Transcript No Slide Title

“Medicaid Compliance
Issues”
Georgia Dodds Foley, Esquire
Chief Compliance Officer
September 26, 2000
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Presentation Overview
• Company Overview
• Encounter Data - A Medicaid Managed
Care Organization’s Perspective
• Cultural Competency - Interacting with the
Limited English Proficiency (LEP) Member
• Questions & Answers
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Who We Are ...
Keystone Mercy Health Plan/AmeriHealth
Mercy Health Plan (KMHP/AMHP) are
affiliated partnerships which, combined, are
the largest multi-state Medicaid Managed
Care Plan in the nation providing quality
healthcare services to more than 700,000
recipients in six states.
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Mission
KMHP/AMHP exists to provide quality and
accessible health care services to its members, and
is characterized by a special concern for the poor
and disadvantaged.
KMHP/AMHP seeks to assure that care is provided
to its members by compassionate, competent
professionals who are respectful of individual
dignity.
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Values
Compassion
Stewardship
Leadership
Competence
Dignity
Teamwork
Service
Hospitality
Quality
Diversity
Advocacy
Care for the Poor
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Membership
Keystone Mercy
AmeriHealth Mercy
Gateway
Care Partners
Horizon Mercy
Passport
Select Health
Houston
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ENCOUNTER DATA
A Managed Care Organization’s
Perspective
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We Believe ...
• MCOs are capable of providing valid data
• MCOs and state know where the problems are
• There are strategies MCOs and the state can
pursue to improve processes and data quality
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HEALTHCHOICES (Pennsylvania Mandatory
Medical Assistance Managed Care) ENCOUNTER
REPORTING HISTORY AND CONTEXT
1997: Reluctance to address; anxiety leading to
resistance, even denial
1998: Investigation of the issue, advocacy and
commitment to address
1999: Action to implement initial and corrective
processes
2000: Ongoing updating/analysis
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FIRST YEAR:
Reluctance/Anxiety/Denial
Focus: Putting out immediate fires of
HealthChoices Implementation
– Encounter Reporting was “on the back burner” for
MCO’s and State
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SECOND YEAR: Investigation,
Advocacy and Commitment
Health Plan Focus
The Department is Serious
• Corrective Action Plans - Spring 1998
• Plans recognition -- > FFS is extinct under HCs -> Encounter data for future rates
• Department reduces the number of required fields
• Plans begin to delve into the many complicated
operational/policy issues of encounter reporting
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THIRD YEAR: Implementation and
Corrective Process
Health Plan Focus
Getting It Right (We hope!)
•Programming/processes/policy changes made
•Meeting of the minds
•Continue to uncover “glitches” in
processes/interfaces
•Establishing and perfecting the corrections
process
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THIS YEAR: Ongoing
Updating/Analysis
Health Plan Focus
Implementation of New IS System
•Encounter data “issues” will exist eternally
•Resolution of 1999 issues prepared us for
implementation with new vendor
•Processes attempt to ensure that problems are
resolved/corrections completed
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ENCOUNTER REPORTING
CHALLENGES
Collecting and reporting “Encounter Data” has not
and does not support our core business…
managing care for our members
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WHAT’S MOST IMPORTANT TO A
HEATLH PLAN?
• Serving our members
• Managing Care: ensuring access to medicallynecessary and cost effective health care services in
a quality-driven manner
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SERVING OUR MEMBERS
What Do Members Want?
• A doctor that they like (ensuring access)
• Coverage for services that they need (medicallynecessary)
• Be informed about how to access services
(Member Handbook/notices regarding benefit
changes)
• Assistance when necessary (Member
Services/Special Needs Unit)
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ENSURING ACCESS
• Comprehensive network of providers (Provider
Relations/Contracting)


Keeping providers happy so they will to continue to
participate (Claims)
Enrolling new providers (Claims/Contracting)
• Tracking mechanisms to ensure members are
aware of and access necessary health care services
(Quality Management; Member Services)
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UNDER MANAGED CARE
ENSURING ACCESS = PAYING CLAIMS
• Inpatient Care
--Paid on a pre-negotiated rate based on a revenue code
--Authorization done via concurrent review (UM)
• PCPs
--Capitated for most services
--Submit encounter/referral form
• Specialist Claim
--Paid on a pre-negotiated fee schedule for services
--Authorization ensures payment
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MANAGED CARE VS. FEE FOR SERVICE
ENSURING ACCESS = PAYING CLAIMS
•
•
•
•
•
•
•
•
Provider name/number/site number: to identify who gets
the check
Member name/address/ID#
Procedure codes for services rendered
Date of service
Diagnosis code(s)
Authorization/referral
Approximately 33 elements (some conditional)
Each claim needs all the boxes filled...
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WHAT’S MOST IMPORTANT TO A HEALTH
PLAN?
 Medically Necessary and Cost Effective Care
 Right Care
 Right Place
 Right Time


Concurrent/prospective review and prior
authorization processes (UM)
Capitation/Prepaid health care
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QUALITY DRIVEN
• Enrolling qualified providers (credentialing)
• Meeting NCQA standards/processes (Quality
Management/HEDIS Reporting)
• Disease management (Special Needs Unit/Case
Management)
• Plan-wide Indicator Reports - “dashboard” metrics
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MANAGED CARE SYSTEMS
DEVELOPMENT
• Systems developed to meet core business functions:
---
---
Serve members (Member Services)
Ensure access (Provider Relations/
Contracting/Claims)
Assist in evaluation/tracking of medically- necessary
care (Utilization Management)
Provide support for ensuring quality
(Credentialing/Quality Management)
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MANAGED CARE SYSTEMS
DEVELOPMENT (cont.)
Lots of Data
--
Not all in one place (multiple internal and
external sources)
--
Not necessarily captured and stored for our
business purposes (managing care)
--
Not in the format necessary to meet
encounter data requirements
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DO YOU NEED “ENCOUNTER DATA” TO
MANAGE CARE? YES, BUT...
• Multiple subsets of utilization data are used to
manage care
-- Don’t necessarily capture all elements
required for encounter data
-- Strip out certain elements to be better able to
massage the data for its primary intended
purpose
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ENCOUNTER REPORTING
CHALLENGES
• Collecting and reporting “Encounter Data” does
not, has not, supported our core business
• Requires substantial commitment of resources (all
types)
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SUBSTANTIAL COMMITMENT OF
RESOURCES
• Requires plan to re-engineer systems, processes
and operational policy to collect and report
encounter data according to definitions established
by the State Medicaid Agency
Examples:
---
> 2 million over the last 24 months
5 percent of total administrative budget
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WHAT DOES IT TAKE?
What are the steps in collecting and
reporting encounters?
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4 CRITICAL AND COMPLICATED
STEPS
1. Collect information from providers
2. Capture and store information
3. Consolidate data from multiple sources and
report stored data
4. Correct returned data
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STEP 1: COLLECT INFORMATION
• Plan’s contracted providers and subcontractors’
contracted providers
• Education and encouragement to providers
-----
Pay them an incentive
 PCPs are capitated and have already been paid
Reminders when they call provider hotline
Encounter-specific provider notices
Reminder in provider newsletters
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STEP 1: COLLECT INFORMATION (cont.)
• Non-participating providers
-- No contract to enforce
-- Services have been rendered
 Emergency
 Referral from participating provider
-- Timeliness requirements
-- Providers that you want to participate
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STEP 1: COLLECT INFORMATION (cont.)
Business Policy Decision:
How Hard Do You Push to Enforce?
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BALANCING ACT
• Considerations
-- Services have already been rendered
-- Timeliness requirements
-- Serving members (ensuring access)
-- Participating providers
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STEP 2: CAPTURE AND STORE
INFORMATION FROM MULTIPLE SOURCES
• Create a detailed list of each required element and
where it would be captured and stored
• Design and program new claims screens to capture
additional data not previously used in managed
care claims payment system
• Program for appropriate linkages to capture and
store data from various sources
(claims/provider/etc.)
• Replicate processes with subcontractors
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INTEGRATION OF SYSTEMS
• Provider Information
Create uniform definitions
fields to ensure
consistency
• Credentialing
Create a repository to
collect data from
different/disparate sources
• Claims
• Authorization
Build linkages to internal
and external system files
• Member Service
• Enrollment
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STEP 3: CONSOLIDATE AND
REPORT STORED DATA
• Retrieve data from various internal file sources
(claims/provider/utilization management/
credentialling/enrollment)
• Retrieve data from subcontractors (pharmacy,
dental, vision)
• Consolidate into single file formatted according to
department’s specifications
• And….
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REPORT! REPORT! REPORT!
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STEP 4: CORRECT RETURNED DATA
• Reverse Collection Processes
--
Establish accountable interdepartmental team to
ensure rejected records are fixed within required
timeframes
--
Create a process to fix records from multiple sources
--
Systematically fix returned records where applicable
--
Manually correct records not able to be fixed
systematically
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TECHNICAL/PROCESS ISSUES
How Can We Help the State?
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TECHNICAL/PROCESS ISSUES
• Encounter data purposes
• HCFA and State regulatory agencies
inconsistencies
• Timing of code updating
• Denied claims
• Lab/DME information
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ENCOUNTER DATA PURPOSES
• Problem: Data will be used for multiple purposes
(establish financial rates, audit for quality of care,
audit for potential fraud)
-- One-stop shopping?
-- Changing program code
• Proposed Solution: Identify the primary purpose
of the data and build the requirements based on
this purpose
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HCFA AND STATE AGENCY
INCONSISTENCIES
• Problem: HCFA and State Agency Specs for
Encounter Reporting are Different
----
Increases the resources necessary to meet
requirements creating two distinct data sets
DPW specs are not “industry standard” (consistent
with other states)
Exacerbates the challenges already discussed
• Proposed Solution: Adopt HCFA Specifications
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TIMING OF CODING UPDATING
• Problem: Procedure/diagnosis codes are updated
by DPW/Plans/HCFA at different times
• Proposed Solution: Establishing a standard for
updating (or a grace period) among all sources to
eliminate unnecessary rejections
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DENIED CLAIMS
• Problem: Denied claims are rejected in the
encounter reporting process
• Proposed Solution: Eliminate denied claims from
encounter reporting. To audit the denied claims,
do a separate data request for this specific purpose
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CONCLUDING THOUGHTS
Where Do We Go From Here?
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SUGGESTED AREAS OF QUALITY
IMPROVEMENT FOR PLANS
• Data Collection
– assessing provider compliance
• Coding and Mapping Practices
– data transformations to comply with specifications
• Submission Procedures
– quality and edit checks
• Completeness and Reasonability Checks
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ADDITIONAL CONCLUDING
THOUGHTS
• Optimism helps!
• Converting the FSS/MC mindset is like turning a
slip
• Plans have their own bureaucracies/politics to
contend with…
• Resource-intensive/ongoing project
• Beware of unintended consequences!!
• Try a carrot! Performance-based incentives might
work better than penalties
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CULTURAL COMPETENCY
Interacting with the Limited English
Proficiency (LEP) Member
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GENERAL REQUIREMENTS
Title VI of the Civil Rights
Act of 1964
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SECTION 601 OF TITLE VI OF THE
CIVIL RIGHTS ACT OF 1964
No person in the United States shall, on the
grounds of race, color or national origin, be
excluded from participation in, be denied the
benefits of, or be subjected to discrimination
under any program or activity receiving federal
financial assistance (emphasis supplied)
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DISCRIMINATION PROHIBITION
Recipients of federal financial assistance include
the managed care organizations participating in
the Medicaid Program
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TITLE VI REGULATIONS
Regulations implementing Title VI specifically provide
that a recipient of federal financial assistance may not
discriminate and may not, directly or through
contractual or other arrangements, use criteria or
methods of administration which have the effect of
subjecting individuals to discrimination because of
their race, color, or national origin, or have the effect
of defeating or substantially impairing accomplishment
of the objectives of the program with respect to
individuals of a particular race, color or national origin.
45 C.F.R. 80.1 et seq.
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APPLICABILITY TO MANAGED CARE
• MCO must ensure that its policies do not have effect
of excluding from, or limiting participation of, such
persons in its programs and activities, on the basis of
national origin.
• MCO must take reasonable steps to provide services
and information in appropriate languages other than
English in order to ensure that limited-English
proficient (“LEP”) persons are effectively informed,
and can effectively participate in, the benefit of its
programs.
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THE IMPORTANCE OF CULTURAL
COMPETENCY
• In order to support the mission of KMHP/AMHP as
well as comply with federal law and state contractual
requirements, it is essential for the company to be
able to communicate effectively to provide services to
our diverse membership.
• Members must be provided with effective means of
communication in order to receive the delivery of
proper health care services.
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GUIDANCE FROM OCR
The Office of Civil Rights (“OCR”) of the
United States Department of Health and
Human Services (“HHS”) has issued guidance
to its investigative staff intended to ensure
equal access to federally-assisted health,
medical and social service programs for which
LEP persons qualify
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WHO IS COVERED?
• All entities that receive Federal financial
assistance from HHS, either directly or
indirectly through a subgrant or subcontract,
are covered by OCR’s guidance. Covered
entities would thus include any state or local
agency, private institution or organization, or
any public or private individual that operates,
provides or engages in health, medical or
social service programs and activities that
receive or benefit from HHS assistance.
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GUIDANCE FROM OCR (cont.)
OCR recommends that developing policies and
procedures for addressing the language assistance
needs of LEP persons may best be accomplished
through an assessment of the following:
• Points of contact in the program or activity where
language assistance is likely to be needed
• The non-English languages that are most likely to be
encountered
• The resources that will be needed to fulfill this
responsibility
• The location and/or availability of such resources
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GUIDANCE FROM OCR (cont.)
Achieving effective communication with LEP persons may
require the recipient of federal financial assistance to take
all or some of the following steps at no cost or additional
burden to the LEP beneficiary:
• Have a procedure for identifying the language needs of
patients/clients
• Have ready access to, and provide services of, proficient
interpreters in a timely manner during hours of operation
• Develop written policies and procedures regarding
interpreter services
• Disseminate interpreter policies and procedures to staff
procedures and of their Title VI obligations to LEP persons
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DEPARTMENT OF JUSTICE
REGULATIONS
“Where a significant number or proportion of the population
eligible to be served or likely to be directly affected by a
federally assisted program (e.g.) affected by relocation) needs
service or information in a language other than English in
order effectively to be informed of or to participate in the
program, the recipient shall take reasonable steps,
considering the scope of the program and the size and
concentration of such population, to provide information in
appropriate languages to such persons. This requirement
applies with regard to written material of the type which is
ordinarily distributed to the public.” 28 C.F.R. § 42 405(d)(1)
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Example of One State’s
Requirements --
Pennsylvania
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PENNSYLVANIA REQUIREMENTS
• Marketing materials are to be developed such as pamphlets
and brochures which can be used by the Benefit Consultants to
assist MA recipients in choosing an HMO and PCP. The HMO
will be required to print and provide the Benefit Consultant
Contractor with an adequate supply of approved materials on a
continual basis. The HMO must make the above marketing
materials available in all languages spoken by more than five
percent (5%) of the total population in any one of the Health
Choices counties or districts. Marketing materials must also be
available in alternate formats to account for recipient situations
such as visual/hearing impaired and lower literacy levels
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PENNSYLVANIA REQUIREMENTS
(cont.)
• Enrollment - The Department and/or its Benefit Consultants
will notify the HMO when it knows of members who do not
speak English as a first language and who have either selected or
been assigned to the HMO. If the HMO has more than five
percent (5%) of the total population in any one of the
HealthChoices counties or districts who speak a single
language other than English as a first language, it must
make available general services, as such as interpreter
services, in that language. Interpreter services shall be made
available as practical and necessary by telephone, and/or inperson to ensure that members are able to communicate with the
HMO and providers and receive covered benefits in a timely
manner.
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PENNSYLVANIA REQUIREMENTS
(cont.)
• Member Handbook - Languages Other Than
English - The HMO must agree to make available
member handbooks in alternative languages
(other than English) when more than five percent
(5%) of the total population in any one of the
HealthChoices counties or districts speak the
alternative language
• Member Services - HMO Internal Member Hotline Provide for necessary translation assistance including
provisions for the hearing impaired
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PENNSYLVANIA REQUIREMENTS
(cont.)
• Education and Outreach - The Department
strongly encourages HMOs to develop and
implement programs for outreach and education to
the Health Choices populations. Methods of
dissemination may include brochures, videos,
community meetings, and such other methods.
Consideration must be given to meeting the
educational needs of non-English speaking
members, functionally illiterate members,
visually impaired members, etc.
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PENNSYLVANIA REQUIREMENTS
(cont.)
• Tracking - The HMO must have an established process for
reminders, follow-ups and outreach to members that
includes: Written notification of upcoming or missed
appointments within a set time period, taking into
consideration language and literacy capabilities of
members
• Grievance and Appeals - The Contractor agrees to
comply with the Program Standards regarding Grievance
and Appeals which are set forth in the RFP…Notices must
be in accessible formats for individuals with vision
impairments or who do not speak English
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AREAS OF FOCUS IN
IMPLEMENTING PLAN
• Identification of LEP Members
• Communication with LEP Members
– Translation of Written Materials
– Interpreter Services at the Point of Accessing Care
• Provider/Subcontractor Responsibilities
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IDENTIFICATION OF LEP MEMBERS
• Language indicator on state enrollment file
• Member self-identification
• Other Sources:
-- MCO employees, e.g. case managers,
marketing representatives
-- Health benefit/enrollment contractor
-- Healthcare providers
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KMHP/AMHP POLICY
• KMHP/AMHP provides interpreter services
and translated materials to members who are
identified as having Limited English
Proficiency (LEP).
– To ensure compliance with Title VI, which requires the
company and its contracted providers to take
responsible steps to provide services and information in
appropriate languages to LEP members.
– Defines a consistent processes that allows members to
effectively access their health care benefits.
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INTERPRETER SERVICES
In determining the type of interpreter services that will be
provided, a recipient has several options. To meet its Title
VI responsibility with respect to the provision of
interpreter services a recipient may:
•
•
•
•
•
•
•
Hire bilingual staff
Hire staff interpreters
Use volunteer staff interpreters
Arrange for the services of volunteer community interpreters
Contract with an outside interpreter service
Use a telephone interpreter service such as the AT&T Language Line
Develop a notification and outreach plan for LEP beneficiaries
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INTERPRETER SERVICES (cont.)
Factors that may be considered by a recipient in
determining which option(s) will best meet its needs
and the needs of its LEP beneficiaries are:
•
•
•
•
Size of recipient-company
Size of LEP population recipient serves
Setting in which interpreter services are needed
Availability of staff members and/or volunteers available
to provide needed services during recipient’s hours of
operation and proficiency of available staff members or
volunteers available to provide needed services
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INTERPRETER SERVICES (cont.)
• Recipient should not require a beneficiary to use friends or
family members as interpreters
-- Breach of confidentiality or reluctance on the part of beneficiaries
to reveal personal information
-- Could have serious, even life threatening, health consequences
-- May not be competent to act as interpreters, since they may lack
familiarity with specialized terminology
• Family member or friend may be used as an interpreter if
approach is requested by LEP individual and the use of such a
person would not compromise effectiveness of services or
violate beneficiary's confidentiality, and beneficiary is
advised that an interpreter is available at no cost to them.
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INTERPRETER SERVICES -- ISSUES
• Hiring bilingual staff for certain critical
positions,e.g., for patient or client contact
positions, would facilitate participation by LEP
persons
• Where there are several LEP language groups in
an MCO’s service area option may be
impractical as only interpreter option, and
additional language assistance options may be
required
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INTERPRETER SERVICES -- ISSUES
(cont.)
• Use of staff or community volunteers may
provide MCO with a cost-effective method for
providing interpreter services
• MCO should ensure that such a system is
sufficiently organized so that interpreters are
readily available during all hours of its operation
• MCO should ensure that such volunteers are
qualified, trained and capable of ensuring patient
confidentiality
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INTERPRETER SERVICES -- ISSUES
(cont.)
• Use of contract interpreters may be an option
for MCO’s that are small, have significant LEP
population, have less common LEP
language groups in their service areas, or need
to supplement their in-house capabilities on an
as- needed basis
• Contract interpreters should be
readily available, qualified and trained
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INTERPRETER SERVICES -- ISSUES
(cont.)
• Paid staff interpreters appropriate where
there is very large LEP presence in a few major
language groups
• These persons should be qualified and
available
• In most instances these employees are salaried
and entitled to same benefits received by other
employees
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INTERPRETER SERVICES -- ISSUES
(cont.)
• Telephone interpreter service such as the AT&T
language line may be useful option as
supplemental
system, or may be useful when MCO encounters
an unusual language that it cannot otherwise
accommodate
• Often offers interpreting services in quick
response to request
• Such services may not always have readily
available interpreters who are familiar with the
terminology peculiar to the particular program or
service or may require
special
arrangements
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rights reserved
TRANSLATION SERVICES
• Oral/Sign Language
-- Coordinate through Member Services
-- Retain Interpreter
• Written
-- Member Handbook
-- Marketing Materials
-- Denial Letters
-- Notices regarding changes in benefits
• Assignment of PCP with Cultural Competence
• Use of a “tag” line
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KMHP/AMHP TAGLINE
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PROVIDER/SUBCONTRACTOR
RESPONSIBILITIES
• Also recipients of federal financial assistance,
so same rules apply
• Put requirements in contract!
• Education
-- Provider Manual
-- Service Calls
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QUESTIONS & ANSWERS
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