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Healthcare Provider Network Management and Participation Solutions - December 6, 2012

Presented by:

Presented By: David Lloyd, Founder 1

Presented by:

David Lloyd, FounderM.T.M. ServicesP. O. Box 1027, Holly Springs, NC 27540Phone: 919-434-3709 Fax: 919-773-8141E-mail: [email protected] Site: mtmservices.org

Two Focus Areas Today:

1. LME/MCO Operations/Provider Network Management and KPIs

2. Network Providers – “Value” et o o de s a ueIndicators Needed


Three Overarching Themes:

1. Access to Service MCO/Provider Network Focus in an “at risk” 1915(b)/(c) Waiver funding environment

2. Definition of Treatment to support engagement indicators and positive clinical outcomes in a Treat to Target environment

3. CQI instead of QI Change Management Model


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Distributive Justice Ethical Focus of “At Risk” LME/MCO and Network Providers Distributive Justice Ethical Dilemma:

1. How does the LME/MCO/Providers in the Network ensure that it is providing the greatest good to the greatest number of people based on the limited resources available

2. How do the LME/MCO/Providers shift the primary service delivery focus from its current caseloads to an equal focus between current caseloads and persons presenting to access services?

3. The LME/MCOs Provider Network Management (PNM) will need to establish key performance standards to ensure that the needs of ALL of the people in the catchment area are responded to timely and effectively


Key Qualitative Based Utilization Management Focus Area to Secondary Service Capacity

• Are we treating the needs we have professionally diagnosed that each consumer has?

OR

• Are we carrying inactive active caseload members while consumers seeking services are waiting?… (i.e., Clinical Protocols that require Therapist to Carry Chart for Physicians)

5Presented By:

David Lloyd, Founder

Sample Definition of Treatment

Define a definition of “treatment” and therefore what is not treatment:Sample Definition:

“Behavioral health therapeutic interventions pprovided by licensed or trained/certified staff either face to face or by payer recognized telephonic/ Telepsychiatry processes that address assessed needs in the areas of symptoms, behaviors, functional deficits, and other deficits/ barriers directly related to or resulting from the diagnosed behavioral health disorder.”

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MCO and Provider Change Requires A Shift from “Perfect Solution” to Rapid Cycle CQI Process of Improvement

Quality Improvement Process Focus (QI) – Typically Supports Process/Lack of Forward Movement/ Attainment

Vs. Continuous Quality Improvement

Solution Focus (CQI) – Implies Movement Forward/Action Has Happened to Provide Continuous Improvement

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Sample MCO Development Focus Areas


Sample MCO Timeline and Scope of Work


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Provider Re-Credentialing Policy Sample1. It is the policy of the MCO that all individually contracted clinical providers

will be re-credentialed and have clinical privileges reviewed every year. Clinical privilege will be based upon specific license, education, training, experience, competence, and judgment as specified in the attachments to this policy. Providers’ level of competence and professional ethics must be of the highest order, and must continuously meet or exceed the qualifications standards and requirements set forth by MCOqualifications, standards, and requirements set forth by MCO.

2. Every year, the providers must submit a fully completed re-credentialing application. Re-credentialing shall include the primary verification of pertinent information described in the procedure section of this policy. Providers have the right to review information submitted in support of their application and the right to correct erroneous information submitted by another party. Once all information related to each re-credentialing and privileging element has been obtained, the provider’s file with complete information, is forwarded to the Credentialing Committee for review and recommendation for ongoing participation. Final approval is granted by the Board of Directors


Network Provider “Values” Needed

Under a MCO model the Value of Network Providers will depend upon our ability to:

1. Be Accessible (Fast Access to all Needed Services)

2. Be Efficient (Provide high Quality Services at L t P ibl C t)Lowest Possible Cost)

3. Electronic Health Record capacity to connect with other providers

4. Focus on Episodic Care Needs/Treat to Target5. Produce Outcomes!

• Engaged Clients and Natural Support Network• Help Clients Self Manage Their Wellness and Recovery• Greatly Reduce Need for Disruptive/ High Cost Services

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Quality Vs. Quantity Discussion: Quality for Current Caseloads and/or Quality for Persons Waiting For Services? A Scope of Quality Definition Challenge

1. Accessible Services2. Consumer-Centered Services3. Cost-Effective Services 4. Outcome Based Services5. Full integration of Utilization Management


6. CMS Corporate Compliance7. HIPAA Compliance8. State/Federal Standards9. JCAHO/CARF/COA Accreditation Standards10. Clinical Best Practice Performance Standards11. Community Support Best Practice Performance

Standards12. Non-Clinical Best Practice Performance Standards

Poll Results based on over 600 Registrants for the NC LIVE Webinar on Enhanced Revenue Presented by David Lloyd, MTM Services on December 15, 2009 and January 12, 2010

1. From the clinicians’ perspective, are the caseloads in your organization “full” at this time?Yes = 74% No = 26%

2. Do you know the cost and days of wait for your organization’s first call to treatment plan completion process?

Yes = 41% No = 59%3. Indicate the no show/cancellation percentage last quarter in your organization

for the intake/assessment appointments:A. 0 to 19% = 20%B. 20 to 39% = 42%C. 40 to 59% = 15%D. Not aware of percentage = 23%

4. Indicate the no show/cancellation percentage last quarter in your organization for Individual Therapy appointments:

A. 0 to 19% = 24%B. 20% to 39% = 50%C. Not aware of percentage = 26%

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Change Initiatives to Enhance CBHOs “Value” as a Partner in Healthcare Reform1. Reduce access to treatment processes and costs through a reduction in

redundant collection of information and process variances 2. Develop Centralized Schedule Management with clinic/program wide and

individual clinician “Back Fill” management using the “Will Call” procedure

3. Develop scheduling templates and standing appointment protocols for all di ff li k d bill bl h d d ddirect care staff linked to billable hour standards and no show/cancellation percentages

4. Design and implement No Show/Cancellation management principles and practices using an Engagement Specialist to provide qualitative support

5. Design and implement internal levels of care/benefit package designs to support appropriate utilization levels for all consumers

6. Design and Implement re-engagement/transition procedures for current cases not actively in treatment.

7. Develop and implement key performance indicators for all staff including cost-based direct service standards

8. Collaborative Concurrent Documentation training and implementation

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Change Initiatives to Enhance CBHOs “Value” as a Partner in Healthcare Reform9. Design and implement internal utilization management functions

including: Pre-Certs, authorizations and re-authorizations Referrals to clinicians credentialed on the appropriate third

party/ACO panels Co-Pay Collections

Ti l / t l i b i i t t t f i Timely/accurate claim submission to support payment for services provided

10. Develop and implement Supervision/Coaching Plan with coaching/action plans

11. Develop objective and measurable job descriptions including key performance indicators for all staff and develop an objective coaching based Evaluation Process

12. Provide Leadership/Management Training that changes the focus from supervision to a coaching/leadership model

13. Develop public information and collaboration with medical providers in the community through an Image Building and Customer Service plan

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Sample MCO Network Providers KPI Categories

1. Access to treatment indicators2. Utilization Management Indicators3 Clinical Outcome Indicators3. Clinical Outcome Indicators4. Consumer Satisfaction Indicators5. Clinical Performance Indicators6. Non-Clinical Performance Indicators7. Physical Facility Indicators


Recommended Network Provider KPI Format


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Network Providers Access to Treatment Indicators


Access to Treatment Challenge Areas:

1. The primary challenge facing almost every healthcare provider is having adequate service delivery capacity to support timely and effective access to treatment.

2. In an era of integrated healthcare reform, access to treatment is even more critical

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treatment is even more critical.3. The historical three levels of access to care challenge

have been:a. Primary Access – Time to provide client face to face initial

intake/assessment after call for help

b. Secondary Access – Time to provide client face to face service with his/her treating clinician following intake/assessment date

c. Tertiary Access – Time to first face to face service with Psychiatrist/APRN following the intake/assessment data Address a historical

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Measurement Tools/ Processes

First Contact to Treatment Plan Completion Process Flows Created To IdentifyCreated To Identify Redundancy and Wait Times

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Access to Care Process Cost Model

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Access Flow Design Outcomes for National IHP Learning Collaborative

1. Measurement of current processes from first call for routine help to treatment plan completion

2. Measurement processes provided indicate that the cohort of 15 centers have 191 different flow processesp

3. Number of staff hours needed range from .5 hours to 11.7 hours – Cohort average is 5 hours of staff time

4. Cost of processes range from $11 to $855 – Cohort average cost is $369

5. Total days wait to treatment range from less than one day to 150 calendar days – Cohort average wait time is 31.30 calendar days for all divisions/programs

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Access to Treatment Process Flows – Measurement Process Summary

Access Process - Staff vs. Client time by Division

Information based upon 177 individualized GAP Analysis Charts

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Access to Treatment Process Flows – Measurement Process Summary

Access Process - Wait time by Division

Information based upon 177 individualized GAP Analysis Charts

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Access to Treatment Process Flows –Measurement Process Summary

Access Process – Average Cost by DivisionInformation based upon 177 individualized GAP Analysis Charts

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Access to Treatment National Best Practice Target Averages

1. Access to Treatment processes within each center: Gold Standard – Standardized Process for the center Silver Standard – No more than one per division

2. Number of staff hours needed from first call for routine help to treatment plan completion p p prange from 2 hours to 2.5 hours which will require staff to use collaborative documentation process Assessment process target is one hour using CSR

support 3. Cost of processes range from $150 to $2004. Total days wait to treatment for

therapist/case manager is 8 calendar days or less and to MD/APRN is 10 total calendar days or less from Intake/Assessment date

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Measurement Tools/Processes

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Assessment Data Point Collection/Mapping

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Data Mapping to Reduce Access Time

Case Study of Exhaustive Data Collection Model: M.T.M. Services provides project management and consultation services for the Access and Retention Grant. In their work with CBHOs they provide data mapping of the number of data elements each center collects from the first call for services through the completion of the diagnostic assessment/intake. A recent data mapping effort for a community provider produced th f ll i t

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the following outcomes:1. Total number of data elements collected in the process =

1,8542. Total number of redundant data elements collected in the

process = 5643. Total number of data elements really required for access

to treatment planning processes = 9574. Total staff time required to administer the original flow

process = Four hours ten minutes5. Total staff time required to administer the revised flow

process = One hours twenty minutes

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CBHO Consortium EMR Case Study GAIT Consortium Case Study:

1. Six Georgia Community Service Boards (now up to 9 members)

2. Reduced 29 separate process flows to one standardized service flow processRed ced o e 2 700 data elements being3. Reduced over 2,700 data elements being recorded to 975 data elements through data mapping process to reduce staff costs and wait times by over 50%

4. Standardized documentation data elements for all clinical forms processes

5. Co-Location of one IT – electronic record solution6. Consortium based cost savings over $1,000,000

over the next first four years

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Standard Access to Treatment for the Consortium



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National Access and Engagement Grant Outcomes

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Total Annual Savings: • Produced an average annual savings of $231,764 per CBHO – 39% Reduction in costs• 29% reduction in staff time• 17% reduction in the client time• 60% reduction in wait time• 26% increase in Intake Volume Provided• Based on eight first year A&E Centers from seven states - total annual savings equals $1,854,119.

Access and Engagement and Access Redesign Initiatives First Call to Assessment Kept vs. No Show/Cancelled Trend by Days Wait from First Call to Appointment

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Access to Care Timeliness Case Study

Same Day access center produced data that demonstrate the following about the relationship between initial contact for help, Open access, second appointments and no-shows. Sample size is 561 new clients who received an intake between January 1, 2009 and May 31, 2009. The summary of outcomes identified are outlined below:


summary of outcomes identified are outlined below: a. Approximately 95 percent showed for the customers who

have their second appointment scheduled within 12.2 days of their Intake show for that appointment. Therefore the 10 day access standard that is recommended is valid for the second counseling service and medical appointment.

b. Approximately 70 percent of customers did not show who had their second appointment scheduled 22 days or more after their intake

c. 100 percent of the customers whose second appointment was canceled by the Center – never came back.

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NCQA Accreditation Standards for Patient-Centered Medical Homes (PCMH)

NCQA has published accreditation standards for PCMHs

Primary Care Development Corporation has developed a standard version of thehas developed a standard version of the Baseline PCMH Self-Assessment Tool that will guide PCMHs in their need to obtain accreditation

40Presented By: David Lloyd, Founder

Source: Primary Care Corporation – PCMH Self-Assessment Tool


What is Same Day Access? What Does it Mean?

Open Access is a shift in definition of “treatment” from “scheduling a client” as a solution today to a practice management process that expects the practice to respond to the client’s needs by seeing the client the day services are requested and then engage the client in an Episode of Care.

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Four Step Process Change To Move To Same Day Access1. Identify when clients are calling or walking in

seeking help (two hour segments per day of week)2. Identify the current first call for routine help to

treatment plan completion processes, costs and time delays

l d d d h d3. Develop standardized process that is more time and cost effective (i.e., one hour assessment appointment face to face and write up total time)

4. Use new standardized access process as the basis for the Same Day Access model and include JUST IN TIME protocols for assessment capacity beyond on call staff

5. Develop service capacity within center to access new referrals more timely


Same Day Access Models1. Centralized Intake Model2. De-centralized at different locations Measure when clients call for help and

how many – not when we scheduled them historically

Identify two hour on call status for clinical staff to provide intakes

Four step protocol to support on call staff


Open Scheduling Same Day Access Model –Consumer Engagement Standards

1. Open Scheduling Same Day Access - Master’s Level assessment provided the same day of call or walk in for help (If the consumer calls after 3:00 p.m. they will be asked to come in the next morning unless in crisis or urgent need)

2 Initial diagnosis determined2. Initial diagnosis determined3. Level of Care and Benefit Design Identified with

consumer4. Initial treatment plan Developed based on Benefit

Design Package 2nd clinical appointment for TREATMENT within 8 days

of Initial Intake 1st medical appointment within 10 days of Initial Intake


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Same Day Access and Open Meds Models of Care

Encourage staff to view the “Same Day Access and Open Meds” Webinar provided on August 9th, 2012

The National Council for Community Behavioral Healthcare Site:

http://www.thenationalcouncil.org/cs/recordings_presentations


• Kim Beauregard, CEO

• Dr. Ann Price, CMO

• Tyler Booth, COO

• Phone 860-291-1313

• Email: [email protected]

InterCommunity, Inc.

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Identifying The Problem at InterCommunity BH

Recognizing that what we were doing wasn’t working, and that although it seemed to be the norm for most agencies it wasn’t really good care, we began looking at data and meeting in Project Change Teams to identify where we were working harder rather than smarter. Perhaps the most significant issue we discovered was how No-Shows: Prevented clients in need from getting in to see their “booked”

provider Caused providers to manage case loads rather than provide services

Fi i ll i i th t ff id t b b b t Financially were ruining the agency as staff were paid to be busy but were not generating revenue.

No Show Percentage by Service – Sept. – Nov. 2011 Trend


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InterCommunity - Outcomes Achieved with Immediate Access Model

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InterCommunity - Immediate Access Appointment Type Outcomes Achieved: 485 No Shows and Canceled by Clients Vs. 13

1. Average of 54 No Show and Client Canceled Appointments per Month in 2011

2. Compared with an Average of 2 per month in 2012

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Case Study: InterCommunity, E. Hartford, CTMedication Management Services

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Rosecrance Berry Campus Open AccessOpen Access

Richard Jaconette M.D.

Charity Shaw-Moyado, LCSW, Administrator Rosecrance Berry Campus

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Dr. Jaconette: Aggregate of Med Monitoring and Evaluation Events Trend

Open Access Model

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Benefits EXCELLENT CLIENT CARE Increased Capacity to see clients:

Decrease in System Noise Level through reduction in Canceled and No Show events

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Network Providers Clinical Outcome Indicators


National Healthcare Homes New Medicaid Services Under Section 2703 of the Affordable Care Act

1. Comprehensive Care Management2. Care Coordination and Health Promotion3. Patient and Family Support

C h i T iti l C4. Comprehensive Transitional Care5. Referral to Community and Social Support

Services

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“Mental Health Community Case Managementand Its Effect on Healthcare Expenditures”

People with severe mental illness served by public mental health systems have rates of co-occurring chronic medical illnesses that of two to three times higher than the general population, with a corresponding life expectancy of 25 years less.

Treatment of these chronic medical conditions ……. comes from costly ER visits and inpatient stays, rather than routine screenings and preventive

By: Joseph J. Parks, MD; Tim Swinfard, MS; and Paul Stuve, PhD Missouri Department of Mental Health Source: PSYCHIATRIC ANNALS 40:8 | AUGUST 2010

p y , g pmedicine.

In 2003, in Missouri, for example, more than 19,000 participants in Missouri Medicaid had a diagnosis of schizophrenia. The top 2,000 of these had a combined cost of $100 million in Missouri Medicaid claims, with about 80% of these costs being related not to pharmacy, but to numerous urgent care, emergency room, and inpatient episodes.

The $100 million spent on these 2,000 patients represented 2.4% of all Missouri Medicaid expenditures for the state’s 1 million eligible recipients in 2003.


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Total healthcare utilization per user per month, pre- and post-community mental health case management. The graph shows rising total costs for the sample during the 2 years before enrolling in CMHCM, with the average per user per month (PUPM), with total Medicaid costs increasing by over $750 during that time. This trend was reversed by the implementation of CMHCM. Following a brief spike in costs during the CMHCM enrollment month, the graph shows a steady decline over the next year of $500 PUPM, even with the overall costs now including CMHCM services.


Source: PSYCHIATRIC ANNALS 40:8 | AUGUST 2010

Advancing Standards of Care for People with Schizophrenia

Final Project Summary and OutcomesOctober 17, 2011

A National Council for Community Behavioral Healthcare InitiativeSponsored by Sunovion Pharmaceuticals IncSponsored by Sunovion Pharmaceuticals Inc.

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Participating Behavioral Health Organizations

Organization City and State

AltaPointe Health Systems Inc. Mobile, Alabama

AtlantiCare Behavioral Health Egg Harbor Township, New Jersey

Cobb/Douglas Counties Community Services Board Smyrna, Georgia

Family Guidance Center for Behavioral Healthcare Saint Joseph Missouri

Gallahue Mental Health Services Indianapolis, Indiana

Hill Country Mental Health Services Kerrville, Texas

Mental Health Centers of Central Illinois Springfield, Illinois

Recovery Resources Cleveland, Ohio

Seminole Behavioral Healthcare Fern Park, Florida

Spokane Mental Health Spokane, Washington

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Project Background

The National Council in conjunction with the MTM consultants and an expert panel of clinicians, administrators, and researchers in the schizophrenia and mental health arena selected: 523 consumer cohort members who has a primary diagnosis

of Schizophrenia or Schizoaffective Disorder Average age of consumer cohort 46.7 years old The Wellness Self Management Program (New York State

Office of Mental Health in conjunction with the Center for Practice Innovations at Columbia Psychiatry) as the evidence based practice for implementation at pilot sites.

The DLA-20 (Willa Presmanes M.Ed., M.A. and R.L. Scott Ph.D.) as the evidence based functional assessment tool to be used by pilot sites.

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Wellness Self Management Program

Each client in the WSM Program received an individual workbook.

57 L i d i 19 T i 57 Lessons organized into 19 Topic AreasEach Lesson includes:• Important Information • Discussion Points• Personalized Worksheets• Action Steps

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Sample Lessons:

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For more information and access to WSM workbooks and other materials go to the Center for Practice Innovations Website at:

http://practiceinnovations.org/WellnessSelfManagementWSM/tabid/118/Default.aspx

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DLA-20 Functioning Assessment The Daily Living Activities (DLA) Functional Assessment is a functional assessment, proven

to be reliable and valid, designed to assess what daily living areas are impacted by mental and/or substance use disorders or disability. The assessment tool quickly identifies how signs and symptoms of the client’s DSMIV disorder(s) have impacted their wellness as measured by their ability to function in twenty daily living domains. Several of the twenty indicator areas provide the direct care staff the ability to assess an expanded look at the total wellness needs of the client as outlined below:

Health Practices: Assessment of client’s ability to take care of health issues, infections; takes medication as prescribed; follows up on medical appointments.

Nutrition: Assessment of whether client’s eats at least 2 basically nutritious meals daily. Alcohol/Drug Use: Assessment of the client’s ability to avoid abuse or abstains from

alcohol/drugs, cigarettes; understands signs and symptoms of abuse or dependency; avoids misuse or combining alcohol, drugs, medication.

Sexuality: Assessment of the client’s level of appropriate behavior toward others; comfortable with gender, respects privacy and rights of others, practices safe sex or abstains.

Personal Hygiene: Assessment of the client’s ability to care for personal cleanliness, such as bathing, brushing teeth.

NOTE: A recommended protocol to increase the level of internal MH/SU staff referrals to primary care would be if any client MH/SU staff assess has a finding of “1, 2, 3 or 4” in any of the above indicators, the outcome would be a referral to the primary care physician. Presented By:

David Lloyd, Founder 65


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Functioning Level Improvement Outcomes


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Functioning Level Improvement Outcomes for All Providers in Network


Person Centered Engagement Strategies Implemented At Subset A Teams:

A. Collaborative Documentation B. Person Centered Linkage Between

Personal-Life Goals, Identified BH Needs, T Pl G l d Obj ti dTx Plan Goals and Objectives, and Client/Clinician Interactions

C. Addressing Specific Engagement BarriersD. Relapse Prevention/ WRAP Plans

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Medication Adherence:Client Report

90

95

100

Medication Adherence Client Report

70

75

80

85

2 3 4 5 6 7 8 9 10 11

Perc

ent

Subset B %

Subset A %

Linear (Subset B %)

Linear (Subset A %)

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Medication Adherence: Clinician Report

95

100

Medication AdherenceClinician Report

70

75

80

85

90

2 3 4 5 6 7 8 9 10 11

Perc

ent Subset B %

Subset A %Linear (Subset B %)Linear (Subset A %)

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Network Providers Utilization Management Indicators


Utilization Review Vs. Utilization Management

• Utilization Review is primarily focused on retrospective review of what has or has not happened in servicesservices

• Utilization Management is focused on retrospective, concurrent and prospective management of service delivery capacity from intake to discharge and every thing in between

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Focus Areas for UM Plan• Front End (i.e., Screening/Triage,

Eligibility, Emergency Services, Referrals, etc.)

• Concurrent (i.e., Urgent/Routine Transfer/Discharge Criteria/Planning, / g / g,Services for high risk consumers, qualitative review of clinical documentation and treatment planning, etc.)

• Prospective (i.e., what are the next steps with the consumer following current LOC)

• Retrospective (i.e., Qualitative/ Quantitative Review of Charts and Outcomes/Satisfaction Measures, etc.)

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Services Appropriate for Diagnostic/Function Level Profile


Hi Service Utilizers Profile


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Sample UM Plan Table Of Contents


Internal Benefit Design to Support Engagement and Create A Capacity for New Clients to Receive Treatment

Purpose is to establish Group Practice Clinical Guidelines to Facilitate Integration of all services into one service plan

Provide an awareness to consumers at entry to services the types of services and duration of services the practice has found most helpful to meetservices the practice has found most helpful to meet their treatment needs so that the consumer will know and the staff will know what services are needed to complete that level of care

Moves consumers to a more recovery/ resiliency based service planning and service delivery approach

Facilitates being able to use centralized scheduling using the actual service plan of each consumer


Internal Benefit Design/Levels of Care Provide the Required Framework for UM Plans and to Create Capacity for New Clients to Receive Treatment

1. Development of internal levels of care/benefit package designs to support appropriate utilization levels for all consumers

2. Core Elements of Benefit Design/LOC Model:g1. Admission Criteria (as objective as possible using

Diagnostic Profiles, DLA-20/LOCUS scores, etc.)2. Continue Stay Criteria3. Transition/Discharge Criteria4. Service Array and Frequency to be Provided5. Projected Service Duration within each level

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Episodes of Continuous Care Model

Intensity of Need

Episodes of Care Need

Low

Moderate

High

Lifetime of Client/Consumer

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Engagement Based Same Day Access/Treatment Plan Model Using Benefit Design/Level of Care Criteria

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Adult Mental Health Benefit Design Level Two

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Child/Adolescent Mental Health Benefit Design Level Three

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Child/Adolescent Mental Health Benefit Design Level Two

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ASAM Criteria for

Persons with Substance

Use Disorders

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Provider Specific Cost of Services Based on Claims and Clinical Correlation Factors (i.e., LOC, Service Mix, etc.)


Provider Specific Utilization Rates/Penetration Rates Geo Mapping


Third Party/Managed Care Utilization Management Plan Components:

1. Internal utilization management processes and support staff to help ensure:

a. Pre-Certification, authorizations and re-authorizations are obtained

b. Referrals are made to only clinicians credentialed on the appropriate third party panels

c. Appropriate front desk co-pay collectionsd. Timely/Accurate claim submission to support

payment for services provided

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UM Plan Tools Needed

Entry Into Care1. What are the Access to Care standards for consumers per level

of acuity that are required by the third party payers (Emergent = within one hour, Urgent = within 24 hours and Routine = within 7 to 10 days)?

2 Who will:2. Who will: Determine the type of Third Party Insurance a client has Obtain initial authorization prior to service delivery and Refer the client to a clinician that is credentialed on the right insurance company

panel? Confirm if an additional authorization is needed to continue services after the

initial intake/assessment

3. What clinical tool(s)/Reports will they use to make the assignment (i.e., Access data base of all third party payers and the clinicians credentialed on each panel, etc.)?

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UM Plan Tools Needed

Re-Authorizations During Service 1. Who will:

Confirm the number of sessions that have been delivered against the current authorization from payerOb i h i i i h d f h Obtain re-authorization prior to the end of the current authorization if additional services are clinically needed, and

Engage in appeals process with payer if re-authorization is denied?

2. What reports will they need/use to monitor current authorization levels and confirm need for re-authorizations (i.e., Number of remaining session in current authorization are recorded in centralized scheduler, etc.)?

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Roles of Support Staff In External Authorized Services

1. Centralized Scheduling is needed to ensure referral is made to clinician on the appropriate insurance panel Ability to know at all times the availability of clinical

staff that are credential on third party panels will bestaff that are credential on third party panels will be critical to timely acceptance of new referrals

2. Re-think Front Desk functions/needs Collection of Co-Pays prior to Service Confirmation of Insurance via copy of Insurance

cards prior to service Confirmation of the number of authorized services

remaining for client

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Roles of Clinical and Financial Staff In Third Party Billing

3. Completion and submission of all required clinical documentation by direct care staff will be needed to support authorizations after Intake (if required) and re-authorizations – (i.e., Case study from DuPage County MHS IL - 99 9%study from DuPage County MHS, IL 99.9% contained within day of service)

4. Filing timely and accurate claims will be critical5. Monitoring level of unreimbursed third party care

– determine reasons for non payment and correct issues

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Network Provider Consumer Satisfaction Indicators


Consumer Service = Engagement


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Consumer Service Indicators – Action Plan




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Network Provider Clinical Performance Indicators


Sample Network Provider KPIs

1. Provider attainment of a 95% compliance rating on Qualitative and Quantitative Chart Reviews

2. Percent of services that are adequately linked to assessed needs and goals/objectives in the treatment planp

3. Provider attainment of 95% documentation submission on the day services provided

4. Provider attainment of 97% data accuracy of documented services vs. billed services

5. Provider will have 90% of outcome ratings showing maintenance or improvement in the last survey period.

6. Provider will have 90% positive Consumer Satisfaction Ratings regarding their opinions about services provided.



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Practice Variance for Case Management by Provider – Qualitative Review of Charts


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Practice Variance for Medication Check by Provider – Access Capacity Indicator


Treat to Target Attainment Levels:

1. Most of our clinicians use a “treat to target” approach to planning, service delivery, and adjusting the care plan if it’s not working.

2. The majority of clinicians and supervisors have studied the treat to target literature and develop care plans that include measureable targets (e gcare plans that include measureable targets (e.g. enhanced functioning in DLAs within 12 weeks), measure progress at least monthly, and work with consumers to adjust the care plan if targets are not being met.

3. Part of this process includes the use of clinical tools that measure improvement in symptomology, functional status, and recovery and resilience-building for the children, families and adults we serve.


National Engagement Indicators:

National Standard for Appointment Types:Appointment KeptNo Show (less than 36 to 24 hrs

notice)Appointment Canceled by Client

(36 to 24 hrs or more notice)Appointment Canceled by Staff

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No Show Definition Clarification:

1. No Show definition is not based solely on clients behavior as much as the impact of this behavior on service capacity of each direct care staff that day (i.e., Late cancellation y ( ,results in a potential no show to schedule)

2. Cancellations count as No Shows IF the team is not backfilling 90% of pre-cancelled appointments – Therefore, no shows and cancellations carry the same weight of reduced service capacity if the backfilling process is not happening

109Presented By:


National Engagement Key Performance Indicators

1. Initial Intake/Diagnostic Assessment Services = 0% No Show/Cancel rate based on Same Day access models

2. Ongoing Therapy Services = 8% - 12% No Show/Late CancelledShow/Late Cancelled

3. Initial Psychiatric Evaluations = 12% to 15% No Show/Late Cancelled

4. Ongoing Medication Follow Up Services – 5% - 8% No Show/Late Cancelled - NOTE: Medications provided by phone to clients that missed their appointments will have to be addressed to positively impact ongoing no show rates.

110Presented By:


Engagement Level Data Report Sample


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Non-Clinical Performance Indicators


Network Provider Non-Clinical Performance Indicators

1. Percent of clean claims submitted2. Percent of timely claim submission3. Percent of services provided that did

h i h i inot have appropriate authorization or re-authorization from MCO

4. Fiscal Indicators such as Days of Cash on Hand, Current Assets to Current Liability Ratio, etc.

5. IT Capacity to transmit to MCO Presented By:

David Lloyd, Founder 113


39

Physical Facility Indicators




40


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