Welcome The Freedom to Succeed Liberty Healthcare PCS Provider Training September 2015
AGENDA 9:00-9:15 am Welcome and Introductions Lacey Barnes, Executive Director Beth Oakley, Training & Development Manager Liberty Healthcare 9:15-9:35 am ICD-9 to ICD-10 Transition Lyneka Judkins, Director of Operations Liberty Healthcare 9:35-10:40 am Quality Improvement Program w/interactive PCS Provider Panel Q&A Denise Hobson, Director of Clinical Services Liberty Healthcare 10:40-11:10 am Break 11:10-11:30 am Creating a Service Plan The Exceptions 11:30 11:45 am Agency Change of Ownership Guidelines Lyneka Judkins, Director of Operations Liberty Healthcare Lyneka Judkins, Director of Operations Liberty Healthcare 11:45 12:30 pm Q&A Session 2
ICD-9 to ICD-10 Transition The Freedom to Succeed
ICD-10, Coming 10/1/2015 Are you ready? 4
ICD-10 and PCS Why are ICD-10 diagnosis codes important for PCS? Eligibility: Clinical Coverage Policy 3L, section 5.4.3 Requirements for PCS Eligibility Assessments states A physician must complete the 3051 form and include: The medical diagnosis or diagnoses and related medical information that result in the unmet need for PCS assistance and The current diagnosis code associated with the identified medical diagnosis. In addition to the indication on the 3051 form, in accordance with section 3.2.3 Medicaid Additional Criteria Covered : The beneficiary is under the ongoing direct care of a physician for the medical condition or diagnosis causing the functional limitations. 5
ICD-10 and PCS (continued) Why are ICD-10 diagnosis codes important for PCS? Need Determination: In accordance with section 5.4.9 Determination of the Beneficiary s ADL Self-Performance Capacities - The assessment tool must be a standardized functional assessment with the following components: The medical diagnosis or diagnoses causing the need for the PCS The IAE assessor shall evaluate and document the following factors for each qualifying ADL: Medical conditions and symptoms that affect ADL selfperformance and assistance time 6
PCS Provider Responsibility For compliance with the policy, PCS Providers will be required to submit DMA 3137 PCS ICD-10 Transition Form to Liberty Healthcare prior to the scheduled annual assessment for each beneficiary currently receiving PCS. 7
8 PCS ICD-10 Transition Form
PCS ICD-10 Transition Form Required Fields: Section A, Beneficiary Demographics Name, DOB, MID Address and Phone Section B, Beneficiary s Conditions that Result in Need for Assistance with ADLs Current diagnosis description with correlating ICD-10 code 9
PCS ICD-10 Transition Form Required Fields: Section C, Practitioner Information Practitioner Name and NPI Practice Name and Phone Signature with Credentials NOTE: Signature stamps will not be accepted. A valid signature must be provided by an MD, NP, or PA. 10
PCS ICD-10 Transition Form Completed forms can be submitted to Liberty in one of two ways: Fax The PCS Provider or Practitioner can fax the form directly to Liberty at 919-573-9694. Upload The PCS Provider can upload the completed form to Supporting Docs through the provider portal. 11
PCS ICD-10 Transition Form To upload the Transition Form through the provider portal, select the Referrals tab on the top toolbar, then click Supporting Docs from the left index bar: 2. Select Supporting Docs to upload form. 1. Select the Referrals tab. 12
PCS ICD-10 Transition Form Once you have selected Supporting Docs, click the Add button. 3. Select Add to open browser to upload form. 13
PCS ICD-10 Transition Form Once you have selected Add, a box will pop up that allows you to select the Record Type, locate the file, and save. NOTE: The Record Type should be ICD-10 Transition Form. If another document type is selected, Liberty will be unable to acknowledge the submission of the transition form. 3. Select Add to open browser to upload form 4. Select ICD-10 Transition Form as the Record Type. 5. Locate the completed form. 6. Click Save to upload to the beneficiary s profile. 14
PCS ICD-10 Transition Form Where is the DMA 3137 PCS ICD-10 Transition Form located? 1. Liberty website: http://nc-pcs.com/medicaid-pcs-forms/ 2. N.C. Division of Medical Assistance (DMA) PCS webpage under Forms. http://www2.ncdhhs.gov/dma/pcs/pas.html 15
PCS ICD-10 Transition Form What happens if the PCS Provider is unable to obtain a completed PCS ICD-10 Transition Form from the Practitioner? 16
PCS ICD-10 Transition Form Retrieving a Completed PCS ICD-10 Transition Form: The provider must obtain a completed Transition Form prior to the annual assessment. If unable to obtain, Liberty will assist in the retrieval by attempting to call the practitioner on file. If retrieval is unsuccessful on the part of both Liberty and the PCS Provider, the PCS Provider will be notified and PCS may be effected. 17
Key Points Effective 10/1/2015, a valid ICD-10 code is required to process a PCS assessment. Any request sent prior to 10/1/2015, but the assessment is scheduled after 10/1/2015, will require a valid ICD-10 code. The PCS ICD-10 Transition Form is REQUIRED on every beneficiary for their annual assessment but will also be required in order to obtain a valid ICD-10 code for other assessment types conducted after 10/1/2015. All Requests for an Independent Assessment will require a valid ICD-10 diagnosis code effective 10/1/2015. 18
In Conclusion 19
Quality Improvement Program PCS Provider Panel The Freedom to Succeed
What does Medicaid Require? Clinical Policy 3L Section 7.7 DMA Form 3136 21
7.7 Internal Quality Improvement Program The PCS Provider Organization shall: a. develop, and update at least quarterly, an organizational Quality Improvement Plan or set of quality improvement policies and procedures that describe the PCS CQI program and activities; b. implement an organizational CQI Program designed to identify and correct quality of care and quality of service problems; c. conduct at least annually a written beneficiary PCS satisfaction survey for beneficiaries and their legally responsible person; d. maintain complete records of all CQI activities and results; e. PCS Providers shall submit by December 31 of each year an attestation to DMA that they are in compliance with a through d of this Subsection. The attestation form and instructions are posted on the DMA PCS website; and f. provide these documents to DMA or a DHHS designated contractor upon request in conjunction with any on-site or desktop quality improvement review. 22
DMA 3136 - Attestation Form Submit to DMA by December 31 st of each year certifying compliance. Internal Quality Improvement Requirements section : Initial items a. through d. to certify compliance of Clinical Coverage Policy 3L Section 7.7. Complete signature and date. 23
DMA 3136 - Attestation Form Instructions Providers must indicate which of the general Provider cohort designations fit their organization. Forms cannot be processed with any missing information. Providers must review each requirement before initialing each item individually in the area provided. Forms should not be submitted prior to the completion of requirements which include continuous quality improvement programs and activities conducted at least quarterly. 24
What is a Quality Improvement (QI) Plan? Detailed work plan of an organization s activities of Quality Improvement. Explains how your organization manages, deploys, and reviews quality services. Updated regularly to include your organization s quality priorities and how you are performing/improving. 25
Key Elements For an Effective QI Plan The Plan describes: The mission, values, goals and objectives How the organization will select, manage and monitor all QI projects Methodologies that will be used Communication to staff on the plan, any updates and results Staff training and education Evaluation and effectiveness 26
Common Barriers Absence of: Resources (financial, staff) Ongoing communication and feedback Periodic re-evaluation Staff interest/training Accountability of QI committee Focus in QI priorities/changes 27
Implementing A QI Plan 1. Determine priorities based on customer needs 2. Define the plan s purpose, goal and policies 3. Determine the sample size 4. Identify the QI committee and assign roles and responsibilities 5. Establish process for achieving customer input 6. Determine key measurement 7. Evaluate and communicate results 28
An Example of a QI Methodology PDSA: Plan Do Study Act 29
PLAN Develop the QI plan as related to the organization s priorities, mission, goals, population served, services provided and customer needs. Always consider external or regulatory requirements. 30
Do Implement the plan as a defined map or guide for the organization-wide Quality Program. Document identified problems and unexpected events observed. 31
Study Evaluate the plan: Ask Did we do what we said we were going to do? Why or why not? What are the results? How can we do better next year? What needs to be modified? 32
ACT Act on what was learned Revise the plan as needed Monitor the plan on a regular and defined basis Determine if it was successful at meeting or exceeding your expectations Evaluate or update quarterly* *REMINDER: This is a PCS Provider requirement per Policy 3L 7.7a. Develop and update, at least quarterly, an organizational quality improvement plan or set of quality improvement policies and procedures that describe the PCA CQI program and activities. 33
Additional Resources http://www.qualityforum.org http://www.hrsa.gov/quality/toolbox/methodology http://www.isixsigma.com/tools-templates http://patientsafetyed.duhs.duke.edu/module_a/modul e_overview.html 34
BREAK
HAPPY! https://youtu.be/xqg89cwhmju 36
Creating a PCS Service Plan: The Exceptions
Service Plan - Recap Effective June 10, 2015. Required each time an assessment is completed. Must be completed within 7 business days of acceptance. Must be signed and uploaded to Supporting Docs within 14 business days from completion of Service Plan. PAs will not be generated until the on-line service plan is entered into the portal and validated. Not a Plan of Care. Required when providing PCS under Maintenance of Service (MOS). *Reference Section 6.1.3 of Clinical Coverage Policy 3L 38
Service Plan The Numbers As of XX 2015 Assessment Breakdown Assessment Type Total Beneficiaries % Annual Assessment 608 63% Appeal 82 8% Change of Provider 134 14% Change of Status 25 3% Expedited 4 0% New Request 117 12% Grand Total 970 100% Service Plan Aging Days Past Due Total Beneficiaries % 1-10 270 27% 11-20 209 21% 21-30 226 23% 31-40 155 16% 40+ 125 13% 39
Service Plan When the approved hours do not match the Service Plan. 40
Service Plan The Exceptions When the approved hours do not match the total hours awarded in the assessment, a Service Plan will need to be completed outside of the system. PCS Providers should complete their own assessment to determine task and frequency need and reflect those tasks in their manual Service Plan. The Service Plan must reflect service for the total hours approved. 41
Service Plan The Exceptions (continued) PCS Providers can use a template of their choice to create a manual Service Plan. The manual Service Plan must be uploaded to Supporting Docs within 7 business days of acceptance. Anytime a Service Plan must be completed outside of the system, call Liberty so that PAs can be generated. 42
Service Plan - The Exceptions (continued) A Service Plan must be submitted outside of QiRePort when: EPSDT temporary summer hours are awarded. Mediation or court settlements resulting in different hours. Expedited assessments resulting in hours awarded. A Change of Provider request when the beneficiary has an active appeal. A Change of Provider request and the beneficiary is currently approved for more hours than what is reflected in the current assessment. The level of MOS that the beneficiary receives is not reflected within the system from the previous year s assessment. (The beneficiary s MOS hours were awarded from a settlement the previous year and not from an independent assessment). 43
Service Plan- The Exceptions (continued) When a Service Plan will be removed: The beneficiary requested a Change of Provider, but the previous provider never completed the Service Plan. The beneficiary is on Maintenance of Service (MOS),reached a mediated settlement, but the PCS Provider never completed the MOS Service Plan. Action 1. Liberty will call the PCS Provider and give them 1 day to complete the Service Plan before removal. 2. Removal of the Service Plan will result in non-compliance to the Service Plan requirement and subject the PCS Provider to a Program Integrity audit. 44
Service Plan- The Exceptions (continued) When a Service Plan will be removed: A beneficiary is discharged before the Service Plan can be completed. The PCS Provider accepted the beneficiary in error which generated a request for a Service Plan. If a Service Plan is requested for hours that do not match an independent assessment. (Ex. MOS or COP hours are based on a settlement and not an assessment or there is an active appeal that is paused to process a COP). Action The PCS Provider should call Liberty to request that the Service Plan request be removed. 45
Agency Change of Ownership Guidelines
Change of Ownership - Definition When an agency takes over the ownership of another existing agency. *Change of Ownership is often referred to as CHOW. 47
Change of Ownership The Reality When an agency takes over the ownership of an existing agency: 1. Usually a delay between the date of receipt of an NPI and the date when the provider becomes enrolled in NCTRACKS, which may prevent processing new or existing PCS requests. 2. When an agency comes under new ownership, the guidelines provided today should be followed to ensure proper processing and billing. 48 48 9/4/201
Change of Ownership New PCS Beneficiaries PCS Providers: Should seek to enroll their NPI in NCTracks as soon as possible. Are not guaranteed payment for services rendered to eligible Medicaid beneficiaries prior to approved as participating medical provider. Should check the status of enrollment daily through NCTracks. Once active, contact Liberty Healthcare Corporation of NC. Prior Approvals will not be issued for new PCS beneficiaries who select a provider not enrolled in NCTracks. 49
Change of Ownership New PCS Beneficiaries (continued) PCS authorization may begin when the provider is active in NCTRACKS and a completed DMA 3051 Request for Independent Assessment has been received by Liberty Healthcare Corporation. DMA will not retroactively authorize PCS for new beneficiaries. 50
Change of Ownership Current PCS Beneficiaries A Change of Provider Request must be submitted by the new provider within 30 days of the effective date of the ownership change. Liberty will process the request and retro the PAs to reflect the effective date of changed ownership. If a Change of Provider Request is sent after 30 days of the new ownership, Liberty will process the request and the PAs will be effective the date the request is received. 51 51 9/4/201
Change of Ownership - Questions Questions regarding your application for enrollment in NCTracks or to manage change requests already submitted, contact NCTracks at: 1-800-688-6694 or NCTracksprovider@nctracks.com. If directed to contact DMA, contact DMA Provider Enrollment at: 919-855-4000. 52
Provider Manual New Version September 2015 Located on the Liberty Healthcare website at: http://nc-pcs.com/pcsprovider-manual/ Updates include: CHOW Guidance Service Plan Exceptions 53
Question and Answer Session
The Freedom to Succeed Liberty Healthcare PCS Provider Training September 2015