Transcript Document

Illinois Mental Health Collaborative
For Access And Choice
Presents
Introduction
to
Provider Monitoring
March 25, 2008
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Agenda



Introductions
Background
Provider Monitoring Process
– Post Payment Review
– Clinical Review
– ACT Review
– CST Review
March 25, 2008
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DMH Presenters
• Christopher T. Power, Ph.D.
• Jackie Manker, LCSW
• Tom Miller, MHSA
March 25, 2008
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Collaborative Presenters
• Mike Mulvany, Director of Provider Relations
• Dee Durant, Director, Clinical Operations
• Sandy Potter, VP, Clinical Operations
March 25, 2008
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DMH Overview

Overarching Themes for 4Q FY08
– This year is an introduction to how monitoring will be
conducted in the future.
– A coordinated team approach with DHS/DMH, BALC, and
Collaborative staff.
– No duplication of reviews
– No extrapolation this year – so no penalty
– Compliance with both Rule 132 and the contract
– Evolving process – so we learn and adjust as we go
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The Goals of the Collaborative

Under the direction of DHS/DMH the
Collaborative will perform provider monitoring
activities starting in 4Q, FY08.
–
–
as a coordinated team approach with DHS/DMH
contract managers and BALC.
this is an evolving process.
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Provider Monitoring

Rule
–
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Contract
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Clinical Record Review
Post Payment Review
Coordination of benefits
Non-Medicaid services
Moving mental health system towards recoveryoriented services
–
–
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ACT/CST Fidelity reviews
Crisis Plans
Consumer participation
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Identify/set
schedule of
providers for
review
Is provider on
BALC review list
No
Coordinate with /
DHS/DMH
contract manager
and schedule
review with the
provider
Request reports
1. Utilization
2. Critical Incidents
3. Complaints/
Grievances
4. Claims Sample
Review reports and
generate random
sample of records to
be reviewed for each
review being
performed
Collaborative Regional Liaison
schedules the on-site visit and
notifies the provider of the review,
sends the list of records, review
items, review tools to the provider
(if provider is not due for BALC
review)
Regional Liaison
verbally reviews
results of
Collaborative
portion of review
findings with
provider at
conclusion of
review
Complete the
review at the
provider’s primary
site
Yes
Coordinate review
with BALC
Legend:
BALC – Bureau of Accreditation,
Licensure and Certification
DHS/DMH –Illinois Department of
Human Services, Division of Mental
Health
Collaborative – Illinois Mental
Health Collaborative for Access and
Choice
Regional Liaison – Collaborative
Staff
POC – Plan of Correction
PR – Collaborative Provider
Relations
QM – Collaborative Quality
Management
Contract Manager – DHS/DMH Staff
QM Analyst scores
tools and returns
results to PR
Director within 10
business days
Within one business
day, submit
completed tools to
Collaborative QM
Analyst for scoring
PR Director Reviews
and submits to DHS/
DMH Regional
Director within 4
business days
DHS/DMH Regional
Director responds within 5
business days with
changes or approval.
Lack of response indicates
approval
POC accepted- copy sent to BALC
and Region for Provider Record –
end process until next review*
Yes
PR Director sends written
review results to the
provider with a copy to the
DHS/DMH Regional Director
and to BALC within 30 days
of completion of the review,
and a copy is placed in the
providers file
POC reviewed by
DHS/DMH
Regional Director
and Collaborative
PR Director within
15 calendar days.
Accepted?
Provider submits
POC to the
Collaborative/PR
Director within 30
Calendar days.
Plan of
Correction
Needed
No
End of process
Yes
No
*DHS/DMH and
Collaborative staff will
monitor to ensure
implementation of POC
between the approval of the
POC and next scheduled
review via resources
applicable to the specific
issues identified.
POC not approved –
Regional Liaison contacts
provider within 7 calendar
days to provide Technical
Assistance in developing
POC
POC resubmitted to
Collaborative within 7
calendar days of
Technical Assistance
and reviewed by PR
Director and DHS/
DMH Regional
Director for Approval
within 7 calendar days.
POC accepted- copy sent to BALC
and Region for Provider Record –
end process until next review*
Post Payment Review
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Process to ensure that the service billed is the
service that was provided by matching claims with
the documentation in the clinical record.
The sample for review will be based on claims
submitted for services provided during FY08.
The review will be on the same sample for either
ACT/CST Fidelity or clinical record reviews.
The review will be only for those providers that have
not had a post payment review by BALC in the past
6 months.
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Overview of Fidelity Monitoring
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One of the goals of the Collaborative is to
ensure appropriate level of care
Record review- not contract review
ACT Fidelity will be based on the Dartmouth
Assertive Community Treatment Scale
(DACTS), recommended by SAMHSA
(available on line at http//:samhsa.hhs.gov/)
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Overview of Fidelity Monitoring (cont)
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CST fidelity will be based on the DHS/DMH
mental health service definitions
There will be on-going Team leader
conference calls held by DHS/DMH and the
Collaborative to support the ACT and CST
Teams
Fidelity monitoring is Team based
(not agency based)
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CST Fidelity Monitoring
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The CST Fidelity tool:
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developed from the DHS/DMH mental health
service definitions
contains program-specific items required by the
rule
measures the degree of implementation of CST
services
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ACT Fidelity Monitoring
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The ACT Fidelity tool
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contains 28 program-specific items
designed to measure the degree of
implementation of ACT programs
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Next Steps
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Review Tools
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Scheduling Site Visits
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advance notification of reviews
Monitoring Activities
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will be posted on the Collaborative website
4th quarter- FY08
verbal results shared with providers
written results within 30 days of completion of the review
Follow-up with providers
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Questions and Answers
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Presentation
Today’s presentation will be available online within 2 weeks at:
http://www.IllinoisMentalHealthCollaborative.com/providers/Training/Trai
ning_Workshops_Archives.htm
Be sure to share this information with your staff!
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For More Information
Today’s presentation will be available online at:
http://www.illinoismentalhealthcollaborative.com
You can follow these steps:
Step 1: Go to www.illinoismentalhealthcollaborative.com
Step 2: Click on “Providers”
Step 3: Click on “Education Center”
Step 4: Click on “Trainings/Workshops”
Step 5: Click on “Archive Forums”
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Thank you!
Illinois Mental Health Collaborative for
Access and Choice
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