Transcript Document

New York Care Coordination Program
Western Region Behavioral Health Organization
Western Region BHO Provider Webinar
December 30, 2011
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Agenda
• What admissions should NYCCP/Beacon be notified of?
• When and how to notify NYCCP/Beacon of an admission
• The Clinical Review Process and Notices
• Long Stay Individuals
• Discharge Information
• Questions
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What Medicaid admissions should NYCCP/Beacon be
notified of?
• NYCCP/Beacon should be notified and is responsible for reviewing the
following populations:
• All fee-for-service admissions to OMH-licensed psychiatric units (all ages)
in general hospitals (Article 28 hospitals).
• Fee-for-service children and youth admitted to OMH licensed private
psychiatric hospitals (Article 31 hospitals).
• Fee-for-service direct admissions to OMH State-operated children’s
psychiatric centers or children’s units of psychiatric centers.
• Fee-for-service OASAS Certified Part 816 Inpatient Detoxification Services
(Article 28/32).
• Fee-for-service OASAS certified hospital (Art 28/32) or freestanding
(Article 32 only) Part 818 Chemical Dependence Inpatient Rehabilitation
Services.
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When and how to notify NYCCP/Beacon of an admission:
1. Inpatient providers are to notify Beacon clinical staff within 24 hours of a patient’s
admission or by 5 P.M. the next business day following weekend and holiday admission.
Notification is done via an online Notice of Admission portal or telephonically at 855209-1142. The office is open from 8:30 until 5:30 Monday through Friday.
A. All notifications will be done telephonically initially.
i. Beacon will be rolling out the electronic notification process later in January.
B. When notifying telephonically, please have available the patient’s First Name, Last
Name, Medicaid ID (CIN #), the Type of Admission (MH, SA-Detox, Rehab, etc.).
Note: NYCCP/Beacon cannot accept a notice of admission without a beneficiary’s
Medicaid CIN number and name.
i. While not required; if treatment plan, discharge planning, and Axis 1-4 diagnosis
info is available Beacon will be able to take this information at the Notice of
Admission as well. This may speed the next concurrent review.
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When and how to notify NYCCP/Beacon of an admission (cont):
2. Upon receipt of the notification of admission, Beacon’s clinical staff will:
A. Confirm beneficiary’s eligibility
B. Determine the nature of the service, review the patient’s past clinical history and
plan for a concurrent review to discuss the case with the facility and begin
treatment and discharge planning efforts.
C. Beacon’s clinical staff will generate and share with the facility a report that details
the patient’s past Medicaid service history.
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The Clinical Review Process and Notices:
1. Within 72 hours of admission, or by 5 P.M. the next business day following notification of
the admission by provider, whichever is later, the initial clinical review will occur. At this
review the Beacon clinician and facility clinician will review the continued need for stay
at the current level of care. The patient’s current treatment plan, discharge plan and
past Medicaid service history will be discussed at this initial review.
A. If the beneficiary is discharged prior to the initial review, the facility should notify
NYCCP/Beacon of the discharge either telephonically or via the online NOA portal
(when available).
B. All admissions will be reviewed against the Beacon Level of Care Criteria (See
12/22 email).
C. Special attention will be given to individuals with high needs and readmissions.
2. At the end of the initial review, a date will be scheduled for the next call with Beacon
regarding the patient. These check in calls will occur at an interval of not more than 5
days for inpatient mental health; 2 days for inpatient detoxification; and for inpatient
rehabilitation, the reviews will occur no later than the 21st day of admission and thereafter
at an interval of not more than 7 days (“maximum concurrent review intervals”).
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The Clinical Review Process and Notices (cont):
DURING THE CLINICAL REVIEW PROCESS, DISCUSSION SHALL INCLUDE, BUT NOT BE LIMITED TO, KEY
ELEMENTS SUCH AS:
1. Presenting Issue
2. Current Symptoms
3. Agency Involvement
4. Past Treatment History
5. Medical History
6. Medication History
7. Substance Abuse History
8. Family and Any Other Supports
9. Diagnosis Axis I-IV
12.Treatment records from applicable
inpatient and outpatient practitioners and
providers
13.Information from conversations with the
beneficiary, the beneficiary’s guardian/s
and/or treating practitioners/providers
14.Results of tests and evaluations
15.Information from conversations with
specialty consultants and,
16.Individual beneficiary needs (including
the potential benefit of peer services
and/or supports)
10.Proposed Treatment Plan
11.Proposed Discharge Plan
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The Clinical Review Process and Notices (cont):
4. Beacon’s UR Clinician enters information into FlexCare (defined as Beacon’s
proprietary, fully integrated Behavioral Health Management Information System). If the
clinical information supports the continued stay at the current level of care, the UR
Clinician documents agreement of the continued stay in FlexCare. The UR Clinician and
facility clinician will agree upon a date at which the next clinical discussion should occur.
5. If on initial review, or during a subsequent concurrent review, the clinical information
available does not support the current level of care, the Beacon UR Clinician discusses
alternative levels of care which match the patient’s presenting clinical symptomatology
with the facility. If an alternative setting is agreed to by the provider, the UR Clinician
documents agreement of the discharge plan, records it in FlexCare, and verbally informs
the provider of the agreement.
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The Clinical Review Process and Notices (cont):
6. If an agreement cannot be reached between the Beacon UR Clinician and the provider, the
Beacon UR Clinician consults with a Beacon Psychiatrist or Physician Advisor (PA).
A. All Beacon Physician Advisors are board certified psychiatrists of the same or similar specialty as
the services being discussed. For example if a recommendation is being rendered for a child’s
service, they will be made by a board certified child psychiatrist.
7. The Beacon PA reviews all the information collected by the UR Clinician. If there is not enough
information to make a decision, s/he may request additional documents and/or contact the
requestor or other party for further information. If Beacon does not receive the requested
information within the timeframes identified, a recommendation is made with the information
available.
8. If the Beacon PA is in agreement with the provider, the UR Clinician documents agreement in the
Beacon system and verbally informs the provider of the agreement and the facility is notified of the
recommendation by phone and/or by secure fax within 24 hours. The verbal notification includes:
a) The reference number
b) The date of admission
c) The date the PA discussion occurred
d) The next anticipated BHO contact date
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The Clinical Review Process and Notices (cont):
9. If the Beacon PA is unable to make a determination that the beneficiary meets
Beacon’s criteria for continued inpatient care, Beacon will furnish the provider with a
Notice of Preliminary Finding. This verbal notice shall indicate that the BHO’s opinion is
advisory, and the need for continued inpatient care should be determined by the
treatment team based upon the beneficiary’s clinical condition and best interests.
A. Additionally the provider will be notified that they may submit a reconsideration
within 24 hours of the verbal Notice of Preliminary Finding. As part of the
reconsideration the provider may submit further information and documentation to
demonstrate that inpatient care is still warranted. Additional information can be
submitted to NYCCP/Beacon by calling 855-209-1142.
10. If the provider does not pursue reconsideration and does not submit further information
within 24 hours of verbal receipt of the Notice of Preliminary Finding, and the individual is
not discharged within 48 hours of the Notice of Preliminary Finding, Beacon will issue a
formal Notice of Clinical Determination indicating such determination and its clinical basis.
NYCCP/Beacon will forward such Notice of Clinical Determination to the provider and to
The Offices (OMH and OASAS).
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The Clinical Review Process and Notices (cont):
11. If the provider does submit a reconsideration and documentation within 24 hours of its
receipt of the Notice of Preliminary Finding, Beacon shall review such information and
documentation with 24 hours. If Beacon’s reconsideration review determines that the
individual does not require treatment in an inpatient setting, and the individual is not
discharged within 72 hours of the Notice of Preliminary Finding, NYCCP/Beacon will issue a
Notice of Clinical Determination to the provider and to The Offices (OMH and OASAS).
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Long Stay Individuals
NYCCP/Beacon recognize that certain individuals may have extended admissions due to
extenuating circumstances. In those cases, the requirement for maximum concurrent
review intervals will be waived for individuals designated as “Long Stay” individuals.
Individuals will be designated as “Long Stay” when all of the following criteria are met:
1. The individual meets the criteria for inpatient care.
2. The individual presents with symptoms and/or history that demonstrates a significant
likelihood of deterioration in functioning/relapse if transitioned to a less intensive level of
care.
3. The Beacon Clinical Manager and provider concur that the current treatment and
discharge plans best meet the individual’s needs.
4. The individual’s discharge is delayed pending availability of resources that both the
provider and BHO believe are necessary to keep the beneficiary out of the current
hospital setting, e.g., intermediate care inpatient, residential treatment, or foster care
beds.
For Long Stay individuals, NYCCP/Beacon will schedule follow-up discussions at intervals deemed
appropriate based upon clinical judgment.
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Discharge Information:
Review of discharge planning shall include, but not be limited to, key elements such as:
1. The status of the individual and the expected length of stay.
2. The content of the treatment plan.
3. The anticipated discharge date.
4. The completion of assessments of physical and behavioral health needs with referrals as needed to
meet the needs identified.
5. Contact with case management if applicable.
A. Assessment of the need for case management if the individual has not been receiving such care
management services,
6. Assessment of need for post-discharge treatment.
7. Assessment of housing status, including but not limited to the housing status of the individual at the
time of admission and the anticipated status upon discharge.
8. Assessment of consumer/family participation. (Did the consumer/family (for individuals under the
age of 18) have substantial involvement in the development of the discharge plan?
9. Assessment of post-discharge linkage of children with other service systems, e.g., juvenile justice,
education, child welfare.
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Discharge Information (cont)
1. When a beneficiary is ready for discharge, the provider is to notify Beacon via an
online Notice of Admission portal or telephonically at 855-209-1142 within 24 hours of
discharge.
A.Please provide the beneficiary’s name, Medicaid CIN number, and scheduled
aftercare appointments.
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Frequently Asked Questions
Question: What admissions are to be reported?
Answer : Any new Medicaid FFS admissions occurring on or after January 3, 2012.
Question: If an inpatient unit serves patients from a multi-county area, but some of the
counties in our service area are not included in the Western Region. For those patients
who need a call to a BHO, do we need to call the BHO that covers the other NY region or
do we call Beacon Health Strategies?
Answer: The BHO regions and notification requirements are based on the location of the
Facility/Provider and not the county the patient resides in. If a facility/provider is located
in the western region they should notify NYCCP/Beacon regardless of the county the
patient resides in.
Question: How do you determine which admissions are Medicaid FFS admissions?
Answer : You need to work with your billing office to determine where the bills are going to
go for the admission.
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Frequently Asked Questions (cont)
Question: Do these patients need to sign a consent form before the BHO is notified?
Answer: For Mental Health admissions a signed consent for is not needed as the BHO is
acting on behalf of Medicaid. For substance use/chemical dependency admissions
OASAS has provided a universal consent form that can be used for the purposes of the
BHO notifications. Additional guidance from OMH/OASAS is forthcoming
Question: Can the initial clinical review be done at a time that is convenient to the
provider?
Answer: Beacon will contact the provider once the information concerning the admission
is received to begin the initial clinical review. The provider may choose to call Beacon
back at a time that is more convenient to the provider as long as it is within the operating
hours of the Beacon office (8:30 to 5:30, Monday through Friday) and allows the review to
be completed within 72 hours of the admission.
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Frequently Asked Questions (cont)
Question: Can a template be provided concerning the information to be collected during
the initial clinical review?
Answer : Yes, Beacon will work on this template and send it out to inpatient providers by
the end of the day on Friday.
Question: Can Beacon only speak with QHPs when completing the clinical reviews?
Answer : At least during Phase 1, it will not need to be a QHP participating in the clinical
review.
Question: What if the call about the new admission is not made with 24 hours or by 5 PM
the next business day following a weekend and holiday?
Answer : Please do your best and notify us as soon as you can.
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Frequently Asked Questions (cont)
Question: Should providers keep their billing offices informed about the work of this
project?
Answer: It makes sense to keep the billing office informed of this work even though there is
no financial impact at this time.
Question: Will providers receive help in addressing obstacles related to the long stay
patients?
Answer Yes, there are positions within the Beacon staff that will offer support. NYCCP also
plans on convening provider groups to look at system level solutions to obstacles
identified.
Question: How much weight will a BHO recommendation have in the Medicaid audit
process?
Answer : This question is best answered by the state agencies, but recall that the purpose
of this program is to collect information in order to better understand the system and
address obstacles, not to have a financial impact.
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Frequently Asked Questions (cont)
Question: What if a provider receives a verbal notice of Preliminary Finding on a Friday?
How much time does the provider have to respond with the reconsideration?
Answer: The reconsideration will need to be submitted by 5:00 P.M . on Monday of the
next week.
Question: What if the person calling to provide information about an admission is not the
person that Beacon should speak with concerning the initial clinical review?
Answer? When leaving a message about an admission, please include the name and
phone number of the person that Beacon should speak with concerning the clinical
review.
Question: True or False ? None of the BHO work has any impact on Medicaid
reimbursement or patient liability.
Answer: True
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