South Country Health Alliance

Transcription

1 Minnesota Department of Health Compliance Monitoring Division Managed Care Systems Section Final Report South Country Health Alliance Quality Assurance Examination For the period: December 1, 2007 Through December 31, 2009 Final Issue Date: August 31, 2010 Revised: March 3, 2011 Examiners: Susan Margot, M.A. Elaine Johnson, RN, BS, CPHQ

2 Minnesota Department of Health Executive Summary: The Minnesota Department of Health (MDH) conducted a Quality Assurance Examination of South Country Health Alliance (SCHA) to determine whether it is operating in accordance with Minnesota law. MDH has found that SCHA is compliant with Minnesota and Federal law, except in the areas outlined in the Deficiencies and Mandatory Improvements sections of this report. Mandatory Improvements are required corrections that must be made to noncompliant policies, documents or procedures where evidence of actual compliance is found in relevant files or where the file sample did not include any instances of the specific issue of concern. The Recommendations listed are areas where, although compliant with law, MDH identified improvement opportunities. To address recommendations, SCHA should: Develop policies/procedures for review of delegate reports, including documentation of the review and approval of the delegate s UM Program description. Indicate in its policy the suggested timeframe guidelines in which quality of care cases should be investigated. In order to assure geographic accessibility, add to its provider network policy the requirements of Minnesota Statutes, section 62D.08, subdivision 5, which states that any cancellation or discontinuation of any contract or agreement must be reported to MDH. Include the status of its pharmacy network when reporting on access and availability of its networks. When making a determination to deny a service authorization for clinical reasons, the professional should personally document the decision in the member s record. To address mandatory improvements, SCHA must: Revise its policies/procedures, CR 01, Credentialing and CR 03, Organizational Credentialing, to clarify the following: SCHA s requirement of primary source verification. SCHA s process to delegate, what may be delegated and how the plan decides to delegate, including those entities with whom SCHA will delegate. SCHA s process to notify practitioners of their rights. SCHA s process to ensure that verification of required items is within the prescribed time limits. 2

3 Revise its policy and practice such that they are able to show evidence of ongoing evaluation of medical records to assure that medical records are maintained with timely, legible and accurate documentation as well as containing the necessary information. Include a description of all of its PIPs in the annual work plan and use the revised format for including PIPs in its future annual work plans. Use the more stringent language of same or similar specialty that typically manages the medical condition, procedure or treatment under discussion to be more specific as to how to handle appeals. In addition, language in all appeal policies must be changed to clearly and accurately reflect that the decision to deny is upheld or overturned in the appeal process. Clearly and accurately communicate to its participating providers the access and availability standards they are expected to follow. Ensure that each entity performing UM on behalf of its enrollees must have a UM policy and the specific procedures the entity will follow to implement the policy. Revise UM policies/procedures as follows: Consistently specify which providers must receive oral and written notices. Specify that the provider or enrollee will be given the criteria used to make the determination of the necessity, appropriateness, and efficacy of the health care service and identify the database, professional treatment parameter, or other basis for the criteria. Clarify that the notice of an expedited initial determination will be given within 72 hours of the request. Clarify MMSI policies/procedures to include the enrollee s and attending health care professional s right to file an expedited appeal. Develop a written Lack of Information policy/procedure. SCHA should implement its own policy. Clarify SCHA s actual practices with regard to benefit exceptions. SCHA should implement its written policy. Revise its policies/procedures to list the specific items that must be provided to the enrollee and provider when the denial is upheld upon appeal. Ensure policies/procedures clarify appropriately licensed professionals are to review mental health or substance abuse denials, including 2009 amendments to the statute. Ensure consistent application of its clinical criteria and review procedures by establishing procedures for inter-rater reliability, implement and report inter-rater reliability and identify areas of opportunity for continued clarification and improvement. 3

4 To address deficiencies, SCHA and its delegates must: Perform initial credentialing when it cannot obtain recredentialing files from a terminated delegate. Monitor practitioner specific complaints and quality issues between recredentialing cycles. Confirm that the organizational provider is in good standing with state and federal regulatory bodies and this must be included in the organizational credentialing policy. Perform organizational credentialing prior to contracting to ensure appropriate licensure, determining if the organization is in good standing with state and federal regulatory bodies, and verification of accreditation status. Offer to provide the enrollee with assistance in completing forms, offer any assistance needed to submit a written grievance, including an offer to complete the grievance form and must inform the enrollee of options for further assistance through the managed care ombudsman and/or review by the Minnesota Department of Health. Use a more detailed notice, such as free text or different language to explain the denial. This report including these deficiencies, mandatory improvements and recommendations is approved and adopted by the Minnesota Commissioner of Health pursuant to authority in Minnesota Statutes, chapter 62D. Darcy Miner, Director Compliance Monitoring Division Date 4

5 Table of Contents II. Quality Program Administration... 7 Minnesota Rules, Part Program...7 Minnesota Rules, Part Activities...11 Minnesota Rules, Part Quality Evaluation Steps...11 Minnesota Rules, Part Focused Study Steps...11 Minnesota Rules, Part Filed Written Plan and Work Plan...11 III. Grievance System Section General Requirements...12 Section Internal Grievance Process Requirements...12 Section DTR Notice of Action to Enrollees...13 Section Internal Appeals Process Requirements...14 Section (c) Maintenance of Grievance and Appeal Records...15 Section (f) State Fair Hearings...15 Minnesota Rules, Part Records of Complaints...16 IV. Access and Availability Minnesota Statutes, Section 62D.124. Geographic Accessibility...16 Minnesota Rules, Part Availability and Accessibility...16 Minnesota Statutes, Section 62Q.55. Emergency Services...17 Minnesota Statutes, Section 62Q.121. Licensure of Medical Directors...17 Minnesota Statutes, Section 62Q.527. Coverage of Nonformulary Drugs for Mental Illness and Emotional Disturbance...17 Minnesota Statutes, Section 62Q.535. Coverage for Court-Ordered Mental Health Services...17 Minnesota Statutes, Section 62Q.56. Continuity of Care...17 V. Utilization Review Minnesota Statutes, Section 62M.04. Standards for Utilization Review Performance...18 Minnesota Statutes, Section 62M.05. Procedures for Review Determination...18 Minnesota Statutes, Section 62M.06. Appeals of Determinations not to Certify...20 Minnesota Statutes, Section 62M.08. Confidentiality...21 Minnesota Statutes, Section 62M.09. Staff and Program Qualifications...21 Minnesota Statutes, Section 62M.10. Accessibility and On-Site Review Procedures...22 Minnesota Statutes, Section 62M.11. Complaints to Commerce or Health...22 Minnesota Statutes, Section 62M.12. Prohibition on Inappropriate Incentives...22 Minnesota Statutes, Section 62D.12. Prohibited Practices...23 VI. Recommendations VII. Mandatory Improvements VIII. Deficiencies

6 I. Introduction A. History: South Country Health Alliance (South Country or SCHA) began operations November 1, The service area included Brown, Dodge, Freeborn, Goodhue, Kanabec, Sibley, Steele, Wabasha, and Waseca Counties, nine rural counties located in the southern half of Minnesota. Initial product offerings included Pre-Paid Medical Assistance (PMAP) and General Assistance (GA). Product offerings were expanded to include Minnesota Senior Care Plus (MSC+) and a Minnesota Senior Health Options (MSHO) Program in 2005, and Minnesota Care (MNCare) and AbilityCare (a Medicare Advantage Special Needs Program) in South Country expanded its service area in January 2007 to add five northern Minnesota counties: Cass, Crow Wing, Morrison, Todd, and Wadena Counties. Under contract with the Minnesota Department of Human Services (DHS), South Country is fully at risk for guaranteeing payment for covered services and must meet all requirements that apply to HMOs. As a county-based purchasing entity, South Country is governed through a Joint Powers Agreement among the fourteen member counties. The Joint Powers Board is comprised of one commissioner from each member county. Board members lead or serve on each South Country committee. South Country has Community Resource Management Teams (CRMTs), of county social workers and public health nurses that coordinate services among community health and social services and local medical and behavioral health services. South Country provides ITV (closed-circuit television) equipment in participating counties. The technology has proven valuable for committee and work groups, professional education and training and telemedicine services for behavioral health in counties with limited access to providers. South Country has continued to enhance the Client Contact Management (CCM) an Internet-based system providing a comprehensive record of member-specific data and a single common record accessible as appropriate among all members of the care team. In 2009 South Country transitioned Disease Management Programs, the Restricted Recipient Program and Mental Health Targeted Case Management benefit in-house; developed an internal data warehouse for increased timeliness and availability of clinical and claims data; contracted directly for the collection and auditing of HEDIS data and medical record review; developed its own comprehensive provider network; brought Member Services and Grievance and Appeal services for all products in-house and contracted with a single TPA: MMSI. 6

7 B. Membership: SCHA self-reported enrollment as of December 31, 2008 consisted of the following: Product Enrollment Minnesota Health Care Programs-Managed Care (MHCP-MC) Families & Children MA 24,828 GAMC 852 MinnesotaCare 2,690 Minnesota Senior Care (MSC+) 1,010 Minnesota Senior Health Options (MSHO) 1,879 Minnesota Disability Health Options (MnDHO) 0 Special Needs Basic Care (SNBC) 795 Total 32,054 C. Onsite Examination Dates: March 8-15, D. Examination Period: December 1, 2007 through December 31, File Review Period: January 1, 2009 through December 31, E. Sampling Methodology: Due to the small sample sizes and the methodology used for sample selection for the quality assurance examination, the results cannot be extrapolated as an overall deficiency rate for the health plan. F. Performance Standard: For each instance of non-compliance with applicable law or rule identified during the course of the quality assurance examination, which covers a threeyear audit period, the health plan is cited with a deficiency. A deficiency will not be based solely on one outlier file if MDH had sufficient evidence obtained through: 1) file review; 2) policies and procedures; and 3) interviews that a plan s overall operation is compliant with an applicable law. II. Quality Program Administration Minnesota Rules, Part Program Subp. 1. Written Quality Assurance Plan Subp. 2. Documentation of Responsibility Subp. 3. Appointed Entity Subp. 4. Physician Participation Subp. 5. Staff Resources Subp. 6. Delegated Activities Subp. 7. Information System Subp. 8. Program Evaluation Subp. 9. Complaints 7

8 Subp. 10. Utilization Review Subp. 11. Provider Selection and Credentialing Subp. 12. Qualifications Subp. 13. Medical Records Subp. 6. Minnesota Rules, part , subpart 6, states the HMO must develop and implement review and reporting requirements to assure that the delegated entity performs all delegated activities. The standards established by the National Committee for Quality Assurance (NCQA) for delegation are considered the community standard and, as such, were used for the purposes of this examination. The following delegated entities and functions were reviewed: UM Delegated Entities and Functions UM Appeals QM Grievances Cred Claims Network Care Coord Mayo Management Systems Inc. (MMSI) Prime Therapeutics, Inc. (PTI) X Clinical Resource Group, Inc. (CRG) DentaQuest X X X X X X X Brown County Cass County Kanabec County MeritCare X X X X X X X X X X X It is evident that SCHA did much more rigorous oversight of its delegates. Extensive partnering, monitoring and oversight is done with the counties and the care coordination and care planning functions. The SCHA delegation agreement to MMSI states that SCHA will review and approve the MMSI UM program description or the documents will be deemed approved. In interviews, SCHA stated UM department reviews the program description and it is presented to the Regulatory, Internal Audit, Delegation Entities (RIDE) committee. MDH reviewed the RIDE committee minutes received, but the MMSI UM program description was not in the minutes. MDH also reviewed UM and Quality Committees minutes without finding documented review or approval. SCHA should develop policies/procedures for review of delegate reports, including documentation of the review and approval of the delegate s UM Program description. (Recommendation #1) X X X X Subp. 9. Minnesota Rules, part , subpart 9, states the quality program must conduct ongoing evaluation of enrollee complaints related to quality of care. All of the four quality of care grievance files were reviewed and were found to be well investigated. In one file, in which the case took 141 days to close, it stated that the Medical Director had reviewed the case but there was no documentation in the file by the Medical Director. SCHA s policy states that the Medical Director will write a summary of the case, determine if a quality concern is confirmed and determine/confirm severity level. There was no indication in the policy of the suggested 8

9 timeframe in which quality of care cases should be investigated and closed. SCHA may want to add some timeframe guidelines to its policy. (Recommendation #2) Subp. 11. Minnesota Rules, part , subpart 11, states that the health plan must have procedures for credentialing and recredentialing providers that are, at a minimum, consistent with accepted community standards. MDH understands the community standard to be NCQA credentialing and recredentialing standards. MDH reviewed a total of 72 credentialing and recredentialing files from SCHA and its delegates as follows: Credentialing and Recredentialing File Review File Source # Reviewed Cred #Reviewed Recred # Organizational Reviewed SCHA MMSI na na 8 SMDC 7 8 na Innovis 8 8 na Total Recredentialing MDH reviewed a sample of five SCHA recredentialing files. In January 2009, SCHA began credentialing its own network of providers and ceased its contract with one of its TPA credentialing delegates. Since the delegate would not release files to SCHA providers it previously credentialed, SCHA obtained a General Affidavit Under Oath from the Allina Health System Manager of Provider Enrollment attesting to the credentialing status of the providers through December Hence, January 1, 2007, was used as the previous committee date for recredentialing purposes. An unbroken string of recredentialing at least every three years is required. Since the previous recredentialing files could not be obtained from the delegate, SCHA must perform initial credentialing within six months of the delegate s termination date. (Deficiency #1) Even using the date January 1, 2007, there was one file that was outside of the 36 month/three year recredentialing time frame (38 months). The plan must monitor practitioner complaints and quality issues between recredentialing cycles. In five recredentialing files there was no documentation that practitioner specific complaints and quality issues were monitored in the recredentialing process. (Deficiency #2) Organizational Credentialing The plan must confirm that the organizational provider is in good standing with state and federal regulatory bodies. Of the 14 SCHA organizational credentialing files reviewed, none of the files had documentation that sanction reports were checked. In addition, the policy/procedure CR03 Organizational Credentialing does not indicate that one of the credentialing requirements for all contracted organizations is that the provider is in good standing with state and federal regulatory bodies. (Deficiency #3) 9

10 All of the organizational providers had contracts dated January 1, 2009, but organizational credentialing was not done until March Credentialing must be done prior to contracting to ensure appropriate licensure, determining if the organization is in good standing with state and federal regulatory bodies, and verification of accreditation status. (Deficiency #4) SCHA provided its policies/procedures, CR 01, Credentialing and CR 03, Organizational Credentialing. In reviewing SCHA s policies/procedures, MDH had the following findings: Verification of credentials must come from a primary source or an agent of a primary source. SCHA CR 01, page 3 states, Initial Credentialing that includes... verification of information from primary and secondary sources. Page 10 states that credentialing staff will send the completed applications to its delegated NCQA accredited Credentialing Verification Organization (CVO). MedAdvantage verifies credentials according to NCQA standards for primary verification of applicants. SCHA CR 01 should state primary source verification. Policies/procedures must specify the process used to delegate, what may be delegated and how the plan decides to delegate. SCHA CR 01, page 22 states that SCHA may choose to delegate credentialing activities to a TPA, who may choose to subdelegate. The subdelegate s policies must comply with the TPA and SCHA standards. This statement does not meet the intent of the standards. In addition, this language is outdated since SCHA delegates credentialing to other entities, not just its TPAs. Policies/procedures must include practitioner rights, including the right to be notified of their rights. SCHA CR 01 does not discuss how practitioners will be notified of their rights. Policies/procedures to include the specific items are present for initial credentialing and within the prescribed time limits. SCHA CR 01 includes the specific items, but does not require that the verification be within the prescribed time limits. (Mandatory Improvement #1) Subp. 13. Minnesota Rules, part , subpart 13, states that the HMO must implement a system to assure that medical records are maintained with timely, legible, and accurate documentation of all patient interactions. Documentation must include information regarding patient history, health status, diagnosis, treatment, and referred service notes. Additionally, the HMO must maintain a medical record retrieval system that ensures that medical records, reports, and other documents are readily accessible to the HMO. SCHA performed medical record reviews in 2007, 2008 and through the risk adjustment process in SCHA s medical record policy states that it has its primary care and behavioral health facilities perform a medical record self-survey to address the medical record requirements. A self-survey does not assure that medical records are maintained with timely, legible and accurate documentation. Nor does it ensure that all necessary content and information is included in each medical record. Staff stated that non-responders will get a site visit; however, this is not included in the medical record policy. SCHA must change its policy and practice such that they are able to show evidence of ongoing evaluation of medical records to assure that medical records are maintained with timely, legible and accurate documentation as well as containing the necessary information. For example, a sample of medical records from network providers could be audited, results analyzed 10

11 and a summary report written that includes any follow up improvement actions that took place. (Mandatory Improvement #2) Minnesota Rules, Part Activities Subp. 1. Ongoing Quality Evaluation Subp. 2. Scope Minnesota Rules, Part Quality Evaluation Steps Subp. 1. Problem Identification Subp. 2. Problem Selection Subp. 3. Corrective Action Subp. 4. Evaluation of Corrective Action Minnesota Rules, Part Focused Study Steps Subp. 1. Focused Studies Subp. 2. Topic Identification and Selection Subp. 3. Study Subp. 4. Corrective Action Subp. 5. Other Studies Minnesota Rules, Part Filed Written Plan and Work Plan Subp. 1. Written Plan Subp. 2. Work Plan Subp. 2. Minnesota Rules, part , subpart 2, states, in pertinent part, that the work plan must give a detailed description of the proposed quality activities that will be conducted in the following year and must include a description of the proposed focus studies (performance improvement projects or PIPs). All the PIPs SCHA will be working on for the year are not specifically addressed or described in the 2009 annual work plan. The work plan states Implement 2009 PIPs: Preventive Visits and Continue 2008 PIP interventions. SCHA submitted committee minutes and other documentation indicating that PIPs are adequately and regularly reported up through the quality committee structure; however the annual work plan does not give a description of the all the PIPs that will be conducted in the following year as stated in the Rule. (Mandatory Improvement #3) SCHA submitted a draft revision of the PIP section of the annual work plan on September 2, 2010 that will fully comply with this Rule and will use this revised format for including PIPs in its future annual work plans. 11

12 III. Grievance System MDH examined SCHA s Minnesota Health Care Programs-Managed Care (MHCP-MC) grievance system for compliance with the federal law (42 CFR 438, subpart F) and the DHS 2009 Model Contract, Article 8. MDH reviewed a total of 52 grievance system files as follows: Grievance System File Review File Source # Reviewed Grievances SCHA 34 Non Clinical Appeals SCHA DentaQuest 8 6 Clinical Appeals (see UM) State Fair Hearings SCHA 4 Total 52 Section General Requirements Sec Components of Grievance System Section Internal Grievance Process Requirements Sec (b) Filing Requirements Sec (b)(1) Timeframe for Resolution of Grievances Sec (c) Timeframe for Extension of Resolution of Grievances Sec Handling of Grievances (A) (a)(2) Written Acknowledgement (B) Log of Grievances (C) (b)(3) Oral or Written Grievances (D) (a)(1) Reasonable Assistance (E) (a)(3)(i) Individual Making Decision (F) (a)(3)(ii) Appropriate Clinical Expertise Sec (d)(1) Notice of Disposition of a Grievance. (A) (d)(1) Oral Grievances (B) (d)(1) Written Grievance 12

13 (d)(1). 42 CFR (d)(1) (contract section 8.2.5(A)) and 42 CFR (a)(1) (contract section 8.2.4(D)) states the MCO must offer to give enrollees assistance in completing forms, and offer to provide the enrollee with any assistance needed to submit a written grievance, including an offer to complete the grievance form. Oral resolution must include the results of the MCO investigation and actions related to the grievance, and the MCO must inform the enrollee of options for further assistance through the managed care ombudsman and/or review by the Minnesota Department of Health. In five files there was no documentation that assistance was offered in completing forms. In four files there was no documentation that a written grievance form and assistance was offered. In seven files (four of which are the same files as above) there was no documentation that options for further assistance was offered. SCHA began internal administration of the member call center for all products beginning January 1, 2009, for which they hired new customer service staff that started in December. In January SCHA experienced telephone problems as well as problems with member pharmacy cards. SCHA stated they had a corrective action plan to address these grievance issues. SCHA submitted this corrective action plan to MDH as evidence that the grievance issues were addressed and corrected. The CAP was dated 1/1/09, prior to any issues occurring and addressed employee training that took place on 12/5/08, 6/5/09, 6/16/09, and 8/11/09. There was no timeframe for resolution of the issue in that the CAP stated ongoing. The telephone problems were not addressed on the CAP nor were the pharmacy card issues. The wording in the CAP is in the past tense. A follow-up audit was not done until October 2009 where only five grievances were audited, and only one was a verbal grievance. Despite the CAP, there is not adequate evidence that the issues were addressed and corrected as evidenced by one of the files at issue (from June) occurred six months after the CAP was initiated. (Deficiency #5) Section DTR Notice of Action to Enrollees Sec General requirements Sec (c) Timing of DTR Notice (A) (c) Previously Authorized Services (B) (c)(2) Denials of Payment (C) (c) Standard Authorizations (D) (d)(2)(i) Expedited Authorizations (E) (d)(1) Extensions of Time (F) (d) Delay in Authorizations Sec (b) Continuation of Benefits Pending Decision (b)(3). 42 CFR (b)(2) (contract section 8.3.1(B)(3)) requires that the DTR include a clear detailed description in plain language of the reasons for the action. In seven PTI files the attending health care professional submitted a formulary exception request. The DTR informed the enrollee the requested drug was a non-formulary drug and the enrollee should contact their doctor. The doctor was faxed the telephone notice of determination with the drugs 13

14 required in step therapy. DHS states the reason code used on the enrollee s notice is not sufficiently clear or understandable in response to a formulary exception request. The DTR requires additional free text information to state that the drug did not meet criteria or what drugs are required in step therapy. Consequently, PTI s denial notices do not provide the enrollee a clear detailed description in plain language of the reasons for the action. SCHA must use a more detailed notice, such as free text or different language to explain the denial. [Also see MS section 62M.05, subd. 3a(c)] (Deficiency #6) In addition, the content of the DTR must include the specific federal or state regulation that support or require the action. Ten CRG retroactive denials were reviewed. In these files a DTR is sent to the enrollee, however, in five files the DTR did not contain the specific state regulation that supported the denial. This was a systems problem found by SCHA in November of 2009 during the annual oversight audit. CRG subsequently corrected the problem and conducted audits of 100 percent of the DTR letters going out in December and all were found to be compliant. CRG continues to audit DTR letters on a monthly basis. Since the problem was identified and corrected prior to the MDH examination, this is not a deficiency. Section Internal Appeals Process Requirements Sec (b) Filing Requirements Sec (b)(2) Timeframe for Resolution of Standard Appeals Sec (b) Timeframe for Resolution of Expedited Appeals (A) (b)(3) Expedited Resolution of Oral and Written Appeals (B) (c) Expedited Resolution Denied (C) (a) Expedited Appeal by Telephone Sec (c) Timeframe for Extension of Resolution of Appeals Sec Handling of Appeals (A) (b)(1) Oral Inquiries (B) (a)(2) Written Acknowledgement (C) (a)(1) Reasonable Assistance. (D) (a)(3) Individual Making Decision (E) (a)(3) Appropriate Clinical Expertise [See Minnesota Statutes, sections 62M.06, subd. 3(f) and 62M.09] (F) (b)(2) Opportunity to Present Evidence (G) (b)(3) Opportunity to Examine the Case File (H) (b)(4) Parties to the Appeal (I) (b) Prohibition of Punitive Action Sec Subsequent Appeals 14

15 Sec (d)(2) and (e) Notice of Resolution of Appeals (A) (d)(2) and (e) Written Notice Content (B) (c) Appeals of UM Decisions (C) (c) and.408(d)(2)(ii) Telephone Notification of Expedited Appeals [Also see Minnesota Statutes, section 62M.06, subd. 2] Sec Reversed Appeal Resolutions (a)(3). 42 CFR (a)(3) (contract section 8.4.5(E)) states if the MCO is deciding an appeal regarding denial of a service based on lack of medical necessity, the MCO must ensure that the individual making the decision is a health care professional with appropriate clinical expertise in treating the enrollee s condition or disease, as provided for in Minnesota Statutes, sections 62M.06 and 62M.09 and 42 CFR (a)(3)(ii). Minnesota Statutes, section 62M.06, subdivision 3(f), uses the more stringent language of same or similar specialty that typically manages the medical condition, procedure or treatment under discussion. SCHA should use this language in its policy to be specific as to how to handle these appeals. In addition, the SCHA appeal policies state approve or overturn the appeal. The appeal is not approved or overturned. The decision to deny is upheld or overturned upon appeal. Language in all appeal policies must be changed to clearly and accurately reflect the appeal process. (Mandatory Improvement #4) (c). 42 CFR (c) (contract section 8.4.4) states the plan may extend the timeframe for resolution of appeals. The plan must justify the extension in a written notice to the enrollee with the reason for the extension. One CRG file had an extension letter, but the letter did not include the reason for the extension. Section (c) Maintenance of Grievance and Appeal Records Section (f) State Fair Hearings Section (f) Standard Hearing Decisions Section Continuation of Benefits Pending Resolution of State Fair Hearing Section Compliance with State Fair Hearing Resolution 15

16 Minnesota Rules, Part Records of Complaints Subp. 1. Record Requirements Subp. 2. Log of Complaints ( (a)) IV. Access and Availability Minnesota Statutes, Section 62D.124. Geographic Accessibility Subd. 1. Primary Care; Mental Health Services; General Hospital Services Subd. 2. Other Health Services Subd. 3. Exception Subd. 1. Minnesota Statutes, section 62D.124, subdivision 1, states that the MCO must ensure that the maximum travel distance or time is 30 miles or 30 minutes to the nearest provider. In order to ensure geographic accessibility, MS 62D.08, subdivision 5, states that any cancellation or discontinuation of any contract or agreement shall be reported to MDH. This should be added to policy Provider Network PR04 to assure MDH is notified of contract terminations and to ensure adequate accessibility. (Recommendation #3) There is good reporting to the quality committee regarding geographic access of the SCHA provider network, DentaQuest dental network and CRG chiropractic network. However, no report of geographic access of the pharmacy network was included. SCHA submitted documentation that geographic access of the pharmacy network was done for the Medicare network in 2009 by Prime Therapeutics, LLC, (PTI) (the pharmacy benefit manager). According to SCHA, the Medicaid and Medicare networks are very similar and they have chosen to review pharmacy access on a two year cycle. Medicaid network was reviewed in No gaps in the network were identified and SCHA monitors grievances related to pharmacy access throughout the year. SCHA may want to include the status of the pharmacy network when reporting on access and availability of its networks. (Recommendation #4) Minnesota Rules, Part Availability and Accessibility Subp. 2. Basic Services Subp. 5. Coordination of Care Subp. 6. Timely Access to Health Care Services Subp. 6. Minnesota Rules, part , subpart 6, states the HMO in coordination with its participating providers must develop and implement written appointment scheduling guidelines based on type of health care service. DHS has clearly spelled out required scheduling guidelines in its contracts. In the August 2009 cover letter to primary care clinics asking them to fill out a survey to assess availability of services, SCHA stated In compliance with NCQA requirements The scheduling requirements need to be in compliance with state law since in some cases they are different and more stringent than NCQA. By only referring to NCQA in the 16

17 letter, SCHA is sending an incorrect message to its providers. SCHA must clearly and accurately communicate to its providers the access and availability standards they are expected to follow. (Mandatory Improvement #5) Minnesota Statutes, Section 62Q.55. Emergency Services Met Not Met Minnesota Statutes, Section 62Q.121. Licensure of Medical Directors Minnesota Statutes, Section 62Q.527. Coverage of Nonformulary Drugs for Mental Illness and Emotional Disturbance Subd. 2. Required Coverage for Anti-psychotic Drugs Subd. 3. Continuing Care Subd. 4. Exception to formulary Minnesota Statutes, Section 62Q.535. Coverage for Court-Ordered Mental Health Services Subd. 1. Mental health services Subd. 2. Coverage required Minnesota Statutes, Section 62Q.56. Continuity of Care Subd. 1. Change in health care provider; general notification Subd. 1a. Change in health care provider; termination not for cause. Subd. 1b. Change in health care provider; termination for cause Subd. 2. Change in health plans Subd. 2a. Limitations Subd. 2b. Request for authorization Subd. 3. Disclosures 17

18 V. Utilization Review Utilization File Review File Source # of Service Authorization Denials Reviewed # of Clinical Appeals Reviewed SCHA 2* 21 MMSI 15 0 DentaQuest (formerly Doral 10 5 Dental) PrimeTherapeutics 8 0 (pharmacy services) CRG (chiropractic services) 10** 5 Totals Please note cross-referenced findings under Section III, Grievance and Appeal Systems, of this report. *In 2009, SCHA performed some UM internally. MDH reviewed all ten denials; however four of these were related to Mental Health Targeted Case Management (MHTCM). Since DHS is still determining the MCO standards related to MHTCM services, MDH disregarded those denial files and will report information to DHS only. In addition, four files were benefit determinations, which are not subject to the requirements of 62M. SCHA resolves clinical appeals for MMSI and PrimeTherapeutics issued denials. **SCHA and CRG do not perform prior authorization for chiropractic services, but CRG audits files retrospectively. CRG resolves clinical appeals on behalf of SCHA. In the 45 denial files and 31 clinical appeal files, MDH had the following findings: Minnesota Statutes, Section 62M.04. Standards for Utilization Review Performance Subd. 1. Responsibility on Obtaining Certification Subd. 2. Information upon which Utilization Review is Conducted Subd. 3. Data Elements Subd. 4. Additional Information Subd. 5. Sharing of Information Minnesota Statutes, Section 62M.05. Procedures for Review Determination Subd. 1. Written Procedures Subd. 2. Concurrent Review Subd. 3. Notification of Determinations Subd. 3a. Standard Review Determination (a) Initial determination to certify (10 business days) (b) Initial determination to certify (telephone notification) 18

19 (c) Initial determination not to certify (d) Initial determination not to certify (notice of rights to internal appeal) Subd. 3b. Expedited Review Determination Subd. 4. Failure to Provide Necessary Information Subd. 5. Notifications to Claims Administrator Subd. 1. Minnesota Statutes, section 62M.05, subdivision 1, states the plan must have written procedures to ensure that reviews are conducted as required in Minnesota Statutes, chapter 62M. SCHA performs UM for certain programs and delegates the remainder. As part of this Quality Assurance Examination, SCHA provided a mix of SCHA and MMSI UM policies/procedures. During the exam, SCHA also stated that it adopts the policies/procedures of MMSI. However neither SCHA s nor MMSI s were a complete set of policies/procedures. Since both entities perform utilization management for SCHA enrollees, both SCHA and MMSI must each have a complete set of UM policies/procedures to which SCHA and MMSI will comply. (Mandatory Improvement #6) In reviewing the policies and procedures provided, MDH had the following findings: Minnesota Statutes, section 62M.05, subdivision 3a(c), states, When an initial determination is made not to certify, notification must be provided by telephone within one working day after making the determination to the attending health care professional and hospital. SCHA policy/procedure, UM 03 page 3, states, The requesting provider s office and member will be notified for approvals promptly and for denials by telephone within one business day of decision. The policy/procedure doesn t mention one day telephone notice to the hospital. The procedure further states, If the requested service or procedure is denied, the member and requesting provider are informed in writing. The MMSI policy/procedure also states the notice will be given to the provider. In the circumstance that the provider is a DME or PCA vendor, the requesting provider may be the vendor and not the attending health care professional. In practice, MMSI correctly gave fax notice to the attending health care professional and the provider/vendor. SCHA and MMSI policy/procedures should be revised to consistently specify which provider receives oral and written notices. Minnesota Statutes, section 62M.05, subdivision 3a(c), states that, upon request, the health plan must provide the provider or enrollee with the criteria used to make the determination of the necessity, appropriateness, and efficacy of the health care service and identify the database, professional treatment parameter, or other basis for the criteria. The DTR includes the offer; however the policy/procedure does not include the specifics of the requirement. Minnesota Statutes, section 62M.05, subdivision 3b(b), states that notice of an expedited initial determination to either certify or not to certify must be provided to the hospital, the attending health care professional, and the enrollee as expeditiously as the enrollee's medical condition requires, but no later than 72 hours from the initial request. SCHA policy/procedure, UM03 page 3 states no longer than 72 hours after receiving the necessary information upon which to determine the request, rather than from receipt. The policy/procedure should state that the 72 hours begins upon receipt of the request. 19

20 Minnesota Statutes, section 62M.05, subdivision 3b(b), states that when an expedited initial determination is made not to certify, the plan must also notify the enrollee and the attending health care professional of the right to submit an expedited appeal. The MMSI policies/procedures do not address the right to file an expedited appeal. Minnesota Statutes, section 62M.05, subdivision 4, states that the plan must have written procedures to address the failure to provide the necessary information for review. If the information is not released, the plan may deny certification in accordance with its own policy. SCHA did not provide a lack of information policy. MMSI provided a lack of information procedure that when combined with its UM policy, includes the correct information. Since SCHA is currently performing some UM for specific programs, SCHA must also have a written lack of information procedure. SCHA has a benefit exception policy/procedure describing the request form and the implementation of an internal review panel. In one file, SCHA completed the exception request form. However, there is no documentation of an investigation or panel review of the request consistent with SCHA benefit exception policy/procedure. The policy/procedure must be revised to state SCHA s actual practice and SCHA must follow its policy/procedure. (Mandatory Improvement #7) Subd. 3a(c). Minnesota Statutes, section 62M.05, subdivision 3a(c), states that the written notice must include the principal reason or reasons for the determination. In seven PTI files the attending health care professional submitted a formulary exception request. The DTR informed the enrollee the requested drug was a non-formulary drug and the enrollee should contact their doctor. The doctor was faxed the telephone notice of determination with the drugs required in step therapy. The reason (code) used on the enrollee s notice is not sufficiently clear or understandable in response to a formulary exception request. The DTR requires additional free text to state that the drug did not meet criteria or what drugs are required in step therapy. Consequently, PTI s DTR notices do no provide the enrollee a clear detailed reason for the determination. (Deficiency #6) [Also see (b)(2), (contract section 8.3.1(B)(3)), DTRs] Minnesota Statutes, Section 62M.06. Appeals of Determinations not to Certify Subd. 1. Procedures for Appeal Subd. 2. Expedited Appeal Subd. 3. Standard Appeal (a) Appeal resolution notice timeline (b) Documentation requirements (c) Review by a different physician (d) Time limit in which to appeal (e) Unsuccessful appeal to reverse determination (f) Same or similar specialty review (g) Notice of rights to External Review Subd. 4. Notifications to Claims Administrator 20

21 Subd. 1. Minnesota Statutes, section 62M.06, subdivision 1, states the plan must have written procedures for UM appeals. Minnesota Statutes, section 62M.06, subdivision 3(e), states that if an attending health care professional or enrollee has been unsuccessful in an appeal of the determination the plan must provide the following: (1) a complete summary of the review findings; (2) qualifications of the reviewers, (3) the relationship between the enrollee's diagnosis and the review criteria used, including the specific rationale for the reviewer's decision. SCHA s policy/procedure CA 07 does not include these items. (Mandatory Improvement #8) Subd. 3 (a). Minnesota Statutes, section 62M.06, subdivision 3(a), states the written notice of resolution must be made within 30 days from receipt. If the plan cannot make a determination within 30 days, it may take up to 14 additional days. The plan must inform the enrollee and attending health care professional, in advance, of the extension and the reasons for the extension. SCHA policy/procedure doesn t state the notice is also sent to the attending health care professional or that the extension should be issued in advance. One CRG file had an extension letter, but the letter did not include the reason for the extension. [Also see (c), DHS 8.4.4] Minnesota Statutes, Section 62M.08. Confidentiality Met Not Met Minnesota Statutes, Section 62M.09. Staff and Program Qualifications Subd. 1. Staff Criteria Subd. 2. Licensure Requirement Subd. 3. Physician Reviewer Involvement Subd. 3a. Mental Health and Substance Abuse Review Subd. 4. Dentist Plan Reviews Subd. 4a. Chiropractic Reviews Subd. 5. Written Clinical Criteria Subd. 6. Physician Consultants Subd. 7. Training for Program Staff Subd. 8. Quality Assessment Program Subd. 3(a). Minnesota Statutes, section 62M.09, subdivision 3(a), states a physician (or the health care professional with the appropriate expertise) must review all cases in which the plan has concluded that a determination not to certify for clinical reasons is appropriate. In DentaQuest files, it is the practice for UM staff to document the electronic notes with the dentist s initials and determination. SCHA staff also documents the Medical Director s decision in the electronic notes. However, the preferred method of documentation is a unique electronic identifier in the electronic file notes entered by the professional making the determination. Alternatively, the professional making the determination may document the decision with a 21

22 handwritten signature and date, or the initialed and dated stamp of that person. (Recommendation #5) Subd. 3a. Minnesota Statutes, section 62M.09, subdivision 3a, states a peer of the treating mental health or substance abuse provider or a physician must review denials for mental health or substance abuse services. SCHA policy/procedure UM01 states denials can only be made by appropriately licensed professionals. MMSI doesn t detail appropriately licensed professionals. MDH found that all MMSI mental health initial denials were performed by board-certified psychiatrists. The MMSI policy/procedure must identify appropriately licensed professionals who may review denials for mental health or substance abuse services, including 2009 amendments to this statute. (Mandatory Improvement #9) Subd. 5. Minnesota Statutes, section 62M.09, subdivision 5, states the organization s decisions must be supported by written clinical criteria and review procedures. To ensure consistent application of clinical criteria and review procedures, the plan must perform inter-rater reliability testing. SCHA began to perform some UM reviews internally in It has not yet performed inter-rater reliability testing, but will begin in MMSI performs most medical UM review for SCHA enrollees. SCHA policies/procedures do not address inter-rater reliability. SCHA provided a one page description of an MMSI inter-rater reliability process from November 2009 stating MMSI UM staff performed at 94 percent reliability in the reviewed files. This description is not sufficient documentation of an active inter-rater reliability assessment process. The description is undated. It does not appear as part of another standard report. No opportunities for improvement are identified. SCHA and its delegates must establish procedures for inter-rater reliability, implement and report inter-rater reliability and identify areas of opportunity for continued clarification and improvement. (Mandatory Improvement #10) Minnesota Statutes, Section 62M.10. Accessibility and On-Site Review Procedures Subd. 1. Toll-free Number Subd. 2. Reviews during Normal Business Hours Subd. 7. Availability of Criteria Minnesota Statutes, Section 62M.11. Complaints to Commerce or Health Minnesota Statutes, Section 62M.12. Prohibition on Inappropriate Incentives 22

23 Minnesota Statutes, Section 62D.12. Prohibited Practices Subd. 19. Coverage of service VI. Recommendations 1. To better comply with Minnesota Rules, part , subpart 6, SCHA should develop policies/procedures for review of delegate reports, including documentation of the review and approval of the delegate s UM Program description. 2. To better comply with Minnesota Rules, part , subpart 9, SCHA should indicate in its policy the suggested timeframe guidelines in which quality of care cases should be investigated. 3. To better comply with Minnesota Statutes, section 62D.124, subdivision 1, in order to assure adequate geographic accessibility, SCHA should add to its provider network policy the requirements of Minnesota Statutes, section 62D.08, subdivision 5, which states that any cancellation or discontinuation of any contract or agreement must be reported to MDH. 4. To better comply with Minnesota Statutes, section 62D.124, subdivision 2, SCHA should include the status of its pharmacy network when reporting on access and availability of its networks. 5. To better comply with Minnesota Statutes, section 62M.09, subdivision 3(a), the professional making a determination to deny a service authorization for clinical reasons should personally document the decision in the member s record. VII. Mandatory Improvements 1. To comply with Minnesota Rules, part , subpart 11, SCHA must revise its policies/procedures, CR 01, Credentialing and CR 03, Organizational Credentialing, to clarify the following: SCHA s requirement of primary source verification. SCHA s process to delegate, what may be delegated and how the plan decides to delegate, including those entities with whom SCHA will delegate. SCHA s process to notify practitioners of their rights. SCHA s process to ensure that verification of required items is within the prescribed time limits. 2. To comply with Minnesota Rules, part , subpart 13, SCHA must revise its policy and practice such that they are able to show evidence of ongoing evaluation of medical records to assure that medical records are maintained with timely, legible and accurate documentation as well as containing the necessary information. 23