dhs/dmh/the collaborative contractual overview presentation february 13, 2013 february 14, 2013...
TRANSCRIPT
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?