Transcript IDHS, Division of Mental Health Provider Briefing: Changes

IDHS, Division of Mental Health
Provider Briefing:
Changes to Provider Monitoring
April 3, 2009
2-3:30pm
April 6, 2009
10-11:30am
Speakers
Jackie Manker, LCSW – Associate Director of Community
Services, DHS/DMH
Lee Ann Reinert, LCSW – ASO Clinical Policy Manager,
DHS/DMH
Cathy Cumpston – Chief, DHS Bureau of Accreditation,
Licensure and Certification (BALC)
Aissa Bell – Director, Provider Relations, IL Mental Health
Collaborative for Access and Choice
Rusty Dennison, MA, MBA – President, Parker Dennison &
Associates, Ltd.
Introduction
•Beginning in FY09, DMH incorporated Post Payment
Reviews (PPR) into DMH/Collaborative provider
monitoring site visits
•Current DMH/Collaborative site visits include:
- Post Payment Reviews
- Clinical Practice and Guidance Reviews
- Fidelity Reviews (PSR in FY09)
•DHS BALC is still performing Certification reviews
Introduction
 DMH reviewed and approved all policies, forms, and
training materials implemented by the Collaborative for
PPR
 At the time PPR was implemented, DMH instituted
managerial oversight of the Collaborative’s practices
 Weekly meetings with reviewers as well as the
Collaborative’s Provider Relations Director
 Made available DMH clinical staff and BALC staff to consult
with the Collaborative’s reviewers in the field
 Involved DMH Regional Contract Managers in reviews
Introduction
•Consistent with continuous quality improvement,
DMH asked Parker Dennison to evaluate our provider
monitoring process in February 2009
•Parker Dennison completed this analysis and has
provided DMH with recommendations
•DMH has considered these recommendations and
has begun to implement changes to the process
•Find the Parker Dennison report on the DMH website
at:
http://www.dhs.state.il.us/page.aspx?item=4
3483
BALC Coordination with
DMH/Collaborative PPR
 Participation in development of PPR/monitoring model
 Participation in Collaborative’s PPR staff and provider
training
 Participation in weekly PPR Collaborative/DMH
coordination and problem solving calls
PPR vs. Certification:
Differences?
Example~
Post Payment Review
 Finds 50% of claims reviewed have no current ITP in record
 Outcome: provider will lose value of those claims
Certification Review
 Finds 5 of 10 records reviewed (50%) have no current ITP
 Outcome: provider will lose 42 points on certification
 As a result will have 422 of 464 points on their certification
for a total score of 91%
Parker Dennison Assessment of Post
Payment Review
 Assessment conducted in January/February 2009
 Information sources included:
 Focus group with 25 providers statewide
 Feedback from other stakeholders
 Review of policies, forms, training materials, protocols
 Review of Federal OIG reports from IL and other states
 Review of applicable state and Federal rules
 Analysis of audit results through 12/31/08
 Included 3,070 claims and audits from 32 providers
Parker Dennison Report:
Focus of Post Payment Review
 All PPR elements consistent with those found in other OIG
reports
 Some elements found in OIG reports are not present in IL PPR
 Federal OIG does identify some elements that can be deficient,
need correction but not recoupment
 This is inconsistent even within different OIG audits
 Recommendations include:
 DMH should periodically rotate in new/different elements
(annually review/update)
 DMH can consider a limited amount of ‘procedural’
designations, at least as a transition
Parker Dennison Report:
Training & Communication
 Provider training was adequate compared to other states but
not best practice
 Training was provided regarding Rule 132 (basis of PPR)
 Training was provided regarding the PPR tool and protocol
 Recommendations include:
 Detailed interpretive guidelines
 On-going Frequently Asked Questions (FAQs)
 On-going feedback to providers about aggregate results,
common problems, recommendations
Parker Dennison Report:
Audit Staff Resources
 All Collaborative reviewers are LPHAs, including two who are
also Certified Recovery Specialists
 Represents the highest standard of practice in audits
 Overall feedback was positive regarding professionalism and
clinical knowledge
 Recommendations include:
 Expand inter-rater reliability monitoring of reviewers
 Involve DMH contract managers for cross training where
feasible
 Include reviewer competency training in training for new
reviewers
Parker Dennison Report:
Post Payment Review Process
 Unannounced reviews are problematic
 Some inconsistency on provider staff involvement
 Lack of public interpretive guidelines
 Recommendations include:
 Discontinue unannounced reviews (unless there is a providerspecific reason)
 Clarify provider staff involvement protocol and be consistent
 Include interpretive guidelines in provider training materials
 More detail on PPR report to providers
Parker Dennison Report:
Analysis of PPR Results (12/31/08)
 Key statistics:
 32 providers
 3,070 claims
 Avg. of 55% of claims unsubstantiated
 Value of unsubstantiated claims (no extrapolation) = $101,937
 Avg. unsubstantiated claims per provider (no extrapolation) =
$3,186
 Average of two deficiencies per unsubstantiated claim
 Overwhelming majority of deficiencies confined to 7 elements
on PPR tool
 Only these 7 fell below 95% compliance level
 All 7 elements were cited in other Federal OIG reports
Parker Dennison Report:
Analysis of PPR Results (12/31/08)
 Lowest compliance %:
 Q2 – (66.87%): MHA contains all required elements
 Q10 – (81.14%): Note contains description of interaction
w/consumer including response and progress toward ITP
goal(s)
 All other questions had compliance of 92% or greater
 Remediation of top 7 deficiencies would reduce statewide
average to 12% unsubstantiated claims (from 55%)
 No data demonstrating an inter-rater reliability issue
DMH Response
 Pleased with the overall assessment results of the Post
Payment Review process
 Appears to be identifying targeted areas for improvement
in moving the system forward
 Identified areas for improvement can be addressed in
training
 Validates the risk and need for continued efforts for
continuous improvement in compliance
 Will continue the established managerial oversight
practices
DMH Changes to the Process
 Announce site visits (began 3/20/09)
 Improve communication with providers
 Post interpretive guidelines to website
 Provider alerts with summaries of issues and trends
 Analyze and use provider post-review survey feedback
 Collect provider questions through the
[email protected] address
 Post provider FAQs to website
 Ensure reviewer consistency
 Strengthen inter-rater reliability and monitoring
 Continue weekly reviewer check-ins with DMH, BALC, and
the Collaborative
DMH Changes to the Process (cont.)
 Change Post Payment Review scoring
 Split claim status into two parts: claims disallowed and
procedural deficiencies
 Begin requesting plans of improvement based on compliance
(including all claims findings)
 Begin tracking the individual parts of the Mental Health
Assessment in the database
 Allow some types of claims to be corrected
 Begin scoring changes going forward and re-score those already
reviewed this fiscal year
[see the separate document “Claims Guide”]
Feedback and Questions
Available to Answer Your Questions—Thanks!
Jackie Manker, LCSW – Associate Director of Community
Services, DHS/DMH
Lee Ann Reinert, LCSW – ASO Clinical Policy Manager, DHS/DMH
Cathy Cumpston – Chief, DHS Bureau of Accreditation, Licensure
and Certification (BALC)
Aissa Bell – Director, Provider Relations, IL Mental Health
Collaborative for Access and Choice
Rusty Dennison, MA, MBA – President, Parker Dennison &
Associates, Ltd.