ValueOptions Provider Forum East Lansing, MI. May 6, 2005

Transcription

1 ValueOptions Provider Forum East Lansing, MI May 6, 2005

2 Agenda Welcome and Introductions ValueOptions Staff Kathy Balcom, Service Center Vice President, GLSC Stan Golec, MD MPH, Medical Director, GLSC Gary Lalicki, Director Clinical Operations, ESD-GLSC Jane Trupiano, Director, Claims GLSC Marvin Guynes, Interim QM Director - GLSC Ruth Barry, Manager, Provider Relations GLSC Greg Irey, Account Representative Lynne Tolbert, Team Leader, Clinical Operations-HPD-GLSC Cathy Gilbert, Director, Corporate Provider Relations Guest Speaker James Keener, Owner- River s Bend PC, Troy MI Provider Relations BCN and Blue Choice Updates 2

3 Agenda (cont) The New IVR - TeleConnect Demonstration Coming soon to Web Self Service Demonstration ProviderConnect Eligibility Authorizations Claims Clinical Initiatives ITR Focus Care Management EAP Claims Electronic Claims Submission and Scanning Fraud and Abuse Issues Quality QIAs Member and Provider Satisfaction Surveys Questions and Answers

4 Partnering with Managed Care James Keener Guest Speaker Jim Keener has worked in the behavioral medicine field for over 27 years. He has served on the MAADAC board for the past 3 years. He has served as chair of the Ethics Committee, and chair of the Website Committee. Keener has served on the EAPA-GDC board as Ethics Committee chair and served a term as President. Keener has worked successfully with labor and management in the Detroit area and nationally to implement and grow EAP programs. Most notably, secured and developed the first external labor/management EAP for the auto industry at Saturn Corporation. He has over twenty years of experience partnering with local labor unions as well as management around EAP/Work Life programs. Directed and designed behavioral medicine programs at numerous facilities including: St. Joseph s Mercy Hospital Fox Center St. John s Hospital Oxford Institute Comprehensive Psychiatric Services Square Lake Counseling Center Kingswood Hospital Henry Ford Health System Brighton Hospital He currently owns and operates a private for profit outpatient behavioral medicine clinic called River s Bend, PC in Troy, MI. Keener carries an average active caseload of forty clients.

5 Partnering with Managed Care - Clinical Both working toward serving the client/patient Team approach to arrive at best level of care with collaboration between Care Managers and Providers Working together to better serve difficult clients. For Example: Manipulative client i.e. Provider shopping, drug seeking individual MBHO Referrals back to original treating organization leads to better outcomes Tracking through levels of care Facilitate coordination of care thru multiple organizations Inpatient and Outpatient providers Clinical Care Managers at an MBHO can be part of the treatment team by partnering with providers for better outcomes

6 Partnering with Managed Care - Claims Old manual process paper copy and snail mail May take as long as 3 weeks for a response either payment or denial Electronic claims submission Saves time Rapid notification if claim error including missing authorization when using the direct entry of claims through Payment often in less than week from time of submission TAT on payments faster Less staff time following up on denied claims or claims errors Rejections / Denials have decreased from 40% to 0% since starting electronic claims

7 Corporate Provider Relations

8 BCN and Blue Choice Credentialing BCN Process CAQH for MDs and PhDs Acknowledgement agreements Blue Choice De-Implementation Restructuring and Consolidation Transition to BCBSM Effective 9/1/05 Details will be sent to all providers around July 1, 2005

9 Technology

10 Technology Enhancements Increased convenience & decreased administrative burden TeleConnect (Interactive Voice Response) May 2005 Voice recognition software that will allow for eligibility verification, claims status, benefits, form requests and outpatient authorizations* ProviderConnect (Provider Online Services) July 2005 Enhanced online claims submission, claims status, benefits, eligibility verification, form request and Web-based outpatient authorizations* * Outpatient Authorizations via TeleConnect & ProviderConnect will be introduced beginning in Q4 05.

11 TeleConnect (Interactive Voice Response) Replacing our existing touch tone telephonic systems. Offers easy-to-navigate voice response self-service. The new system will give you 24/7 access to conduct authorization approvals, claims inquiries, eligibility and benefit inquiries - that is, the ability to retrieve information at your convenience.

12 ProviderConnect (Provider Online Service) Provides an online alternative to the telephonic services of TeleConnect. Gives providers a 24/7 available, easy-to-use tool for completing everyday service requests. Will allow users to check eligibility, benefits, outpatient authorizations claims status, claims history, claims payment and view correspondence on-line in Fall Allows single and batch claims submissions Enable providers to view their demographic information and submit changes online.

13 ValueOptions Website

14 Corporate Website

15 Corporate Provider Relations Website

16 Corporate Provider Relations Website Company News: Read the most recent news about our company. Network-Specific Information: Find handbooks, forms, and other details that pertain to program-specific networks. Educational Opportunities: View educational articles and 2005 Provider Forums. elearning under development. The Valued Provider: Access articles found in our provider newsletter. Read informative articles and learn about new initiatives underway at ValueOptions. Change of Address and W-9 forms: Help us keep the information we have on file for you current by downloading, completing and sending these forms to us. Online Services: ProviderConnect - confirm eligibility of our members for service, submit claims directly over the internet, and check the status of a claim you submitted (etc.). Forms: Current VO forms posted for your convenience to download and submit. Provider Handbook: Available online. Always up-to-date.

17 Provider Handbook Prepared as a guide to ValueOptions policies and procedures for individual providers, affiliates, group practices, programs and facilities. Provides important information regarding the managed care features incorporated in the ValueOptions provider contract; and also reflects the policies that are applicable to our general commercial product lines. Divided into the following sections: Administration Provider Responsibilities, Credentialing and Sanctions, Claims, Online Services, Referral, Quality Management, and Utilization Clinical Criteria EAP Information Treatment Guidelines Forms Glossary of Terms We also made each section printer friendly for your convenience.

18 Corporate Member Website

19 Corporate Member Website Resource Center Print Members Rights and Responsibilities poster Post in your office - visible to all members Education Center Offers information on various Mental Health topics

20 Clinical

21 Clinical Initiatives 2005 Health Plans Clinical Redesign Care Team Inpatient Team Psychiatry Consults on Medical Unit Bariatric Assessments BCN specific Current IVR Outpatient authorization process Aftercare Follow-Up PCP Coordination

22 Outpatient Authorizations HPD ValueOptions is making the following changes to the Outpatient Authorization process for Health Plan Accounts in 2005: The 6 visit pass through for Health Plan Accounts was discontinued for 2005 this is for BCN, OmniCare, Oakwood, M-Care and DMC Care. IVR will now be used for the first and second authorizations for Outpatient care. The first call will register the care and authorize an initial 4 sessions. The second call to the IVR will authorize up to 6 additional sessions. The IVR will back date up to 30 days. For additional visits after 10 visits, you speak to a care manager to complete a clinical review. For members who have been in treatment and utilized their full benefit during 2003 and 2004, providers will be notified to contact VO to review the case. The toll free number for the IVR for all of the health plans is: The IVR allows you to register care for your clients 24 hours a day, 7 days a week. Please use IVR to obtain authorization for all outpatient services. This change will be effective for all claims submitted after 1/1/2005, regardless of date of service.

23 Clinical Initiatives 2005 Employer Solutions Division Inpatient Treatment Record (ITR) Integrated Case Activity Form (CAF)/Billing Form for EAP Services EAP Providers needed in area Overview of EAP Programs Focus Care Management

24 EAP Providers EAP Providers/Counselors - Must be licensed in one of the disciplines recognized by ValueOptions (MD/DO, PSY, SW, RNCS, ARNP, MFT, or LPC) at the highest level of independent practice in the state where the practice is to occur and meet ValueOptions credentialing criteria. All provider applicants must have a minimum of three (3) years post licensure experience in a mental health / substance abuse/ EAP setting providing direct patient care. Must possess knowledge and work experience of EAP Core Technology by: Active status as a Certified Employee Assistance Professional (CEAP); or Two (2) years of verifiable experience as an internal EAP counselor and/or as an external EAP consultant to other organizations. Examples of verifiable experience include but are not limited to: Management and/or union representative consultation on the impact of personal problems on work, performance issues, the appropriate use of constructive confrontation and the role of the EAP. Direct care functions of an EAP practice including assessment referral, short-term counseling and linkage to treatment and/or community resources. Crisis Intervention including critical incident stress management (CISM) services. Training and experience in organizational dynamics/development, human resource management or industrial social work / psychology. Assessment and identification of drug and alcohol abuse / dependency problems and appropriate treatment interventions.

25 EAP Providers (cont) Must possess knowledge and work experience in the assessment and treatment of substance abuse by: Active status as a Certified Employee Assistance Professional (CEAP) with an acceptable level of experience in the assessment and/or treatment of chemical dependency, or Possess one year of experience in a substance abuse treatment facility: or Completed a state-level certification acceptable to support eligibility for the National Certified Addiction Counselor (NCAC) credential: or Possess International Certified Alcohol and Drug Counselor Certification (ICADC): or Possess a minimum of six (6) units of continuing education (CEU s, PDH s etc) in chemical dependency assessment/treatment: or Completed three (3) graduate level hours of coursework in chemical dependency.

26 GM CareLine - CareLine is for all hourly employees, retirees, surviving spouses and their eligible dependents enrolled in Non HMO Insurance. The CareLine Program has been developed according to the National Agreement between the UAW and the General Motors Corp. The purpose of the CareLine Program is to ensure quality mental health and substance abuse care to covered enrollees in the most appropriate setting. This is accomplished though the coordinated efforts of the Central Review Organization (ValueOptions), the Carrier (CIGNA Behavioral Health), the Central Diagnostic and Referral Agency (Helpnet), the Work/Family Program (EAP) at the local plant, and with the cooperation of the enrollees and providers.

27 GM CareLine (cont) The Central Review Organization (CRO) ValueOptions Confirms eligibility of the patient for mental health/substance abuse coverage Authorizes and approve all mental health services, including inpatient, partial hospitalization, intensive outpatient and traditional outpatient services Credentials providers for the CareLine Program and give recommendation to the Carrier (CIGNA Behavioral Health) Assures that benefits are authorized based on medical necessity

28 GM CareLine (cont) The Carrier-CIGNA Behavioral Health Executes Provider Agreements with qualified providers Processes claims for service and make reimbursement for authorized services Maintains provider information such as tax Id s, addresses, etc Facilitates the Sanction/Overpayment program

29 GM CareLine (cont) The Central Diagnostic and Referral Agency (Helpnet) Conducts face to face assessment of patients under substance abuse diagnosis and develop a continuing care treatment program (CCTP) Makes determinations regarding whether the patient s condition requires mental health and/or substance abuse treatment Monitors compliance of the Continuing Care Treatment Plan and report to the CareLine Program if the patient does not complete treatment as stated in the CCTP, which will lead to a sanction (for the employee only) Coordinates with the CRO the treatment of those enrollees that require both substance abuse and mental health services, and register all substance abuse authorizations with the CRO

30 GM CareLine (cont) Benefits 45 days of inpatient treatment (covers both mental health and substance abuse) 45 days are renewed after an absence of 60 days of any inpatient care for either medical or behavioral health services 90 days of partial hospitalization (covers both mental health and substance abuse) 35 outpatient visits for mental health per calendar year (coverage is 100 percent for sessions 1-20 and at 75 percent for sessions 21-35) 35 outpatient visits for substance abuse per calendar year (coverage is at 100 percent for all 35 sessions) All services for mental health and/or substance abuse must be authorized by either the CRO or the CDR in order for the Carrier to reimburse providers for service rendered

31 Claims

32 Scanning Claims Dos and Don ts

33 Critical success factors for scanning Dos Original red line claim forms Black ink machine print Print within the boxes Use upper case letters Use a laser printer Use white correction tape for corrections Use 8 digit dates (e.g ) Use fixed width fonts like Courier Use 8 ½ x 11 paper for any additional notes Complete the patient s date of birth

34 Don ts Factors that may require manual intervention & delay claims: Use black line or copies of claim forms Hand print or hand write Use red ink Use dashes, slashes, or circles Use type smaller than 10 point Use proportional fonts like Times New Roman Use of stamps, highlighters, correction fluid, labels, stickers Folding or stapling items to the claim form Use of handwritten signatures (use signature on file)

35 EDI ValueOptions can receive your 837 transaction directly Access the VO web site at Access For Providers on the left hand side of the screen Access Handbooks Administration- Online Services. EDI help is available from esupport Services at

36 FRAUD AND ABUSE

37 37 Fighting fraud and abuse strengthens and preserves ValueOptions services to providers and members and enhances the health care delivery system as a whole.

38 Abuse ValueOptions defines abuse as any practice, direct or indirect, that is inconsistent with sound or established fiscal, business, insurance, or medical practices and results in an unnecessary cost to a behavioral health benefits program. It also consists of reimbursement for services performed that are not medically necessary or that fail to meet professionally recognized standards for health care. A provider may or may not have knowingly and/or intentionally misrepresented facts to obtain payment. Abuse also includes any practices by a member that results in unnecessary costs to a behavioral health program. 38

39 Fraud ValueOptions defines fraud as an intentional deception or misrepresentation made by an entity or person in any managed care setting with the knowledge that the deception could result in some unauthorized benefit to the entity, himself/herself, or some other person. In the context of health care claims, purposely billing for services that were never given, for a service that has a higher reimbursement than the service provided, or at the incorrect reimbursement level. 39

40 Common Examples of Fraud and Abuse Submitting claims for services that were not provided (this includes no shows or canceled appointments) Misrepresenting the diagnosis for the member in order to justify payment Utilizing split billing schemes (i.e., billing procedures over a period of days when all treatment occurred during one visit) Coding a service at a higher level that what was rendered (i.e. up-coding) 40

41 Common Examples of Fraud and Abuse Continued Inappropriate documentation of services rendered Billing for all participants of a family therapy session Billing for services by a provider for services actually rendered by an affiliated (i.e. employed or associated with same group etc.) provider who is not a contracted or credentialed provider of ValueOptions. 41

42 When Fraud is Committed... Automatic Termination Providers will be immediately terminated upon the happening of any of the following events: Insolvency or Dissolution Loss of License Conviction of Fraud Limited Ability to Practice Death 42

43 Eliminating Fraud and Abuse To eliminate fraud and abuse successfully, providers, facilities, and members must work together to prevent and identify inappropriate and potentially fraudulent billings. This can only occur by: Monitoring claims submitted for compliance with billing guidelines Adherence by providers and facilities to Treatment Record Standards Education of all staff members responsible for dealing with medical records (including documentation, storage, retrieval, or review) or who are involved with billing Referring cases of suspected fraud and abuse 43

44 For More Information Contact Us FHC Ethics and HIPAA Hotline at Visit our Website 44

45 Quality

46 Quality Management Department Evaluates quality of care across the entire range of services Fully operational quality structure NCQA/URAC accreditation status

47 Quality Improvement Activities Ongoing Activity: Improving Ambulatory Follow-up Care After Discharge from an Acute Mental Health Level of Care New Activities for 2005: Increasing the Identification, Initiation and Engagement of Treatment for Members in Need of Alcohol or Other Drug Services Increasing Time in Community for Members Treated for Major Depression in an Inpatient Setting Enhancing the Management of Care for Children and Adolescents

48 Ambulatory Follow-up Rates 100.0% 90.0% 80.0% 80.5% 91.2% 85.2% 81.1% 77.7% Percentage of Compliance 70.0% 60.0% 50.0% 40.0% 69.4% 65.6% 62.2% 38.6% 58.2% 30.0% 20.0% 10.0% 0.0% Within 7 days Within 30 days Baseline: (1/1/00-12/31/00) 2001: (1/1/01-12/31/01) 2002: (1/1/02-12/31/02) 2003: (1/1/03-12/31/03) 2004: (1/1/04-12/31/04)

49 Continuity of Care Initiatives 1. Between Behavioral Health Providers: An audit was conducted during 2003/2004. Charts were reviewed on members that had been discharged from inpatient to outpatient care in 2003 and had at least three outpatient visits by the time of the audit. The percentage of outpatient cases that demonstrated coordination of care was 45%. Information on discharge medications was found in 43% of the cases. Ongoing onsite education instituted on mechanisms to improve communications between Behavioral Health Providers 2. Between Primary Care Physicians for 2004 the compliance rate was 71% - Performance Standard is 80%

50 Prevention Programs Major Depression-Keys to Recovering From Depression ADHD -Parenting the Child With Attention Deficit/Hyperactivity Disorder (ADHD) Workbooks are available on the ValueOptions web site at or if you have any questions please call 1-(866) On-line screening available to health plan members as of September 2003 Post-Partum Depression Program

51 Member Satisfaction Survey Quarterly Surveys completed by FactFinders 2004 Great Lakes Service Center Results Overall Member Satisfaction with Providers Positive Response 90.4% of Health Plan Members 89.1% of Employer Group/EAP members 89.2 of Employer Group MH/SA Members Quality of Service from Therapist Positive Response 91% of Health Plan Members 85.8% of EAP Members 88.9% of Employer Group MH/SA Members

52 Annual Provider Satisfaction Survey Great Lakes Regional Results Conducted 3 rd 4 th quarter Telephone interviews by Fact Finders, Inc Overview of ValueOptions National Results

53 Provider Collaboration and Feedback Annual Provider Satisfaction Survey - independent auditor National Network Results - 91% overall satisfaction - 96% availability across all licensure types

54 Provider Satisfaction With ValueOptions Annual Survey completed in December 2004 Overall Satisfaction with ValueOptions % 90.0% 80.0% 85.2% 90.3% 88.1% 92.3% 80.4% 86.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% % 0.0% Very Satisfied 59.3% 36.6% 50.0% 41.0% 39.1% 24.0% Somewhat Satisfied 25.9% 53.7% 38.1% 51.3% 41.3% 62.0% Not Satisfied 11.1% 2.4% 11.9% 7.7% 19.6% 14.0% Satisfaction 85.2% 90.3% 88.1% 92.3% 80.4% 86.0%

55 Helpfulness with Certification of Care NOT HELPFUL 8% VERY HELPFUL 37% SOMEWHAT HELPFUL 55%

56 Provider Satisfaction with Certification of Care % WHO THINK CERTIFICATION IS EASY 74% 13% OUTPATIENT CARE INPATIENT CARE

57 Practice Characteristics by Professional Discipline 22% 18% 22% 38% Psychiatrist Psychologist Social Worker All Other Disciplines

58 2004 TREATMENT RECORD DOCUMENTATION OPPORTUNITIES FOR IMPROVEMENT Each page in the treatment record contains the enrollees name or ID number Special situations-imminent risks of harm to members must be noted Documentation of a medical/psychiatric history Treatment plans are consistent with diagnosis and have measurable timely goals The treatment record has evidence of continuity and coordination of care between Behavioral healthcare practitioners and the member s Primary care Physician (PCP) Treatment record reflects evidence of coordination with EAP/employer if a referral was made

59 Website has the following documents available: PCP Communication Form ValueOptions Quality Management Program in the ValueOptions Provider Handbook (Section C). The ValueOptions After-Care Tip Sheet for members. The ValueOptions My Medication Log for members. Member Rights and Responsibilities Statement

60 HIPAA Reminders is not secure unless encrypted Do not send member information via . This includes: Member name or initials I.D. numbers Any identifying information New HIPAA Security Rules Effective For details on HIPAA issues please use the links on under the Compliance section of the Provider Handbook.

61 Questions and Answers

62 Thank you!