2000 all rights reserved “medicaid compliance issues” georgia dodds foley, esquire chief...

2000 All rights reserved

““Medicaid Compliance Medicaid Compliance Issues”Issues”

Georgia Dodds Foley, EsquireGeorgia Dodds Foley, Esquire

Chief Compliance OfficerChief Compliance Officer

September 26, 2000September 26, 2000


Presentation OverviewPresentation Overview

• Company Overview

• Encounter Data - A Medicaid Managed Care Organization’s Perspective

• Cultural Competency - Interacting with the Limited English Proficiency (LEP) Member

• Questions & Answers


Who We Are ...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.


MissionMission

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.


ValuesValues

Leadership

Dignity

Service

Quality

Diversity Advocacy

Care for the Poor

Hospitality

Teamwork

Stewardship

Competence

Compassion


MembershipMembership

Care Partners

Houston

Passport

GatewayHorizon Mercy

Keystone MercyAmeriHealth Mercy

Select Health


ENCOUNTER DATAENCOUNTER DATA

A Managed Care Organization’sPerspective


We Believe ...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


HEALTHCHOICES (Pennsylvania Mandatory Medical HEALTHCHOICES (Pennsylvania Mandatory Medical Assistance Managed Care) ENCOUNTER REPORTING Assistance Managed Care) ENCOUNTER REPORTING

HISTORY AND CONTEXTHISTORY 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


FIRST YEAR: FIRST YEAR: Reluctance/Anxiety/DenialReluctance/Anxiety/Denial

Focus: Putting out immediate fires of HealthChoices Implementation

– Encounter Reporting was “on the back burner” for MCO’s and State


SECOND YEAR: Investigation, SECOND YEAR: Investigation, Advocacy and CommitmentAdvocacy 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


THIRD YEAR: Implementation and THIRD YEAR: Implementation and Corrective ProcessCorrective 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


THIS YEAR: Ongoing THIS YEAR: Ongoing Updating/AnalysisUpdating/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


ENCOUNTER REPORTING CHALLENGESENCOUNTER REPORTING CHALLENGES

Collecting and reporting “Encounter Data” has not and does not support our core business…

managing care for our members


WHAT’S MOST IMPORTANT TO A WHAT’S MOST IMPORTANT TO A HEATLH PLAN?HEATLH PLAN?

• Serving our members

• Managing Care: ensuring access to medically-necessary and cost effective health care services in a quality-driven manner


SERVING OUR MEMBERSSERVING OUR MEMBERS

What Do Members Want?

• A doctor that they like (ensuring access)• Coverage for services that they need (medically-

necessary)• Be informed about how to access services (Member

Handbook/notices regarding benefit changes)• Assistance when necessary (Member

Services/Special Needs Unit)


ENSURING ACCESSENSURING 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)


UNDER MANAGED CAREUNDER 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


MANAGED CARE VS. FEE FOR SERVICEMANAGED 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...


WHAT’S MOST IMPORTANT TO A HEALTH WHAT’S MOST IMPORTANT TO A HEALTH PLAN?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


QUALITY DRIVENQUALITY 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


MANAGED CARE SYSTEMS MANAGED CARE SYSTEMS DEVELOPMENTDEVELOPMENT

• 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)


MANAGED CARE SYSTEMS DEVELOPMENT MANAGED CARE SYSTEMS DEVELOPMENT (cont.)(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


• 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

DO YOU NEED “ENCOUNTER DATA” TO DO YOU NEED “ENCOUNTER DATA” TO MANAGE CARE? YES, BUT...MANAGE CARE? YES, BUT...


ENCOUNTER REPORTING ENCOUNTER REPORTING CHALLENGESCHALLENGES

• Collecting and reporting “Encounter Data” does not, has not, supported our core business

• Requires substantial commitment of resources (all types)


SUBSTANTIAL COMMITMENT OF SUBSTANTIAL COMMITMENT OF RESOURCESRESOURCES

• 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


WHAT DOES IT TAKE?WHAT DOES IT TAKE?

What are the steps in collecting and

reporting encounters?


4 CRITICAL AND COMPLICATED STEPS4 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


STEP 1: COLLECT INFORMATIONSTEP 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


STEP 1: COLLECT INFORMATION (cont.)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


STEP 1: COLLECT INFORMATION STEP 1: COLLECT INFORMATION (cont.)(cont.)

Business Policy Decision:

How Hard Do You Push to Enforce?


BALANCING ACTBALANCING ACT

• Considerations

-- Services have already been rendered

-- Timeliness requirements

-- Serving members (ensuring access)

-- Participating providers


STEP 2: CAPTURE AND STORE INFORMATION STEP 2: CAPTURE AND STORE INFORMATION FROM MULTIPLE SOURCESFROM 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


INTEGRATION OF SYSTEMSINTEGRATION OF SYSTEMS

• Provider Information Create uniform definitionsfields 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


STEP 3: CONSOLIDATE AND REPORT STEP 3: CONSOLIDATE AND REPORT STORED DATASTORED 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….


REPORT! REPORT! REPORT!REPORT! REPORT! REPORT!


STEP 4: CORRECT RETURNED DATASTEP 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


TECHNICAL/PROCESS ISSUESTECHNICAL/PROCESS ISSUES

How Can We Help the State?


TECHNICAL/PROCESS ISSUESTECHNICAL/PROCESS ISSUES

• Encounter data purposes

• HCFA and State regulatory agencies inconsistencies

• Timing of code updating

• Denied claims

• Lab/DME information


ENCOUNTER DATA PURPOSESENCOUNTER 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


HCFA AND STATE AGENCY HCFA AND STATE AGENCY INCONSISTENCIESINCONSISTENCIES

• 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


TIMING OF CODING UPDATINGTIMING 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


DENIED CLAIMSDENIED 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


CONCLUDING THOUGHTSCONCLUDING THOUGHTS

Where Do We Go From Here?


SUGGESTED AREAS OF QUALITY SUGGESTED AREAS OF QUALITY IMPROVEMENT FOR PLANSIMPROVEMENT 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


ADDITIONAL CONCLUDING THOUGHTSADDITIONAL 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


CULTURAL COMPETENCYCULTURAL COMPETENCY

Interacting with the Limited English Proficiency (LEP) Member


GENERAL REQUIREMENTSGENERAL REQUIREMENTS

Title VI of the Civil RightsTitle VI of the Civil Rights Act of 1964Act of 1964


SECTION 601 OF TITLE VI OF THE SECTION 601 OF TITLE VI OF THE CIVIL RIGHTS ACT OF 1964CIVIL 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)


DISCRIMINATION PROHIBITIONDISCRIMINATION PROHIBITION

Recipients of federal financial assistance include the managed care organizations participating in the Medicaid Program


TITLE VI REGULATIONSTITLE VI REGULATIONSRegulations implementing Title VI specifically providethat a recipient of federal financial assistance may notdiscriminate and may not, directly or throughcontractual or other arrangements, use criteria ormethods of administration which have the effect ofsubjecting individuals to discrimination because oftheir race, color, or national origin, or have the effectof defeating or substantially impairing accomplishmentof the objectives of the program with respect toindividuals of a particular race, color or national origin.45 C.F.R. 80.1 et seq.


APPLICABILITY TO MANAGED CAREAPPLICABILITY 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.


THE IMPORTANCE OF CULTURAL COMPETENCYTHE 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.


GUIDANCE FROM OCRGUIDANCE 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


WHO IS COVERED?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.


GUIDANCE FROM OCR (cont.)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


GUIDANCE FROM OCR (cont.)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


DEPARTMENT OF JUSTICE REGULATIONSDEPARTMENT OF JUSTICE REGULATIONS

“Where a significant number or proportion of the populationeligible to be served or likely to be directly affected by afederally assisted program (e.g.) affected by relocation) needsservice or information in a language other than English inorder effectively to be informed of or to participate in theprogram, the recipient shall take reasonable steps,considering the scope of the program and the size andconcentration of such population, to provide information inappropriate languages to such persons. This requirementapplies with regard to written material of the type which isordinarily distributed to the public.” 28 C.F.R. § 42 405(d)(1)


PennsylvaniaPennsylvania

Example of One State’s Requirements --Example of One State’s Requirements --


PENNSYLVANIA REQUIREMENTSPENNSYLVANIA 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


PENNSYLVANIA REQUIREMENTSPENNSYLVANIA REQUIREMENTS(cont.)(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 in-person to ensure that members are able to communicate with the HMO and providers and receive covered benefits in a timely manner.



• 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



• 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.



• 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


AREAS OF FOCUS IN IMPLEMENTING AREAS OF FOCUS IN IMPLEMENTING PLANPLAN

• Identification of LEP Members

• Communication with LEP Members– Translation of Written Materials

– Interpreter Services at the Point of Accessing Care

• Provider/Subcontractor Responsibilities


IDENTIFICATION OF LEP MEMBERSIDENTIFICATION 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


KMHP/AMHP POLICYKMHP/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.


INTERPRETER SERVICESINTERPRETER SERVICESIn 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


INTERPRETER SERVICES (cont.)INTERPRETER SERVICES (cont.)Factors that may be considered by a recipient in determining which option(s) will best meet its needsand 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


INTERPRETER SERVICES (cont.)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.


INTERPRETER SERVICES -- ISSUESINTERPRETER 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 beimpractical as only interpreter option, andadditional language assistance options may berequired


INTERPRETER SERVICES -- ISSUESINTERPRETER SERVICES -- ISSUES(cont.)(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



• Use of contract interpreters may be an optionfor MCO’s that are small, have significant LEPpopulation, have less common LEPlanguage groups in their service areas, or need to supplement their in-house capabilities on an as- needed basis

• Contract interpreters should bereadily available, qualified and trained



• 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



• Telephone interpreter service such as the AT&Tlanguage line may be useful option as supplementalsystem, or may be useful when MCO encountersan unusual language that it cannot otherwiseaccommodate

• 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


TRANSLATION SERVICESTRANSLATION 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


KMHP/AMHP TAGLINEKMHP/AMHP TAGLINE


PROVIDER/SUBCONTRACTOR PROVIDER/SUBCONTRACTOR RESPONSIBILITIESRESPONSIBILITIES

• Also recipients of federal financial assistance, so same rules apply

• Put requirements in contract!

• Education-- Provider Manual-- Service Calls


QUESTIONS & ANSWERSQUESTIONS & ANSWERS

2000 all rights reserved “medicaid compliance issues” georgia dodds foley, esquire chief...

Documents

health slide

rights reserved encounter

state slide

data quality slide

ongoing updatinganalysis

corrections process

commitment health plan

system encounter data