VALUEOPTIONS Presents: Outpatient Services: Revised Clinical and Administrative Processes under Federal Mental Health Parity (FMHP) December 2010 & January 2011 1
Agenda Introductions What is Federal Mental Health Parity? General Parity Guidelines What Does This Mean to Providers? Clinical Model ProviderConnect sm Demonstration Contacts 2
3 Introductions
What is the Federal Mental Health Parity? The full name is : The Paul Wellstone and Pete Domenici Mental Health Parity & Addition Equity Act of 2008 Passed October 2008 Most plans effective January 1, 2011 4
General Parity Guidelines This interim final rule will take effect for plans on the first day of their plan year which begins or renews on or after July 1, 2010 The 2008 Act requires that mental health and substance abuse disorder benefits, provided by group health plans with more than 50 employees, must be available on an equivalent or better basis to any medical and surgical benefits To establish parity, the regulations provide a framework of determining whether a mental health and substance abuse disorder benefits are subject to the same financial requirements (deductibles, co-payments) and treatment limitations (number of treatments, days of coverage, conditioning benefits upon completion of a course of treatments) as medical and surgical benefits 5
What Plans are Impacted? ValueOptions Commercial Plans (including selffunded) Group health plans and health insurers that provide coverage to group health plans (employers with over 50 employees) State children s health insurance program Medicaid managed care plans (additional guidance will be forthcoming) Federal employees health benefits plans voluntarily decided to comply, thus expanding parity to Out-of- Network (OON) benefits 6
What Plans are Impacted? Non-federal government plans (State, Municipal, School Employees) however, these plans can decline to comply with the law simply by notifying CMS (Centers for Medicare and Medicaid Services) Some state based plans may have additional state specific requirements that are separate from Federal Parity. For example, NYS has some diagnosis specific requirements (MVP) 7
What plans are not covered? A retiree plan is not subject to parity if placed in its own ERISA plan separate from the active plan. In order to be exempt, a plan needs to be 100% retiree population with no full-time or part-time employees Plans subject to collective bargaining agreements will not have to comply until their agreement expires Medicare Advantage Plans are not subject to parity as they are not health plans as defined under ERISA EAP benefit plans 8
What plans are not covered? Self-funded, non-federal governmental employee plans (may elect to exempt its plan by filing an election with CMS). Example: State of NC (parent code SNC) Small employers of 50 or fewer employees State parity laws will continue to apply to these employers Cost Exemption: If a group health plan experiences an increase in actual total costs with respect to medical/surgical and mental health/substance abuse benefits of 1 percent (2 percent in the first plan year that this Act is applicable), the plan can be exempted from the law 9
What Does this Mean to Providers? All Benefit information will continue to be in ProviderConnect sm under the Eligibility sections Other ways providers can check eligibility changes: Use Benefits at a Glance Call the toll-free number on the back of the member s card Check with the member 10
What Does this Mean to Providers? Out of network benefits may be added to plans Notification and review requirements may change or be modified to be in line with medical plans Note: medical necessity still applies 11
How Will Providers Receive Parity Updates? Provider enewsletter Articles The Provider enewsletter is posted on the ValueOptions Web site on a monthly basis http://www.valueoptions.com/providers/pronews.htm EIVR/Telephone reminders ProviderConnect sm Quarterly Provider Webinars Other Educational Materials: Frequently Asked Question (FAQ) Document 12
Checking Member Eligibility/Benefits Providers should always check member eligibility for any changes Use ProviderConnect sm to prepare for the changes by: Checking member benefits Many benefit plans are changing to meet Mental Health Parity requirements Sending inquiries to Customer Service in regards to the member s benefits Read important messages or Provider Newsletter items about the Mental Health Parity 13
Claims Providers submitting claims to ValueOptions are required to split outpatient claims Split the claims so each claim in a specific benefit year is on one claim For example, a claim will need to be submitted for outpatient services with 2010 dates of service (DOS) & a separate claim will need to be submitted for outpatient services with 2011 DOS. (Inpatient services can span years) Message on Provider Summary Vouchers when Medical Records are required for consideration of your claim Upon receipt and review of your patient s medical records, the claim will be processed and you will receive notification of the benefit determination If you are a ValueOptions contracted provider, you should not bill your patient as a result of this request for medical records 14
15 Clinical Model
Will Parity change the Inpatient Authorization Process? In place of current preauthorization provisions, ValueOptions will require that notification of a member s admission to inpatient mental health or substance abuse treatment facility be made within 24 hours Notification Requirements and Pre-authorization may still be required for HLOC Notice can be provided via ProviderConnect sm using the Authorization Request link or by calling the appropriate telephone number on the back of the member s benefit card. Failure to provide notification as required by the benefit plan may result in penalties being applied as follows: Claims payment may be made at a reduced rate, Services may be subject to an additional deductible, Denial of coverage 16
Will Parity change the Outpatient Authorization Process? With regard to Outpatient Services, for those plans that are affected by FMHP, authorization prior to beginning treatment is no longer required. Psych testing and Outpatient ECT will still require preauthorization Some clients will still require authorization of outpatient services In place of the current pass through/registration outpatient processes, ValueOptions will initiate an outlier care management model. This outlier model will focus on individual cases by diagnostic category where the course of treatment varies significantly from expected norms. If a case is identified as an outlier, ValueOptions will request additional clinical information about the member s treatment in order to conduct appropriate utilization management. Similarly, if an individual provider s treatment patterns within a diagnosis varies significantly from expected norms, additional information will be requested. 17
Will Parity change the Outpatient Authorization Process? ValueOptions will also continue its focus on those members diagnosed with complex mental health and substance abuse illnesses. ValueOptions will be contacting the treating provider early in these patients treatment regimen in order to develop, in conjunction with the provider, an individualized plan of care. The goal of this process is to help assure, in cooperation with the provider, the best possible outcome for the patient. 18
Clinical Model CURRENT ONCE PARITY TAKES EFFECT PRIOR AUTHORIZATION Required after claims for first 10 sessions are processed Not required MEDICAL NECESSITY Required for all levels of care Required for all levels of care RETRO REVIEWS Provider is able to submit if they fail to request precertification Provider may be required to submit if they fail to notify VO of an admission COMPLEX DIAGNOSIS Members enrolled in ICM program, Provider may or may not be contacted Provider will be contacted at multiple events during the course of treatment 19
Clinical Model The non-quantitative provision requires ValueOptions to establish a new approach to medical management and implement new clinical processes This will impact benefit design such as eliminating many authorization requirements for outpatient services Inpatient and higher level of care will require precertification or notification based on medical plan requirements Financial penalties such as a percentage off the claims payment will more frequently apply Retro reviews will be allowed by contract There will be requests for records or additional clinical information at key points Administrative denials will apply for network providers who do not respond to such requests Clinical denials will apply for out of network providers who do not respond to such requests 20
Clinical Model: Key Points Outpatient Model via claims or claims extract Since pass through or registration no longer applies to outpatient services, authorization can not be required Some clients will still require pre-certification for HLOC notification requirements may also vary A few clients will still require authorization of outpatient services Outpatient care management will be conducted primarily through front-end claims or claims extracts, and will emphasize 3 areas: Complex Diagnoses Outlier cases Outlier Providers Intensive Care Management 21
Complex Diagnosis: High cost/high risk Diagnostic categories Identified through claims analysis High Risk/High dollar categories may vary by account Process: Initial letter sent to provider at time of first claim advising them to follow certain treatment practice guidelines (example: Eating Disorders) Providers that use ProviderConnect sm will receive the first claim and threshold notifications via the web in their message center Members evaluated for Intensive Care Management services at time of an Emergency Room or inpatient claim Outlier review requiring submission of an Outpatient Review Form via ProviderConnect sm with specific endorsement of best practice treatment guidelines 22
Outlier Diagnosis Review: Identified by: same provider; same member; same diagnosis Outlier review at comparable limits of current pass through or registration model (10 to 26 sessions) Outlier thresholds may vary by client Outlier review requiring submission via ProviderConnect sm of an Outpatient Review Form with specific endorsement of best practice guidelines 23
Outpatient Review Form elements, with treatment guideline endorsement Generic Treatment Guidelines apply to all DX categories Co-occurring medical conditions have been assessed and addressed, if applicable, in treatment plan For primary psychiatric disorders, co-occurring substance use conditions have been assessed and addressed, if applicable, in treatment plan For primary substance abuse disorders, co-occurring psychiatric conditions have been assessed and addressed, if applicable, in treatment plan For biologically based conditions, appropriate pharmacological intervention has been prescribed and/or evaluated by members PCP/psychiatrist 24
Outpatient Review Form elements, with treatment guideline endorsement (cont) Treatment process includes one or more evidenced based psychosocial treatment modalities: Cognitive behavioral therapies including social skills training, destabilization prevention, relapse prevention, standard cognitive therapy Motivational Enhancement therapy Illness management skills Family interventions/ therapy as indicated Community based self-help organizations and peer support groups Clinical impairment rating and treatment plan reflects either improvement in symptoms within 90 days of treatment onset, or, if not, patient s condition has been re-evaluated and adjustments in treatment plan made accordingly Risk issues have been assessed and addressed in treatment plan and are continually monitored during treatment Additional treatment guideline endorsements required for complex diagnosis review 25
26 Outpatient Review Form
Parity Clinical Outpatient Model - Common Question and Answers Q: Will ValueOptions be requesting clinical information when the benefit doesn t require precertification for authorizations? A: Yes. Although, the benefit design doesn t require precertification for outpatient treatment it does require treatment to be medically necessary. Specific types of outpatient cases for more intensive review and care management have been preselected. In-network providers can complete clinical reviews online Out-of-network providers can fax the Outpatient Review Form to ValueOptions Q: What types of cases are being selected? A: ValueOptions outpatient medical necessity review process includes review of specific high risk and outliers cases based on diagnosis and treatment based guidelines appropriate standards. This may vary over time and by account 27
Parity Clinical Outpatient Model - Common Question and Answers Q: How many sessions can I use before a case is considered an outlier case? A: ValueOptions identifies high risk diagnostic categories and outliers through ongoing analytical reviews Q: What will happen if I don t respond to the request for clinical information? A: A denial will be issued for further treatment services. Denials will be issued with appropriate appeal options Q: Does the Federal Parity regulations allow ValueOptions to request an Outpatient Review Form (ORF)? A: Yes. Parity allows for medical necessity review. ValueOptions is asking for an ORF as a part of the medical necessity review process. 28
29 Message Center
30 Message Center
31 Message Center Threshold Claim
32 Outpatient Outlier Request for Information
33 Message Center Treatment Guideline Notification
34 Request for Clinical Information Response Process
35 Request for Clinical Information Response Process
36 Request for Clinical Information Response Process
37 Request for Clinical Information Response Process
38 Request for Clinical Information Response Process
39 Request for Clinical Information Response Process
40 Request for Clinical Information Response Process
41 Request for Clinical Information Response Process
ProviderConnect sm Demo 42
ProviderConnect sm (Provider Online Services) What is ProviderConnect sm? An online tool where providers can: Verify member eligibility Access and print forms View authorizations Submit requests for services Download and print authorization letters Submit claims and view status Access Provider Summary Voucher Submit customer service inquiries Submit updates to provider demographic information Access and print forms like electronic authorization letters Increased convenience, decreased administrative processes Disclaimer: Please note that ProviderConnect sm may look different and have different functionalities based on individual contract needs, therefore some functions may not be available or may look different for your specific contract. 43
ProviderConnect sm Benefits What are the benefits of ProviderConnect sm? Free and secure online application Access routine information 24 hours a day, 7 days a week Complete multiple transactions in single sitting Environmentally friendly application which allows providers to: View information Print Information Save and download electronic copies Reduce calls for routine information 44
How to Access ProviderConnect sm? Go to www.valueoptions.com, choose Providers All in-network providers can obtain one online registration per provider ID number If additional logons for ProviderConnect sm are desired, please contact the ValueOptions EDI Helpdesk at 1-888-247-9311, press option 3 (Monday to Friday, 8:00 a.m. - 6:00 p.m. ET) Additional log on turnaround time is 48 hours If provider has both a commercial and network-specific contract with ValueOptions, an ID is required for each individual contract 45
46 ProviderConnect sm Login Screen
47 User Agreement Page
48 Search/View Member Eligibility
49 Member Eligibility Search
50 Member Eligibility Results
51 Member Eligibility Enrollment History
52 Member Eligibility - COB
53 Member Eligibility - Benefits
Contacts For eligibility questions please call the number on the back of the member s insurance card For general parity questions please call the Provider Services Line at (800)397-1630 ProviderConnect sm Technical questions please call the EDI help desk at (888)247-9311 54
55 Questions?
56 Thank You!