Bi-annual Stakeholder Meeting. May 8, 2013

Transcription

1 Bi-annual Stakeholder Meeting May 8,

2 May 8, am to 12 pm Main Library Bi-annual Stakeholder Meeting Agenda Welcome and Introductions Anita Castleberry, DMS Updates to Payment Improvement Initiative F. Lee Clark, DHS Inspection of Care Policy revisions Robbie Nix, DMS Inspection of Care Revisions to report templates Jennifer Brezee, ValueOptions Inspection of Care New CPT codes July 1- Jennifer Brezee, ValueOptions Retrospective Reviews Jennifer Brezee, ValueOptions Question and Answer Session 2 Feedback and additional questions can be sent to ARInspectionofCare@valueoptions.com

3 Members of the IOC focus group ValueOptions Kerri Brazzel Provider Relations Jennifer Brezee Clinical Services Manager Patricia Gann Project Director Dr. Justin Hunt Medical Director Nicole May Executive Director Melissa Ortega Project Director Miranda White Retrospective Team Lead State of Arkansas Anita Castleberry DMS Vivian Jackson DMS Dr. Laurence Miller DMS Robbie Nix DMS Marilyn Strickland DMS Paula Stone DBHS Frank Vega DBHS Dixie Wallace DMS Provider Representatives Joe Alford, CEO BirchTree Joyce Cloud, CEO The Pointe Outpatient Services Chad Cornelius, Interim Administrator Methodist Jannie Cotton, CEO Professional Counseling Associates Pam Dodson, Clinical Director Ascent Jim Gregory, CEO Counseling Clinic Ryan Martin, Director of Outpatient Services Vista Health Carol Moore, Clinical Director Alternative Opportunities/DaySpring Lee Roberson Koone, Director of Children Services Counseling Associates Jason Turner, Director of Quality Assurance Families Inc 3

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7 Updates on Payment Improvement Initiative 7

8 Arkansas Payment Improvement Initiative (APII) ADHD Episode of Care Statewide Webinar May 13,

9 Contents ADHD episode clinical foundation and version 1.0 structure Detailed version 1.0 episode design decisions Historical data for the ADHD episode based on version 1.0 design 9

10 May 20, pm 5pm ADHD Webinar 2 ADHD Certifications & Reports

11 For more information talk with provider support representatives Online More information on the Payment Improvement Initiative can be found at Further detail on the initiative, PAP and portal Printable flyers for bulletin boards, staff offices, etc. Specific details on all episodes Contact information for each payer s support staff All previous workgroup materials Phone/ Medicaid: (in state) or (local and out of state) or ARKPII@hp.com Blue Cross Blue Shield: Providers , direct to EBI , APIICustomerSupport@arkbluecross.com QualChoice: , providerrelations@qualchoice.com 11

12 Episodes Update PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE For Medicaid, work has occurred on 15 Episodes, with 5 having gone live Wave 1 Wave 2 Wave 1a Wave 1b Wave 2a Wave 2b Wave 2c (not started) Episode Legislative Review Reporting Period Start Date 1 Upper Respiratory Infection Spring 2012 July Attention Deficit Hyperactivity Disorder (ADHD) Spring 2012 July Perinatal Spring 2012 July Congestive Heart Failure November 2012 December Total Joint Replacement (Hip & Knee) November 2012 December Colonoscopy May 2013 Q2 CY Cholecystectomy (Gallbladder Removal) May 2013 Q2 CY Tonsillectomy May 2013 Q2 CY Oppositional Defiance Disorder (ODD) May 2013 Q2 CY Coronary Artery Bypass Grafting (CABG) July 2013 Q3 CY Percutaneous Coronary Intervention (PCI) 12 Asthma July 2013 Q3 CY Chronic Obstructive Pulmonary Disease (COPD) 14 ADHD/ODD Comorbidity July 2013 Q3 CY Neonatal Q3 CY 2013 H2 CY 2013 Undecided Q Undecided Q Undecided Q Undecided Q Participation includes development and rollout of episode In Development Live Seeking clinical input Pending legislative review Multipayer Participation 1 12

13 13 Revisions to Policy

14 Proposed revision to IOC policy *see full policies under Presentations Section of IOC Focus Group on arkansas.valueoptions.com 14

15 Proposed revision to IOC provider report and upcoming changes to the tool IOC OP Report IOC OP Tool *see full report examples and the draft of the tool under Presentations Section of IOC Focus Group on arkansas.valueoptions.com 15

16 Retrospective Reviews 16

17 Timeline for Retrospective Reviews Review completed by ValueOptions within 45 calendar days Adverse findings No adverse findings Adverse determination letter sent to provider and beneficiary. DMS notified of findings Determination letter sent to provider. 17

18 Reconsiderations and Appeals ValueOptions sends provider/ beneficiary Notification of Adverse Findings Reconsideration is submitted within 30 days Retro reviewed by second psychiatrist Reconsideration is not submitted Recoupment sent to HP Provider or beneficiary have the option to file an appeal with the Office of Hearings and Appeals within 30 days after the initial denial or reconsideration denial 2 nd psychiatrist s upholds initial denial 18

19 Results Retrospective Review Results *see Retrospective Review Results under Presentations Section of IOC Focus Group on arkansas.valueoptions.com 9

20 Results so far 1 st Quarter (January 15, 2012 to March 30, 2012) 50 beneficiaries 25 Outpatient RSPMI Providers represented 3 Reconsiderations were submitted, all three were overturned upon reconsideration 14 beneficiaries received recoupment for a total of 39 units of services 2nd Quarter (April 1, 2012 to June 30, 2012) 100 beneficiaries 27 Outpatient RSPMI Providers represented 1 Reconsideration was submitted, the denial was upheld upon reconsideration; but overturned upon Appeal 29 beneficiaries received recoupment for a total of 122 units of services 20

21 Results so far 3 rd Quarter (July 1, 2012 to Sept. 30, 2012) 150 beneficiaries 30 Outpatient RSPMI Providers represented 5 Reconsiderations were submitted, 3 were upheld and 2 were overturned upon reconsideration 80 beneficiaries received recoupment for a total of 188 units of services 4 th Quarter (Oct. 1, 2012 to Dec. 31, 2012) 200 beneficiaries 33 Outpatient RSPMI Providers represented 37 total # of RSPMI providers represented in 3 quarters 21

22 Trends Periodic Review of Master Treatment Plan Psychiatric Diagnostic Assessment YOQs 22

23 90885 Periodic Review of MTP AR RSPMI Medicaid Regulations SERVICE: Periodic Review of Master Treatment Plan DEFINITION: The periodic review and revision of the master treatment plan, in cooperation with the beneficiary, to determine the beneficiary's progress or lack of progress toward the master treatment plan goals and objectives; the efficacy of the services provided; and continued medical necessity of services. This includes a review and revision of the measurable goals and measurable objectives directed at the medically necessary treatment of identified symptoms/mental health condition, individuals or treatment teams responsible for treatment, specific treatment modalities, and necessary accommodations that will be provided to the beneficiary, time limitations for services, and the medical necessity of continued services. Services are to be congruent with the age, strengths, necessary accommodations for any disability, and cultural framework of the beneficiary and his/her family. 23

24 Medical Necessity Starting July 1, 2013 When it is determined by the ValueOptions physician that Medical Necessity for RSPMI services has not been established during the Retrospective Review, services billed outside the Retrospective Review time frame will be subject to recoupment. The recoupment will go back to the point when Medical Necessity was not met, but not prior to January 15, *See AR Medicaid RSPMI Manual for reconsideration and appeal process. 24

25 Thank You Presented by Jennifer Brezee, LCSW Clinical Services Manager 25

26 Additional contacts Melissa Ortega, LCSW Project Director Nicole May, BSN, RN Executive Director Miranda White, LMSW Retrospective Review Team Lead 26