Utilization Management Webinar Series #1:

Developing Effective Agency UM Practices

Managed Care Technical Assistance Center Overview

What is MCTAC? MCTAC is a training, consultation, and educational resource center that offers resources to all mental health and substance use disorder providers in New York State. MCTAC’s Goal Provide training and intensive support on quality improvement strategies, including business, organizational and clinical practices to achieve the overall goal of preparing and assisting providers with the transition to Medicaid Managed Care.

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MCTAC MCTAC is partnering with OASAS and OMH to provide: Foundational information to prepare providers for

Managed Care Support and capacity building for providers tools informational training & group consultation assessment measures

Information on the critical domain areas necessary for Managed Care readiness Aggregate feedback to providers and state authorities

MCTAC Overview (cont.)

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LEARNING OBJECTIVES • Understand the agency investment that will need to be

made in order to secure desired UM outcomes • Understand effective practices for embedding the UM

function into the work of the agency in a way that will : – optimize outcomes – maintain integrity of service provision

• Further consider other restructuring that may need to take place in order to align your services in a way that: – maintains the integrity of your service provision – meets MCO expectations – improves client outcomes

• Learn what some MCOs suggest you consider as you develop your UM process

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What we know and what we don’t know…

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What is Utilization Management?

• The process by which an MCO decides whether specific health care services, or specific level of care, are appropriate for coverage (to be paid) under an enrollee’s plan

• Primary purpose of the program is to ensure that services are necessary, appropriate, cost-effective and at the least restrictive level of care

• Utilization Review (UR) vs. Utilization Management (UM) UR – Regulatory requirement, Internal review. UM – MCO standards, External review

• Maintain fidelity and integrity of service provision

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• Managed Care is an integrated system that manages health services for an enrolled population rather than simply providing or paying for the services (outcomes, service quality and service expenditures).

• Generally MCOs are paid for health benefits administration on a capitated basis (A fixed amount for each member each month/Per Member Per Month -PMPM).

• The MCO’s role is to make sure the individual receives the least restrictive care they require while staying within the dollars available for that year.

• The core function of the UM program is to ensure that the MCO pays for only those services that are “medically necessary.”

• Involves a determination of whether the service is necessary and appropriate for the patient’s symptoms, diagnosis, and treatment and recovery. Also reviews for the appropriate length of care.

• UM applies chiefly to diagnostic and evaluative services, hospital services, and certain specialty services including HCBS; primary care services are not typically subject to prior authorization or concurrent review

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Why do MCOs Conduct Utilization Management?

How might a provider think about UM today?

• It is a painful and time consuming process

• Generates fear due to a degree of uncertainty

and past history (of yours or others) • UM is a way for MCO not to pay for services

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How should a Provider think about the practice of UM ?

• Feedback from MCO can assist in informing practice changes to improve outcomes for the client

• Effective UM helps assure flow of funding for services being provided

• UM helps you better understand your

population

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MCO Feedback - Beacon

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We stress knowing the criteria set, working with the MCO to develop a template for UM activities so that the provider’s clinicians are prepared, and emphasizing care coordination. The latter is especially important. We bring up the topic of Health Homes when discussing care coordination, but we also emphasize that the MCO is there to assist especially if the individual does not have a HH CM yet or is not eligible.

MCO Feedback – Excellus

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It will take some open mindedness on the part of all .... providers and insurers.

Steps for Developing an Effective UM Program:

To support this work, MCTAC is offering the following tools: • Agency Utilization Management Preparation Check

List • Job Description for a UM Supervisor • Job Description for a UM Staff Person • Description of Leadership Role in Developing and

Managing a successful UM Practice

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Agency Utilization Management Preparation Check List

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Agency Utilization Management Preparation Check List

Categories in Check List • Agency Culture • Organizational Structure • Managed Care Organization Information • Agency Practices and Processes • All Agency Staff • UM Staff • Supervision • Technology • Quality Improvement

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Check List

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Area Yes/No If “No,” Action to be Taken by Agency

Agency Culture The organization’s culture recognizes the importance of effective UM practices in managing revenues, meeting customer expectations and improving outcomes for clients.

The organization’s culture recognizes the important role that the UM staff play in working with the MCOs

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Check List

Area Yes/No If “No,” Action to be Taken by Agency

Organizational Structure

UM staff members are an active part of the treatment team for services being provided, attend treatment team meetings and receive regular updates from all members, especially the Transition/Discharge Planners

UM staff member work space is proximate to service delivery team to allow for timely and convenient communication

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Check List Area Yes/No If “No,” Action to be

Taken by Agency Managed Care Organization Information

Agency knows all MCOs which work within the service area

Agency has provider Manuals for all MCOs

Agency has UM Dep’t contact information for all MCOs, including name and phone number for BH Medical Director

Agency has current Level of Care information including admission, continuing stay and discharge criteria, as well as service volume caps for all services provided by the agency, for each MCO.

MCO Level of Care information is organized to be easy to access and use for all staff members

Agency has reviewed the Level of Care information for each MCO and discussed changes needed in order to meet the MCO expectations

Agency has information concerning the MCOs’ claims denial and appeals processes

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Check List Area Yes/No If “No,” Action to be

Taken by Agency Agency Practices and Processes Agency has developed Initial UM/Authorization Processes based upon the expectations of the MCOs Agency has developed Concurrent UM/Authorization Processes based upon the expectations of the MCOs. Agency has developed a data collection template for each MCO and Service to support the UM process UM staff educates the treatment team about the expectations placed upon the facility by the MCOs and the philosophy of engagement with the MCO that will secure the best outcomes. Treatment team educates the UM staff on the integrity of service provision.

UM starts on day 1 of admission. Participation in Discharge Planning/Transition in care starts very early on (Day 1 for inpatient stays)

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Check List Area Yes/No If “No,” Action to be Taken by

Agency Agency Practices and Processes (con’t) Person centered, recovery focused practices are a part of the transition planning process. Individual is an active participant in the UM process

Agency addresses immediate concerns that could be barriers to transition in level of care or unrelated to immediate health concerns: safe housing, support, finances, etc.

Agency identifies and addresses issues that could be contributing factors to a readmission

Agency addresses both BH and PH service needs of the individual during a hospital stay

Agency develops internal workflows with responsibilities clearly designated for staff members

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Check List Area Yes/No If “No,” Action to be Taken by

Agency Agency Practices and Processes (con’t)

Agency develops population level reporting strategies to identify outliers by program, by staff, and by client level

Agency routinely assesses service “Transition/ Discharge Readiness” of the individual

Agency develops an assessment tool based upon the discharge criteria for the specific service and routinely complete and share with treatment team

Agency develop crisis plan with the individual and make sure they have a copy

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Check List Area Yes/No If “No,” Action to be Taken by

Agency Agency Practices and Processes (con’t)

Agency routinely communicates with primary supports (family, friends, community) and current treatment providers (include d/c summary prior to outpatient appointment)

Schedules BH f/u appointment within 7 days of inpatient discharge

PCP appointment scheduled when need identified

Agency has developed a clear process for timely appeal to the MCOs when claim are denied.

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Check List

Area Yes/No If “No,” Action to be Taken by Agency

All Agency Staff

All staff are aware of service volume caps or limits and incorporate this understanding into the work they do

Agency is aware of any requirements or qualifications expressed by the MCOs for staff delivering the services and address any gaps in staff preparedness

All staff understand the MCO expectations for the review process

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Check List Area Yes/No If “No,” Action to be Taken by

Agency UM Staff

Hire staff members with expertise in specialty being reviewed, e.g.: Behavioral Health (MH or SUD), Physical Health, HCBS (In house-outsourced-central-program specific)

Orient staff to MCO UM language and provide practice opportunities

Provide documentation received from the MCOs concerning UM expectations (HEDIS)

Review and fully understand LOC criteria, continuing stay, and discharge criteria (LOCADTR for SUD) as well as any service volume caps

Participate in case studies: Practice offering justification in a manner that reflects the MCO’s requirements

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Check List Area Yes/No If “No,” Action to be Taken by

Agency Supervision

Select or hire a well-qualified individual to supervise UM staff

Technology

Agency Electronic Health Records (hopefully electronic) provides ready access to information needed by UM staff to have informed conversation with MCO about an individual’s current status, anticipated needs, and longitudinal plan of care

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Check List Area Yes/No If “No,” Action to be Taken by

Agency Quality Improvement

Feedback concerning UM practices are requested from the MCOs.

Performance reports tied to UM practices are prepared and shared broadly across the agency.

Opportunities to improve UM performance are discussed with staff members and improvement plans are developed.

Agency routinely monitors the quality of the BH/HCBS services being provided and look for improvement opportunities.

Utilization Management Staff Supervisor Position

Description

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UM Supervisor Responsibilities • Provides day-to-day supervision of the

Utilization Management staff such as making case assignments, and assuring coverage for UM upcoming reviews. Provides weekly supervision at a minimum.

• Holds case conferences to review cases and develop strategies to manage these cases effectively.

• Reviews records to assure that care plan strategies, transition strategies and documentation meets agency expectations.

• Periodically listens to the calls taking place between the Agency UM staff and the MCO Agency staff to assure appropriateness of the conversations.

• Maintains routine and productive channels of communication with the MCO UM Departments with which the agency contracts. Seeks feedback on the work of the agency.

• Maintains understanding of current UM practices and related expectations for each MCO with which the agency works

• Trains the UM staff on current UM practices

• Develops internal workflows (including tools and schedules) with clearly designated responsibilities to support efficient and timely reviews

• Continually looks for process improvement opportunities

• Member of the agency’s leadership team

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Qualifications: • RN, and/or licensure as a professional w/certification and/or expertise in specialty

being reviewed, e.g.: Behavioral Health, Physical Health, Home & Community Based Services

• Experience with Utilization Management practices • Values person-centered, recovery focused practices • Supervisory experience, including the ability to develop team performance • Demonstrated competency in the interpretation of UM metrics • Knowledge of MCO outcomes/requirements, e.g.: HEDIS • Knowledge of what is unique to each MCO in their review process • Excellent written and oral communication skills • Self-motivated, able to prioritize multiple issues, excellent organizational skills • Ability to track multiple projects/tasks and follow through as needed • Ability to manage and coordinate with internal and external departments • Managed Care experience

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UM Supervisor Qualifications

Utilization Management Staff Position

Description

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• Effectively communicates with MCO UM departments concerning agency cases under review

• Maintains a positive and professional working relationship with MCOs UM Staff. • Maintains understanding of current UM practices and related expectations for each

MCO with which the agency works. Professionally carries out practices • Effectively negotiates resolution when a case review results in a difference of

opinion. • Maintains excellent channels of communication with agency service delivery staff • Participates in case conferences to review cases and to develop strategies to

manage these cases effectively. • Reviews records to assure that care plan strategies, transition strategies and

documentation meet MCO UM expectations. • Monitors UM information sent from MCOs to assure that any changes in UM

practices are incorporated into the agency’s practices. • Continually looks for UM process improvement opportunities

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UM Staff Responsibilities

• RN, licensure as a professional w/certification and/or expertise in specialty being reviewed, e.g.: Behavioral Health, Physical Health, Home & Community Based Services

• Experience with Utilization Management practices • Values person-centered, recovery focused practices • Demonstrated competency in the interpretation of UM metrics • Knowledge of MCO outcomes/requirements, e.g.: HEDIS • Knowledge of what is unique to each MCO in their review process • Excellent oral communication skills • Self-motivated, able to prioritize multiple issues, excellent organizational

skills • Ability to track multiple tasks and follow through as needed • Ability to manage and coordinate with internal and external departments • Managed Care experience

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UM Staff Qualifications

Leadership Role

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Description of Leadership Role in Developing & Managing a successful UM practice

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• Make certain that Agency staff members appreciate the significant changes taking place

• Make certain that all agency staff understand that the MCOs are an important customer and should be treated as such

• Assures that all staff understand the UM process for the agency and the role that successful implementation will play in the agency’s overall financial performance .

• Believes in quality improvement: – Supports the agency’s Quality Plan to promote ongoing improvement in

practice and outcomes • Provides opportunities for ongoing UM staff training to improve outcomes • Invests in effective and knowledgeable supervision • Breaks down organizational silos to support effective and timely

communication between the service providers and the UM staff.

Planning for Change

• Use the UM check list... • What will you start doing? • What will your stop doing? • What will you keep doing? • What will you integrate?

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Upcoming Events

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June

Monday Tuesday Wednesday Thursday Friday

6/1-6/5

6/8-6/12

UM webinar- Effective UM

Practices Overview

HCBS training-

Syracuse

6/15-6/19 UM webinar-

Staffing

6/22-6/26 UM webinar-

Implementation

6/29-7/3

UM webinar-Supervision

Children's Summit-

NYC

Children's Summit-Albany

HOLIDAY

Q & A

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Please submit questions between sessions to: mctac.info@nyu.edu using the subject line ‘UM Overview Questions’

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Visit www.mctac.org to view past trainings, sign-up for updates and event announcements, and access resources.

mctac.info@nyu.edu

@CTACNY

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Thank you for participating! Please visit http://www.ctacny.com/

and http://www.mctac.org/

to sign up for additional offerings and trainings.