAL

OBLIGATIONS

Federal Government

State Government

Payors

Providers

I N T R O T O D E V E LO P I N G A N E F F E C T I V E C O M P L I A N C E P L A N

42

JUSTICE

NEWS

“Home Health Aide Sentenced to Prison for Medicaid Fraud Involving Time at Casinos, Resorts”

� Facts:

– Billed Medicaid as if she was working at several places at once

– Billed for working more than 24-hours in a day

– Claimed she was visiting patients’ homes, but was actually at casinos and resorts

– Medicaid recipients were also charged for taking kickbacks

� Penalty for Health Aide:

– Prison Time – 2 years

– Fines – $234,663.61 restitution

Source: http://www.ohioattorneygeneral.gov/Media/News-Releases/July-2013/Home-Health-Aide-Sentenced-to-Prison-for-Medicaid on

7/18/2013


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43

JUSTICE

NEWS

“Mental Health Counselor Gets 6-Year Prison Sentence”

� Facts:

– Falsely claimed that she was the clinician for services provided to Medicaid recipients when no services were provided

– “Rented out” Medicaid provider number in exchange for a percentage of fraudulent Medicaid reimbursements

– Fraudulently used Medicaid numbers of children whose parents thought they were enrolled in after school programs

� Penalty:


– Fines – $6,156,674.68 restitution

Source: http://www.fbi.gov/charlotte/press-releases/2013/mental-health-counselor-receives-six-year-prison-sentence-for-defrauding-medicaid-

of-6.1-million on 8/8/2013


44

JUSTICE

NEWS

“Executives from Miami-Area Mental Health Care

Hospital Convicted for Participation in $70 Million

Medicare Fraud Scheme”

� Facts:

– Paying bribes to a network of patient recruiters

and falsifying documents

– Created the illusion of providing intensive

psychiatric care to qualifying patients when no care

of substance was provided

– Attempted to conceal payment of bribes and

kickbacks by creating false documents to make it

appear as if legitimate services were being

rendered

Source: http://www.justice.gov/opa/pr/2013/June/13-crm-744.html on 6/28/2013

45

JUSTICE

NEWS

“Long Island Health Care Provider Sentenced to 12 Years in Prison for $10 Million Medicare Fraud and HIPAA

Identity Theft”

� Facts:

– She used her position as a medical equipment company owner to enter nursing homes in order to access and steal patient records

– Falsely assumed a number of titles, including a doctor, nurse practitioner, and wound care expert

– Used the stolen records to create and submit false billings

– Violated the privacy of over 1000 patients

� Penalty:


– Fines – $10M restitution

Source: http://www.justice.gov/usao/nye/pr/2013/2013apr10.html on 4/10/2013


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46

JUSTICE

NEWS

“Health Care Clinic Director Sentenced for Role in $63 Million Health Care Fraud Scheme”

� Facts:

– Clinical director of community mental health center’s partial hospitalization program (“PHP”) conducted group therapy sessions without a therapist

– Paid illegal kickbacks to assisted living facilities (“ALFs”) in exchange for patient referral information, which was used to submit false claims

– Knew that main ALF referral patients were ineligible for partial hospitalization program services because many suffered from mental retardation, dementia, and Alzheimer’s

Source: http://www.justice.gov/opa/pr/2013/July/13-crm-844.html?goback=%2Egmr_5106478#%21 on 7/25/2013


47

JUSTICE

NEWS

“Attorney General Masto Announces Sentencing of Las Vegas Behavioral Health Worker”

� Facts :

– Submitted progress notes and time attendance documents to a behavioral health company for incarcerated individuals who were unable to receive behavioral health services

– Did not call or visit the Medicaid recipients during times or for time periods that he claimed he had provided the behavioral health services

� Penalty:

– Jail: 150 days, suspended

– Community Service: 100 hours

– Fines: $23,946

– Probation: Up to 2 years

Source:

http://ag.nv.gov/News/PR/2013/Medicaid_Fraud/Attorney_General_Masto_Announces_Sentencing_of_Las_Vegas_Behavioral_Health_Worker/

on 10/7/2013


48

PAYORS MAY

NEED TO

EQUIP CERTAIN

PROVIDERS

WITH TOOLS TO

ENSURE

COMPLIANCE

� Contracts with Behavioral Health Providers should provide for Compliance Program Requirements along with:

– Tools to implement Effective Compliance Programs

– Sources and Resources for Continuing Education.

– Expectations for Results

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49

ELEMENT #1:

WRITE AND

D ISTRIBUTE

POLICIES AND

PROCEDURES

� Central component

� Could include:

– Conflict of Interest Policy

– Code of Conduct

– General policies and procedures

– Summary of key laws

and provisions

K E Y E L E M E N T S O F A C O M P L I A N C E P L A N

50

ELEMENT #2:

DESIGNATE A

COMPLIANCE

OFFICER OR

CONTACT

� Roles and responsibilities

� Communication channels

� Write a job description


51

ELEMENT #3:

CONDUCT

APPROPRIATE

TRAINING AND

EDUCATION

� Determine training needs

� Determine best-suited

delivery methods

� Consider:

– Frequency

– Metrics

– Accountability

– Organization-wide effort


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52

ELEMENT #4: D EVELOP O PEN

L INES OF

C OMMUNICATION

� Ideas:

– Number/hotline

– Open Door Policy

– Complaints box

– Reporting form

� Establish policy and procedure

� Communicate importance of reporting

� No retaliation


53

ELEMENT #5:

CONDUCT

INTERNAL

MONITORING

AND AUDITING

� Various types of audits

� Set a baseline and regular intervals

for measurement

� Be proactive!

� Identify and resolve problems


54

ELEMENT #6:

ENFORCE

D ISCIPLINARY

STANDARDS

� Well-publicized guidelines

� Consistent and

appropriate consequences

� Procedures for disciplinary action


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55

ELEMENT #7:

RESPOND

PROMPTLY AND

APPROPRIATELY

� Detecting offenses

– Warning indicators

� Investigating claims

� Documenting steps taken

� Developing an appropriate

response


56

OPERATING

AND

MAINTAINING

YOUR PLAN

� Keep policies and procedures

up-to-date and user-friendly

� Make training and education part

of the job/role

� Solicit feedback

� Maintain visibility

� Proactively audit

� Be consistent with enforcement


Source: HEAT and OIG

MCO: MIT IGAT ION OF RISK

Beyond the Compliance Program, What Can the MCOs Do?

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58

ASSESSING AND DETERMINING RISK FOR MCOS

� Implications for MCO & Providers - new language & new

concepts to understand

– “QA, QI and QM”;

– “Regulatory Compliance”;

– “Risk Management”;

59

MCOS NEED TO THINK “OUTSIDE THE BOX”

1. Stretching “healthcare” for the SPMI Population

A. Housing first

B. Peer Services: credentialing and supervision

C. Supported Employment

D. ACT

2. Integration requires movement away from routine office visits –telehealth, self-management, phone based therapy, etc.

A. Who gets treated where?

B. Value added for somatizers

3. Co-occurring models: where can capacity be built?

A. Who does it well?

4. What if the state stands in the way?

60

CARE COORDINATION

� Who should provide? Who must provide?

� What credentials if provider-based?

– Medical competency – how can that be taught?

� Separate from or integrated into UM?

� Community vs. phone-based CM

� Public sector: transportation issue

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61

ACCESS TO

MEDICATIONS

� Management of pharmacy benefit or not?

� Integration:

– Medical protocol/formulary implementation – must have behavioral health expertise

• Cocktails

• Children: risk based management

• Black box

• Off-label

� Non-integrated: medical protocols, especially focused on high risk individuals

62

CORRECT

LEVEL OF

CARE

ASSIGNMENT

� Utilization Management:

– Protocols for UM that are publicized and that educate providers using objective criteria

• E.g. LOCUS/CALOCUS or other tools

– Trainers need to be experts in provision of services not just management

• Watch out for tools like CANS/ANSA that are being used or promoted by states and courts that were not developed to be level of care criteria

• MCO needs to take lead and designate tools that must be used

63

OUTCOME

BASED

PAYMENTS

� Behavioral health: it would be very

difficult to develop outcomes

based payment at this time

� If MCO decided to move in this

direction, it would require

considerable amounts of expertise

and oversight

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64

I M P L E M E N T I N G S T R AT EGI E S T O M I T I GAT E A N D M A N A G E R I S K

F O R M C O S

� Stretch compliance dollars in behavioral healthcare: audit claims or monitor compliance programming

– The better they are, the less risk you have

� Forge Provider Partnerships to support compliance especially with community based providers who have very few resources to dedicate to compliance

– They need access to information; to new regulatory requirements being contemplated; to new audit information, etc.

– Unless dealing with very large business entities, then the Compliance Officer has 3 or 4 other jobs

65

D E T E R M I N E S T R U C T U R E F O R C O M P L I A N C E P R O G R A M A N D P L A N F O R

M C O

� Use shared template to include seven/eight

components of compliance program

� Identify key areas of a compliance program

necessary to mitigate the risk associated with:

– expanding relationships with managed care

health plans, or

– developing integration strategies with physical

medicine

66

I M P L E M E N T I N G S T R AT EGI E S T O M I T I GAT E A N D M A N A G E R I S K

F O R M C O S

� Use and incorporate other findings - from DHHS,

accreditation, EQRO, individual and aggregate audit

results, current “hot buttons”

– Many providers have multiple

regulatory/licensing agencies involved – don’t

duplicate

� Evaluate which provider-types pose most risk

– An example: private providers –fraud vs. public

providers - waste

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67

QUESTIONS AND ANSWERS

68

THANK YOU FOR YOUR TIME

Gregory W. Moore

248.988.5842

[email protected]

Clark Hill PLC

Lesa Yawn, PhD, JD757.343.8620

[email protected] Consulting Inc.

Peter J. Domas

248.988-5870

[email protected]

Clark Hill PLC

Mary Thornton BSRN, MBA, CHC, CHPC617.730.5800

[email protected] Mary Thornton & Associates,

Inc.

302 behavioralhealthpanel...participant guide 1 compliance in behavioral health for mcos and...

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