ALAMEDA ALLIANCE FOR HEALTH BOARD OF GOVERNORS REGULAR MEETING. March 11, :00 pm 2:00 pm 1240 South Loop Road, Alameda, CA

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1 ALAMEDA ALLIANCE FOR HEALTH BOARD OF GOVERNORS REGULAR MEETING March 11, :00 pm 2:00 pm 1240 South Loop Road, Alameda, CA SUMMARY OF PROCEEDINGS Board Members Present: Jane Garcia, Bertram Lubin, MD., Evan Seevak, MD., Marty Lynch Julian Ray Davis, Jr., MD., Nicholas Peraino, Rollington Ferguson, MD. Excused: Aarondeep Basrai, Pharm.D., David Werlin, Delvecchio Finley, Wilma Chan Unexcused: Alex Briscoe Alliance Staff Present: Scott Coffin, Matt Levin, Matt Woodruff, Neal Jarecki, Debbie Rieger, Michael Griffis, MD, Tiffany Cheang, Elia Gallardo, Craig Kellar AGENDA 1. CALL TO ORDER J. Garcia The regular board meeting was called to order by J. Garcia at 12:10 pm. A board quorum was established by a simple majority for the meeting. 2. AGENDA APPROVAL OR MODIFICATIONS J. Garcia J. Garcia shared the following modifications to the agenda. Items 8d. Finance committee board appointments and 8e. Strategy committee board appointments were delayed until the next meeting. 3. INTRODUCTIONS J. Garcia Introductions were made for all those present including the public audience. 4. PUBLIC COMMENTS (NON-AGENDA S)

2 J. Garcia J. Garcia requested any comments from the public in regards to the agenda. There were no comments. 5. CEO UPDATE S. Coffin S. Coffin provided an update on the recent claims payment issue with the HealthSuite system. The total estimated impact on the claims is $30M, of which $26M or 87% has already been paid for the incorrectly paid claims. The remaining claims will be paid by the end of this month. The impact of this claims issue was greatly diminished by the manual interventions of the Alliance team. The adjudication rate dropped from 80% to 50%. Since expenses have been accruing based on historical trends, there is no financial impact. The financial performance reflects a YTD net income favorable to budget at $22M, not $30M as stated in the CEO report. Projected estimates for end of this fiscal year to be favorable at $50M. Medical expense for January was higher than forecasted due to higher inpatient utilization. The financial reserves policy (TNE policy) will be presented to the board next month. DMHC remote monitoring is tracking toward transition on October 31, The Alliance has 16 performance milestones in the corrective action plan which includes claims processing, member access, provider disputes, financial solvency, compliance, and operational metrics. The new Chief Information Officer (CIO), Aman Bhasin, will start on April 4 th. He will be relocating from New Jersey. This completes the hiring for the executive management team. The Alliance s 20 th Anniversary celebration will be held on April 8 th following the regular board meeting. It will be a community celebration including representatives from DMHC and other community partners. M. Lynch inquired if the claims issue affected private physicians in addition to hospitals. S. Coffin responded that the majority, over twothirds (2/3), of the claims are inpatient claims. M. Lynch s concern was AAH BOG 3/11/ of 13

3 6. CONSENT CALENDAR for the provider network in handling this issue. Efforts in communication to providers have been made to those who are impacted and to provide the timing of action steps being taken to resolve the issue. J. Garcia J. Garcia requested a motion to approve the one (1) item on the Consent Calendar: Approval of Minutes 7.a.1. BOARD BUSINESS STAFF PRESENTATIONS - OPERATIONS M. Woodruff M. Woodruff provided an update on facilities and security. Quotes and pricing have been obtained to renovate the lobby in the main office and also at the Ed Roberts Center (ERC). Cameras and additional card readers have also been installed and monitored. Doors have been installed according to Americans with Disabilities Act (ADA) regulations and a review of the exterior grounds is being conducted for lighting and safety. Policies and procedures (P&Ps) have been put into place for visitors and guests. M. Woodruff presented a diagram of the 1240 South Loop Road office building. Twenty percent (20%) of the total 55,000 sq. ft. is not being used as office space. Approximately 7,000 sq. ft. are currently used as warehouse space. An existing white room is currently empty and the operations team is in the process of getting quotes to convert this to office space. Currently the building is worth approximately $6.5M - $7M (per the internet). The estimate to convert to office space is $1.7M. E. Seevak inquired what was stored in the warehouse and if there was a consideration of leasing the space. M. Woodruff responded that it is generally empty except for old files that are in the process of being scanned and small storage areas for IT and Communications. He will look into an alternative option of leasing the space. Eventually the Alliance would like to have all staff in one place; however, probably only half would be moved over to the main office. Motion: R. Davis Second: S. Coffin Motion passed unanimously AAH BOG 3/11/ of 13

4 R. Ferguson inquired as to the current cost of the lease for the two (2) units at the 1320 building and how many people are in each unit. M. Woodruff responded the cost is $22 per sq. ft. for an annual cost of $450,000. The term of the lease is five (5) years which was renewed last February. S. Coffin added that there is a focus on immediate maintenance and repair needs to provide employees safety and a reasonable work environment. Future discussion will include ideas to consolidate office space based on operations and consider available alternatives in Alameda County. Part of the strategic planning includes an assessment of the current office space. The Provider Relations call center is fully staffed and handling an average of 5,000 calls a month. The highest volume of calls is related to claims. A caller survey and Secret Shopper program will be implemented in the second quarter to test the training and skills of the call center representatives. Field Representatives are assigned areas based on zip code. During the first quarter they have focused on visiting all directly contracted providers with the exception of dialysis centers and laboratories. They have completed 188 visits during the months of January and February. They have received both positive and negative feedback from providers during these visits including opportunities to participate in community health fairs. The field visits uncovered areas for provider training for transportation, interpreter, and case management services. The most concerns raised by providers were in regard to issues with the implementation of the claims system configuration and their understanding of the Medi-Cal guidelines paying contracted rates. The new claims system has experienced difficulty with matching claims with the medical authorization system causing incorrect denials. Issues were identified when the provider contracts did not reflect the correct services. Contract amendments were made and the claims were correctly paid to the providers. AAH BOG 3/11/ of 13

5 Contract amendments for Skilled Nursing Facilities (SNF) are being processed and a group meeting will be scheduled. The amendments will address the contacting issue which currently includes everything in a per diem rate including high cost drugs. The amendment will separate the different costs into different tier levels. M. Lynch inquired if the Alliance is auditing in such a way that consumer rights to get the services they need are being protected? M. Woodruff responded that the Alliance has had placement issues with the SNF, but for the most part they have been seeing members. In addition, workflow issues are being addressed. M. Lynch restated his question as to how the Alliance assures quality when it passes through these contracted responsibilities especially for the vulnerable populations like the nursing homes. Is there a way the Alliance can ensure if it contracts for bundled services that consumers are being protected in the delivery of all those services? R. Ferguson responded that it is governed by Medicare. The quality of care that is expected in the nursing home is decided by Medicare through their audits. M. Griffis MD added that nursing homes are licensed by the state. Through the appeals and grievances process the Alliance monitors nursing home denials. Other considerations to monitor are readmission rates. The Alliance currently has a dedicated case manager who manages members in nursing homes and no quality issues have been identified to date. Currently, approximately 80% of the claims and authorization issues in HealthSuite have been resolved. The issue remains and IT is working on the process to match up the claims with the authorization system (TruCare) and delegated providers. A tracking process has also been implemented for claims that are received and scanned into the system. The system vendor, RAM Technologies, provided two (2) fixes for the claims matching issue and both failed during testing. A third fix is currently in testing which should be completed this week. Without the AAH BOG 3/11/ of 13

6 system fix in place auto adjudication rates have fallen from 84% to 56%. The interest payments to providers for the recent $20M - $30M claims payments issue increased beginning in February. The interest on these claims payments is currently $104,000. J. Garcia inquired as to the impact on the budget? N. Jarecki responded if the Alliance does not pay providers correctly it has an obligation, a liability. The finance team ensures month end financial statements reflect accurately what will be paid as shown in the January financial statements. Until the problem is resolved, the liabilities will be higher but that ensures that the profit and loss results are accurate. Monthly and/or quarterly Joint Operations Meetings (JOM) are scheduled with delegated providers, hospitals, and other vendors. A dedicated Senior Provider Representative is responsible for organizing these meetings in order to maintain good communications with providers in the community. The Alliance will be collecting new demographic information from providers to implement the new regulatory requirement SB 137 which is due on March 31 st for testing in the second quarter and implementation on July 1 st. This process will help in auditing and cleaning up of the credentialing data base and provider repository. A $25 gift card will be offered as an incentive for providers to provide this information. M. Lynch inquired if the 5,000 calls to the call center will decline once HealthSuite issues are resolved? M. Woodruff responded that those are two (2) different issues. The provider call volume will probably not change as claims will always be a main concern. Member services department has increased their bilingual staff and is now divided into five (5) different teams with separate supervisors. Some of the supervisors will be making outbound calls within the next couple weeks. The service level has averaged 92.5% for January and February. AAH BOG 3/11/ of 13

7 The Member Services Customer Satisfaction Survey began in February. Six percent (6%) of the members participated in the survey. Overall results were 98% satisfied, 1.3% neutral, and 0.7% dissatisfied. The Mystery Shopping Project will begin this month. The current call center vendor, Ansafone, will be making five (5) calls per member service representative per month to test the member service representative s knowledge. S. Coffin added that the current service level of call response of 92.5% exceeded the targeted service level of 80% by over 12%. E. Seevak inquired why Credentialing is under Operations now when it was previously under the CMO. M. Woodruff responded that this is currently under discussion with Dr. Griffis. M. Lynch also inquired regarding confirmation whether or not the board needs to approve a list of providers submitted by the credentialing committee as they have done in the past. Does the board have any legal responsibility to approve the providers? M. Levin was concerned about the provider s confidentiality regardless if it was discussed during closed session. Instead, an invitation was offered to the board to join the credential committee meetings for details. B. Lubin inquired if it is in the bylaws that the board is responsible for approving the credential committee recommendations? M. Levin said he will look into what is legally required. R. Ferguson shared that the ACCMA does a similar process to approve a list of physicians. He requested to propose a motion for this process; however, board counsel J. Melching advised that a motion cannot be put forward since it was not on the agenda for today, but it can be a future agenda item. S. Coffin said he will make this an action item to research and bring back options for discussion at the next meeting. M. Woodruff shared a claims quality control process. Quality checks on claims will be done up front working with medical management using clear definitions and workflow processes to identify claims that can t be M. Levin to research the bylaws and process for approval of the physicians submitted by the Credentialing Committee by the board. Bring back options for discussion at next meeting. AAH BOG 3/11/ of 13

8 paid to be denied, pended, or suspended for medical review. 7. a.2. BOARD BUSINESS STAFF PRESENTATIONS COMPLIANCE M. Levin M. Levin reported that the Alliance received the audit close-out letter from DHCS which indicated that out of 83 findings, nine (9) are remaining and provisionally closed. Seven (7) of the remaining findings are expected to be corrected by the end of March. The remaining two (2) findings are related to Case and Disease Management. S. Coffin and M. Levin were asked to be part of a group to work with DHCS to refine their audit plans and improve the process. J. Garcia inquired as to how this affects the remote monitoring. M. Levin responded that DMHC s report has not been received. B. Lubin inquired if there is a healthcare ranking system or process that would convey how the Alliance is doing? As an example, many still don t know that The Alliance is no longer under conservatorship. M. Levin responded the state does not have a mechanism to provide reports about medical audits. Once the report is made public the Alliance can consider ways to communicate the results through a press release. A provider newsletter was raised as an option by J. Garcia. M. Woodruff shared that the provider consensus was to receive more targeted communications for specific issues via versus fax blasts. They are in the process of collecting addresses. E. Seevak agreed that was good feedback from the providers. A financial audit is scheduled with DMHC on April 4 th. A mock audit was conducted. Areas identified for improvement are pre-adjudication and quality control of claims payments. The monthly audit results were shared for various departments. One continuing issue is the interest payments around provider disputes. This will require alignment of the claims and Provider Dispute Resolution AAH BOG 3/11/ of 13

9 (PDR) departments to ensure proper payment. 7. a.3. BOARD BUSINESS STAFF PRESENTATIONS FINANCE N. Jarecki N. Jarecki reported that the monthly and YTD net income is significantly ahead of budget due to the growing MCE population. The Medi-Cal profitability is broken out by five (5) categories of aid: MCE population, children, adults, breast and cervical cancer, and dual eligible members. Most all have a current month and YTD net income except for the SPD population which shows a YTD net loss of $2.8M. The Medical Loss Ratio (MLR) is 86.6% in contrast the SPD MLR which is considerable higher at 93.5%. This tracks similarly with other health plans. The Tangible Net Equity (TNE) is $115M or 573%. This measures the financial viability of the plan. During the month of January the Alliance incurred over $800K in capital investments to upgrade facilities and IT hardware. R. Ferguson inquired about the amount spent on medications. While the TNE is great, is the Alliance denying medications to members? N. Jarecki referred to the pharmacy expense in the profit and loss statement which shows that it has been favorable to budget for both current month and fiscal YTD. R. Ferguson continued to inquire about other medications (e.g. diabetes, heart failure) that continue to be denied. M. Griffis MD responded that medications requiring authorizations are generally dropping. Medi-Cal requires authorizations be approved or denied within 24 hours. If the Alliance needs to reach out to providers for information and does not receive a timely response it must be denied for lack of medical justification. The Alliance must adhere to the 24 hour turnaround time and must provide education and outreach to providers to ensure necessary information is received. R. Ferguson is concerned that other providers may be having the same problems of not being able to get medications. He gave the example of limited medications for diabetes patients with kidney disease. They are not on the formulary. M. Griffis MD is willing to review the authorization S. Coffin AAH BOG 3/11/ of 13

10 requirements for those diabetes medications with R. Ferguson offline after the meeting. S. Coffin suggested to M. Woodruff to poll the experience of the other providers. M. Lynch inquired about a downturn in hospitalization of the SPD category which is a good thing. Is there something new that has been instituted to create that downturn? M. Griffis responded the February data shows that there are still 120 authorizations still open since the report was generated for the board of governors meeting which takes place in the earlier part of the month. J. Garcia requested a motion to approve the January financial report. 7. b. BOARD BUSINESS STAFF PRESENTATIONS VICE CHAIR APPOINTMENT J. Garcia J. Garcia announced there was one (1) nomination for the position of Vice Chair of the board. As there were no other nominations or volunteers, J. Garcia moved to elect Marty Lynch as the Vice Chair of the board. 7. c. MEMBER BOARD APPOINTMENTS S. Coffin S. Coffin reported that there were five (5) community members from the Member Advisory Committee (MAC) who applied for the member board positions. He reviewed the bylaws and the statements and background of the applicants that were interviewed. The applicants were Feda Almaliti, Melinda Mello, Venecia Allen, Will Scott and Linda Straub. S. Coffin moved that Mr. Will Scott and Ms. Feda Almaliti be appointed to the Alameda Alliance Board of Governors in the member seats. B. Lubin inquired about a list of the tenure for current board members and the tenure process. M. Levin responded that the current bylaws state a four (4) year term from appointment. If there is no re-election or members do not remove themselves, they remain in that seat until they retire or someone else is appointed. E. Seevak inquired if the requirements for member board seats could include being a child of a Motion: R. Ferguson Second: E. Seevak Approved Unanimously Motion: J. Garcia Second: R. Ferguson In Favor: 6 Opposed: 0 Abstain: 1 Motion: S. Coffin Second: M. Lynch Approved Unanimously suggested to M. Woodruff to poll the experience of the other providers. M. Levin will AAH BOG 3/11/ of 13

11 member, such as a caregiver. M. Levin will consider amending the bylaws to add a child of a member as a member board member. S. Coffin clarified that the member seats that were just approved are for one (1) year term. S. Coffin confirmed that the new board members will be going through a board training which will include understanding the fiduciary responsibilities as well as an overview of Medi-Cal. This is training is a requirement under the conservatorship exit and remote monitoring. M. Levin added that as they are reviewing the bylaws they can consider extending the member seat term. consider amending the bylaws to add a child of a member, as a member board member. He will also consider extending the member seat term. 8. BOARD MEMBER REPORTS J. Garcia J. Garcia reported that S. Coffin has been asked to prepare a report of the Alliance during his tenure which will be part of his evaluation. The Vice Chair, Marty Lynch, and the other committee chairs (once appointed) will be part of the evaluation committee. The report will be sent out to all the board members for feedback. J. Garcia along with M. Lynch and N. Peraino met with Alliance staff last month. Three (3) people were present. Comments received at the meeting were not related to a previous letter that was received by the board. Major points that were identified included improving communication and processes. Any future complaints will be directed to Human Resources to handle. J. Garcia made a request to board members to complete the online HIPAA Privacy and Security training if they haven t already done so. Last month there were four (4) board members who had not completed the training. A list of outstanding board members who have not completed the training will be sent to S. Coffin. 9. STAFF ADVISORIES ON BOARD BUSINESS FOR FUTURE MEETINGS M. Griffis MD M. Griffis reviewed the operations in his role as CMO and has taken over the clinical oversight for the grievance and appeals process as well as the PDR process, using this as a barometer to focus on various aspects L. Fong to send list of outstanding board members who have not completed the HIPAA training to S. Coffin. AAH BOG 3/11/ of 13

12 in UM and case management. In regards to UM management, his focus will be getting a more detailed understanding of denial patterns and turnaround times including urgent timeframes. Using analytics, more information in these areas is expected next month. S. Coffin T. Cheang S. Coffin shared a reminder $1.2M for Pay for Performance and $800K for Grants were approved. T. Cheang provided an update on the grants program. There has been a call for community members to join the grant committee. A fax blast was sent to all providers on March 3 rd. Nominations are due on March 16 th. The internal grant committee members will make recommendations to S. Coffin to bring to the board at the next meeting in April. The grant application and program information was posted on the website on March 4 th. Applications are due on April 5 th. After review of applications by the grant committee the award decisions will be presented to the board in May. B. Lubin inquired if there was a policy for conflict of interest. M. Levin responded that there is a disclosure form as part of the application. B. Lubin suggested a conflict of interest form be sent for each application to identify any conflicts before the board meeting. S. Coffin S. Coffin shared that the team is continuing to do a lot of clean up at the Alliance. They are working on the HEDIS efforts to improve the overall score by 5%. All indicators show that the Alliance is moving quickly toward this goal. To ensure compliance and timeliness with regard to reporting requirements, the Alliance has developed compliance calendars for both routine and non-routine regulatory reporting including areas in technology, quality, compliance, and claims. A lot of effort has been put into cost controls through implementation of policies and procedures on a capital basis and day to day operational level. The Alliance has the correct oversight in place to scrutinize spending. During this year, following the conservatorship, the Alliance has been AAH BOG 3/11/ of 13

13 working to make improvements to get the job done. Efforts have been recognized by regulators through invitations to participate in workgroups and panels. S. Coffin offered accolades to the entire team and supporters for all the good work. 10. ADJOURNMENT J. Garcia J. Garcia requested to adjourn the meeting. With no objections, the meeting was adjourned at 2:02 PM. Respectfully Submitted By: Lynda Fong, Compliance Coordinator AAH BOG 3/11/ of 13