OPERATIONS/READINESS REVIEW OF EASTPOINTE NORTH CAROLINA DIVISION OF MEDICAL ASSISTANCE October 15, Government Human Services Consulting

Transcription

1 OPERATIONS/READINESS REVIEW OF EASTPOINTE NORTH CAROLINA DIVISION OF MEDICAL ASSISTANCE October 15, 2012 Government Human Services Consulting

2 CONTENTS 1. Introduction... 1 Purpose, Background and Methodology...1 Organization of the Report Highlights of Findings...3 Strengths... 3 Challenges... 4 Findings... 4 Appendix A: Local Management Entity PIHP Criteria...19 Appendix B: Eastpointe Plan of Development MERCER i

3 1 Introduction Purpose, Background and Methodology This report summarizes the findings of the September 20, 2012 readiness review of Eastpointe, a local management entity (LME) in North Carolina, which is implementing a prepaid inpatient health plan (PIHP) with a target date of January 1, Eastpointe was selected by the State of North Carolina (State), Department of Health and Human Services (DHHS), as a successful applicant for the Centers for Medicare and Medicaid Services (CMS) Section 1915(b)(c) Waiver expansion. Background LMEs bidding on the PIHP must fully prepare their systems, staff and processes to implement the program consistent with CMS requirements and the State criteria listed in Appendix A. DHHS also requires the implementing LMEs to adopt a set of policies and procedures (P&Ps) developed by PBH, the first PIHP in North Carolina. PBH has designed effective P&Ps during the past several years in collaboration with the intra-departmental monitoring team (IMT). Thus, DHHS wants to ensure statewide consistency of P&Ps while also addressing local needs. The DHHS Division of Medical Assistance (DMA) contracts with Mercer Government Human Services Consulting (Mercer) to assist the IMT in its oversight of the PIHP implementation process. The IMT includes representatives from DMA and the Division of Mental Health, Developmental Disabilities and Substance Abuse Services. As part of its oversight, the IMT conducts readiness reviews. Mercer provides technical assistance to the IMT on readiness milestones and prepares the readiness review reports. Methodology The review includes a desk review of documentation submitted by the LME in response to a data request prepared by the IMT and Mercer. Results from the desk review are incorporated into an interview questionnaire that lists implementation milestones. The questionnaire and resulting onsite review are organized into the following categories: PIHP organizational management tasks Contracting and capitation Facilities management Member services/access Clinical care management/utilization review (CM/UR) Care coordination Network operations/provider relations MERCER 1

4 Quality assurance (QA) and quality improvement (QI) Financial management/monitoring Claims and information technology (IT) staffing Claims administration system development Reporting The IMT and Mercer would like to express appreciation to Eastpointe for preparation of materials and its active participation during the onsite review. Organization of the Report Section 2 of the report discusses findings, including strengths, challenges and opportunities for improvement. If there are no particular findings related to the review categories listed above, the category is not addressed in the report. Section 3 discusses the plan of development requirements. MERCER 2

5 2 Highlights of Findings This section of the report highlights the key findings and recommendations. The 120-day Operations/Readiness Review findings indicate that Eastpointe has neither tested nor implemented sufficient Medicaid managed care administrative infrastructure, including but not limited to, system development, claims edits, benefit plan, national standard codes, 837 receipt, reporting development and testing. Eastpointe will need to demonstrate significant progress in the areas noted in this report during the 60-day Operations/Readiness Review in November 2012 in order to avoid a recommendation for delay in implementation on January 1, Mercer also recommends that the IMT conduct weekly reviews to monitor completion of recommended tasks outlined in this report. This section of the report highlights the strengths and areas identified for continued improvement. Strengths Establishment of separate positions for a waiver contract manager and a waiver project manager, with a plan to keep the project manager throughout implementation. Creation of a specialist staff position to intervene and assist with special populations that may present with challenging clinical management issues (e.g., traumatic brain injury (TBI), deaf and hard of hearing (HOH), blind, aging, dementia). Leveraging outside vendor support to assist with credentialing activities with almost 700 completed provider applications received to date. Commitment to cross-train all care managers. Two year history of managing Medicaid utilization review for CAP MR/DD in the Eastern Region. Well-organized training function across all functional areas. Establishment of a website that is being utilized by many functions. Collaboration with providers is strong, including establishment of a designated network call center number. Development of 27-member governing board. Utilization Review Accreditation Committee (URAC) accreditation for call center, UR and provider network. Consumer and provider involvement on numerous committees. MERCER 3

6 Challenges Many critical areas in the implementation plan are behind schedule, including but not limited to system development, claims edits, benefit plan, national standard codes, 837I receipt, reporting development and testing. P&Ps for most areas need to be finalized. Reporting capabilities across all areas are not yet in place, with no outsourcing in place to assist. There is no current link between Avatar claims system and Great Plains financial system. Internal system edit codes neither fully developed nor cross-walked to the necessary 835 remittance advice code. Testing has been very limited, and tables have not yet been set up to mirror the production environment. Currently, only revenue or procedure codes from emergency department (ED) settings can be collected and both must be received. Need to complete general ledger conversion, test conversion and standard financial statement development. Need to complete provider contracting process and upload and test contracts in Avatar. Need to complete risk management and dashboard reporting to ensure operational status. Estimation of staffing needs and caseload ratios for care coordination and CM/UR is not supported by data analysis. The proposed 1:65 caseload ratio for intellectual/developmental disabilities (I/DD) care coordination is too high. Senior clinical expertise should be robust and actively involved with care management and care coordination. Care coordination decision trees and protocols are still in development; identification of mental health/substance abuse (MH/SA) members in need of care coordination is unclear. The Netsmart CWS modules to support care coordination activities not developed. No providers are fully credentialed to date. Findings PIHP Organizational Management Tasks Eastpointe currently has an acting medical director and is actively recruiting to fill this important position. The current medical director is not actively integrated within all aspects of clinical operations at this crucial time for Eastpointe. For example, it was reported that the medical director is not a member of the executive management team and is not directly involved in the development and review of clinical policies. This can negatively impact program development and appears to have resulted in limited progress in both the care coordination and CM/UR areas. Eastpointe has established separate positions for a waiver contract manager and a waiver project manager. The project manager has over thirty years of experience in managed care and will remain involved throughout implementation. Eastpointe also recognizes the unique clinical care management challenges certain situations may create for providers and has opted to MERCER 4

7 create a specialist staff position to intervene and assist with special populations (e.g., TBI, deaf and HOH, blind, aging, dementia). The implementation plan has shown progress; however, from January 1 through August 31, 2012, the completion percentages have not moved extensively. Many of the critical areas are still at 50% or less for completion. Being at a point of less than 120-days from implementation, the expectation would be that the PIHP would be at 80% or better for the critical areas of system development, Netsmart Avatar (Avatar) claims edits, benefit plan, national standard codes, 837 receipt, reporting development and testing. Strengths PIHP Organizational Management Tasks Establishment of separate positions for a waiver contract manager and a waiver project manager, with a plan to keep the project manager throughout implementation. Creation of a specialist staff position to intervene and assist with special populations that may present with challenging clinical management issues (e.g., TBI, deaf and HOH, blind, aging, dementia). Ensure strong, knowledgeable and engaged clinical expertise, including a permanent medical director in place. Complete the critical tasks in the implementation plan including report development and areas in system testing. Contracting and Capitation Eastpointe has recently finalized the capitation rates with the State. Now that the rates have been finalized, Eastpointe has analyzed its staffing requirements and is pushing to hire the staff needed to become an operational PIHP. As part of the capitation rate process, Eastpointe analyzed the Medicaid FFS data to determine providers that have provided services within the catchment area. Please reference the network operations/provider relations section of this report for information regarding network contracting. Strengths Contracting and Capitation Eastpointe has finalized the capitation rate with the State and analyzed the FFS data to evaluate provider contracting requirements. Train staff related to detailed procedures for capitation reconciliation. System development for member-level eligibility and capitation payment reconciliation and related reporting. Provider network development ensuring access to care. MERCER 5

8 Facilities Management Eastpointe will maintain facilities (Beulaville, Goldsboro, Lumberton and Rocky Mount) throughout its catchment area to house the PIHP staff. Based upon a review of the Beulaville site, and through discussions with Eastpointe management, the facilities appear to be adequate and ready to start PIHP operations. In addition, based upon finalization of the capitation rates, Eastpointe has evaluated its staffing plan and is moving to fill required positions of the PIHP. Strengths Facilities Management Facilities are acquired and appear to be ready for PIHP operations. Analysis of staffing levels, based upon budgeted capitation payments for administration expenses, has been completed, and Eastpointe is hiring to meet the needs to become a PIHP. Use of multimedia (e.g., WebEx, video conferencing) for meetings. Ensure staffing hires continue in accordance with the needs of the organization to be ready on go-live. Member Services/Access Eastpointe has a centralized call center in Lumberton that is staffed 24/7 with licensed and unlicensed staff. Per URAC, callers can choose to leave a voic message, which must be responded to within 30 minutes. Unlicensed staff answer all calls, unless all lines are busy; at which point, the call would be routed to an available licensed staff person. Depending upon the nature of the call, clinical triage is performed by licensed staff, with both licensed and unlicensed staff on the call and able to access the record simultaneously. Once the licensed staff member determines the urgency of need, he/she may sign off and the unlicensed person takes back over. There is mobile team availability across all Eastpointe counties, and a process is in place to follow up with the mobile team afterwards. The call center staff have the responsibility to arrange aftercare appointments and follow-up with the provider, if necessary, to confirm that the member kept the appointment. The current call volume averages 7,000 calls per month, and Eastpointe anticipates an increase in December as the waiver approaches. Staff from other departments have been cross-trained to assist as needed, additional staff are still being hired (licensed clinicians and two unlicensed staff) and staff from other sites can be accessed if necessary. Avatar is used to document calls but currently does not have the capability to check Medicaid eligibility; that is done through a separate site. Likewise, provider preference information is not currently available through Avatar and must be accessed through the Eastpointe website. While appointments can be scheduled directly through the Calcium system, a separate must be sent to the provider requesting receipt of the appointment. MERCER 6

9 Cisco tracks performance measures, including number of calls answered, blockage rate, average speed of answer, abandonment rate, average wait/hold and call traffic analysis. Real-time tracking capabilities include assessment of individuals on hold, amount of time on hold and staff availability. Avatar develops reports to track timely response to emergent/urgent/routine appointments, emergency 911 dispatches, screening/triage/referral and frequent callers. Consultation is available for call center staff via , phone and face-to-face. Staff supervision is also in place at the same level as for care coordination. In addition, live call monitoring is conducted quarterly and recorded calls are used for auditing purposes. The inter-rater reliability (IRR) P&P is under development. Eastpointe s call center is URAC accredited. Strengths Member Services/Access Coordination between unlicensed and licensed call center staff to perform triage and to barge in when necessary. Mobile team availability and follow-up. Follow up with providers, if necessary, to confirm members kept aftercare appointment. Ability to identify providers able to address unique preferences/needs of members. URAC accreditation achieved. Complete hiring needs (seven licensed clinicians and two unlicensed staff). Complete IRR P&P. Optimize Avatar functionality to assess Medicaid eligibility, provider preference information and to allow acknowledgement of receipt and acceptance of scheduled appointments with providers. Clinical Care Management/Utilization Review Eastpointe has a two-year history of managing Medicaid utilization review as a DMA vendor and is URAC accredited in UR. Care management staffing plans for the LME-managed care organization include four I/DD screeners to verify necessary documentation is present and that the budget is correct, four licensed clinicians for I/DD and twelve licensed clinicians for MH/SA. While there remains only one I/DD vacancy, there are still five MH/SA vacancies. Eastpointe plans to cross-train the licensed clinicians across I/DD and MH/SA. While Eastpointe analyzed historical data (e.g., volume of authorizations) and considered its budget to establish anticipated staffing needs, caseload size projections have not yet been finalized. Providers will use ProviderConnect to confirm member Medicaid eligibility, track when Medicaid redetermination is due, enroll members with the provider and request authorization for services. The ProviderConnect system, however, does not save entered fields unless all mandatory fields are completed. Additionally, the system times out automatically, potentially causing the provider to start over. Requests for authorization are based on the available benefit package and what the specific provider is approved to offer. Level of Care Utilization Scale (LOCUS)/Children and MERCER 7

10 Adolescent Level of Care Utilization Scale, American Society of Addiction Medicines (ASAM), medications and other detailed information is collected, including information that is duplicative of what has already been documented in an electronic health record or written assessment; this could be time-consuming and burdensome for the provider. While some basic information can be auto-populated in ProviderConnect, only one service can be requested with each entry, potentially requiring the same information to be entered repeatedly when more than one service is being requested. Once a provider submits a request for authorization to Eastpointe, utilization management (UM) pulls a report each morning and assigns each request to a care manager staff member based on eligibility (I/DD or MH/SA) and whether a particular care manager is already familiar with the member. Avatar is used for care management documentation. The supervisor can track caseloads and type of review and can reassign as necessary. Decision support tools are loaded and can be easily accessed. Care managers will receive a daily report of pending authorizations, as well as an alert when decision deadlines are approaching. Turnaround times will be tracked. The medical director is available for consultation and feedback. For example, when there is lack of progress or concerns with poly-pharmacy, the medical director could be consulted. IRR testing occurs quarterly, and results are presented at staff meetings or individually when concerns are noted. Using a separate portal, an external review vendor (BHM) provides peer review; replies are cut and pasted into the Avatar system and then plugged into a template decision letter. UR reports have not been developed, and it appears that a comprehensive list of needed reports has not been completed. Eastpointe mentioned plans to track daily census, admissions/1000, average length of stay (ALOS), turnaround time processing, the percent of administrative and clinical denials and productivity, and asked for recommendations for additional reports that would be beneficial. Eastpointe confirmed that inpatient UM is required after three days, which is consistent with DMA expectations. MERCER 8

11 Strengths CM/UR Two-year history of managing Medicaid UR as a DMA vendor. URAC accredited in UR. Cross training I/DD and MH/SA care managers. Complete hiring needs (one I/DD and five MH/SA staff). Use data and planned staffing plan to determine caseload ratios. Determine UR reporting needs and prepare for production. (At a minimum, UR reports should track daily census, daily authorization activity, authorization errors, ALOS, expired authorizations, high volume providers, care manager caseloads, admissions/1000 by level of care, seven/thirty-day follow-up, readmissions, denials by level of care, intensive case management and high utilizer/rapid recidivism). Ensure strong, knowledgeable and engaged clinical expertise, including a permanent medical director in place. Share IRR testing results individually with care managers during supervision to facilitate continuous improvement. Develop efficient, user-friendly functionality in ProviderConnect for providers requesting service authorizations. Care Coordination Eastpointe has identified the need for 37 I/DD care coordinators (this includes the recent decision to add four leads) that will work out of four locations; currently, 19 have been hired, five offers are pending and 13 vacancies remain. While the caseload size remains unclear, Eastpointe estimates caseload sizes of approximately 1:60 for the I/DD population, which is considerably higher than national standards of 30 to 40 per care coordinator. Additionally, three Supports Intensity Scale (SIS) evaluators will be in place, as well as one contractor (Developmental Disabilities Training Institute), to assist with the anticipated initial surge in enrollment due to the number of individuals on the waiver list. Eastpointe is unsure, however, how many SIS evaluators will be needed ongoing and may decrease to one over time. Eastpointe confirms that care coordinators will not have a role with SIS evaluations. Intensive training has been completed on the Innovations Waiver; SIS evaluators just finished SIS evaluator training. The transition plan has been approved by DMA; 18 forums for CAP members and families have taken place, and six forums are planned for individuals on the wait list in September/October Individualized meetings will begin in October to crosswalk services to Innovations. MERCER 9

12 Eastpointe has identified the need for 18 MH/SA care coordinators for high-cost, high-risk members, comprised of six licensed and 12 unlicensed staff. Currently, five licensed clinicians and five unlicensed staff have been hired. It is unclear what role the unlicensed staff will have to support the licensed staff. Furthermore, it is unclear how Eastpointe determined the number of care coordinators needed; data analysis does not appear to have informed this determination, and the anticipated caseload size remains unknown at this time. Decision trees and protocols are still in development; thus, it has not been determined how members in need of care coordination will be identified, assigned to care coordination and discontinued from care coordination services when appropriate. The role of the medical director in this process was unclear. Eastpointe expressed a preference that referrals should not come directly from member services and that care coordinators should not be involved long term. MH/SA care coordinators are not designated for children s services except when members are discharged from a 24-hour facility. They are transferred to children s system of care staff as appropriate. Eastpointe has identified care coordination specialist roles, including two Community Care of North Carolina (CCNC) coordinators and three SOAR specialists, plus others knowledgeable in family drug treatment and jail diversion. Reports that are not yet available, but being considered to help identify members in need of care coordination, include ED and inpatient admissions report, top 20% in cost report, three or more crisis episodes within 12 months report; 30/60/90/180-day readmissions report and a special healthcare population report (based on diagnosis, ASAM and LOCUS score). CMT software is also being pursued to access claims information that may not be in CCNC that could identify appropriate referrals. Care coordinators will use Netsmart CWS System (an Avatar module separate from UM; a firewall between UM and Care Coordination is in place) to document services, but it is not yet functional, so documentation audits cannot begin yet. Eastpointe will use ProviderConnect to request services, and referral reports can be generated currently. Strengths Care Coordination Intensive training has been completed on the Innovations Waiver. SIS evaluators have completed SIS evaluator training. The transition plan has been approved by DMA. Complete decision trees and protocols for identification of members in need of care coordination, for assignment to care coordination and for discontinuation of care coordination for MH/SA members. Use data to establish anticipated staffing needs, consistent with national caseload standards for I/DD and MH/SA care coordination. Establish care management documentation expectations and systems that can be audited. Ensure strong, knowledgeable and engaged clinical expertise, including a permanent medical director in place. MERCER 10

13 Strengths Care Coordination Clarify how MH/SA care coordinators collaborate with the children s system of care staff. Network Operations/Provider Relations Eastpointe has adopted a commitment to partnering with providers during this time of planning and implementation. In addition to a dedicated address and call center with eight provider relations specialists available for providers to use, numerous trainings and webinars have been conducted to date and up-to-date Q&As are maintained. Providers participate on numerous committees and have been afforded the opportunity to provide feedback on the provider manual and sanctions grid. With the exception of one vacancy, all planned network operations and provider relations/monitoring have been filled. In addition, Eastpointe has one community relations staff person for each of the 12 counties, to serve as the face of Eastpointe and partner with community stakeholders. A transition team is functional now and will assist with provider network changes as credentialing and contracting is conducted. All P&Ps have been developed and are pending board approval. A credentialing committee, chaired by the medical director, has been established and includes three provider representatives. Provider network URAC accreditation has been received. Eastpointe is using an external vendor, Medversant, for credentialing and report generation. While almost 700 complete applications have been submitted, no providers have been fully credentialed yet, and no provider contracts are executed. Contract templates are in place, and Eastpointe is confident credentialing and contracting will get back on schedule. Network need analysis is based on historical claims data, and geo-mapping capability is in place. However, geo-mapping at the current time is felt to be inaccurate due to the use of a centralized billing address for some providers. As providers get contracts in place, geo-mapping accuracy will improve. It was noted that Robeson County is home to over 46,000 Native Americans from the Lumbee tribe, and it is important that the provider network meet the unique cultural needs of this area. Eastpointe has both staff who are Native American and current providers in the network who are also Native American. Eastpointe plans to reach out to these priority providers, if necessary, to ensure network sufficiency and cultural competency. Provider monitoring responsibility has been relocated from quality management (QM) to network per earlier recommendations, and monitoring staff is located regionally across three sites. These staff will follow up on quality of care concerns, provide technical assistance, conduct Gold Star monitoring and assess assertive community treatment fidelity. Provider training on the monitoring tools is complete. MERCER 11

14 Network operations reviews reports developed for other areas that inform of potential network needs (e.g., ALOS, claims paid, high-volume providers, grievance/appeals, over- and under-utilization). Additionally, joint meetings are held regularly between network operations staff and monitoring staff to identify concerns and potential gaps. Strengths Network Operations/Provider Relations Provider engagement and collaboration is strong. P&Ps have been developed and are pending board approval. An external vendor is in place and assisting with credentialing process. Provider network URAC accreditation has been received. Complete provider credentialing and execute contracts. Complete geo-mapping to ensure adequate network access and choice. Ensure adequate network to meet unique needs of Robeson County. Consider increasing the number of providers on the Credentialing Committee. Quality Assurance and Quality Improvement Eastpointe s QM department includes training, P&Ps, medical records, QA/QI and grievance/appeals. A QM plan has been developed outlining the committee and subcommittee structure and function. The QM Committee meets at least quarterly and has a standing agenda item for member and provider input. The training unit is responsible for both internal and external training oversight. All training is tracked and documented in Essential Learning, so training reports can be generated. A detailed training map has been developed, so internal training can be tracked by department and by position. Several training topics for QM are not current but are being updated. At this point, 90 P&Ps have been processed; dozens more are still in development. A P&P Committee has been formed and is a subcommittee of the QM Committee. P&Ps are signed-off by the chief executive officer (CEO); currently, the medical director does not sign off on P&Ps that are clinical in nature. According to the organizational chart, the quality improvement unit has a director of QM with six quality review specialists (three positions are vacant) and a data manager with three data specialists (all positions are still vacant). This contradicts what is reflected in the QM plan, which references only three quality review specialists and one data analyst: the graph below indicates staff who are designated to perform specific QM program tasks and coordinate and oversee QM activities to help ensure the QM program development and plan are enacted. Staff Title Medical Director Chief Of Quality Management Quality Management Director Quality Review Specialist Dedicated QM FTE 1.00 FTE 1.00 FTE 1.00 FTE 3.00 FTE MERCER 12

15 Staff Title Clinical Director Data Analyst IT Report Writer Total Resources Dedicated QM FTE.25 FTE 1.00 FTE.50 FTE 7.75 FTE Eastpointe reported that most analysis and report writing functions are performed by the analytics department in Business Operations, which suggests that the organizational chart has been modified. If this is the case, the quality improvement unit may not have adequate resources available. The grievance and appeals unit anticipates the need for six grievance and appeals specialists; currently, there are two vacancies. Complaints are routed to the grievance and appeals unit where they are either handled there or assigned to the appropriate functional unit within the agency for investigation and resolution. Complaints, which are logged and tracked in Avatar, are defined as any expression of dissatisfaction that cannot be resolved to the complainant s satisfaction without further investigation. This definition is consistent with Balance Budget Act (BBA) expectations. However, Eastpointe differentiates between a complaint and a concern, in which a concern is a complaint that can be resolved immediately with the caller/complainant. It was reported that all complaints and concerns are documented and tracked through Avatar. Complaints filed through the Eastpointe website are required to be re-entered into Avatar. IT is currently researching how this process could be made more efficient. For example, when an individual calls member services with a complaint, member services staff use the website to help the caller log the complaint. Once sent to grievance and appeals, the same information must be re-entered into Avatar. Complaints will be tracked and trended, and reports will be developed for review by the QM Committee. MERCER 13

16 Strengths QA and QI All training is tracked and documented in Essential Learning, so training reports can be generated. A detailed training map has been developed for tracking internal training by department and by position. Provider and peer/family input is a standing agenda item in the QM Committee. Clarify the staffing plan and organizational chart for quality improvement, ensuring that resources are sufficient to meet expectations of the program. Complete hiring needs for the quality improvement unit. Finalize all P&Ps. Incorporate medical director signature for P&Ps that are clinical in nature. Determine QM reporting needs and prepare for production. Ensure strong, knowledgeable and engaged clinical expertise, including a permanent medical director in place. Consider reviewing complaint data frequently and closely, as this can be a good source for identifying emerging issues. Develop efficiencies for transfer of complaint information submitted via the website into Avatar. Financial Management/Monitoring Eastpointe demonstrated an appropriate level of knowledge regarding the financial requirements for the PIHP program and has made good progress implementing new operational systems and developing software and processes to meet contractual requirements. Progress noted during the onsite review included hiring qualified staff, development of many P&Ps related to required financial processes and steps taken towards confirming timely and accurate data for reporting. However, many of these tasks are in the early development stages and Eastpointe will need to demonstrate significant progress in general ledger conversion and testing, finalization and development of financial P&Ps, report development and testing, and loading of provider contracts to ensure accurate provider payments. Strengths Financial Management/Monitoring The corporate compliance area is well thought out and placement within its own area reporting to the CEO is a best practice. The incurred but not reported (IBNR) medical expense and liability accrual policy takes into consideration items required to estimate accruals. General ledger conversion and testing. Review the new financial reporting requirements to ensure that Eastpointe develops its system to meet the State requirements. Report development is just under way and needs to be fully tested and implemented prior to go-live. Testing and validation of financial software applications, system interfaces and reporting processes. MERCER 14

17 Strengths Financial Management/Monitoring Eastpointe has developed some of the required P&Ps that are needed for financial processes. They need to complete the development of the detailed procedures related to critical financial processes related to eligibility reconciliation, capitation payment reconciliation and month-end processing, fraud and abuse, and ensure that report development supports the detailed processes. Ensure finalization of the IBNR P&P, and validate that the estimation is accurate and timely to complete month-end accrual accounting. Load provider contracts in claim system and general ledger to ensure accurate provider payments. Claims and Information Technology Staffing Eastpointe will have four locations, with Beulaville as the corporate headquarters, and staff located in Goldsboro, Lumberton and Rocky Mount. IT will have at least one staff at each location to assist with IT technical issues. Eastpointe staffing levels for report writers may be appropriate for the organization after implementation; however, the need for PIHPs report development with business requirements, programming and testing and additional short-term assistance is necessary to meet the implementation timeline. The claims auditor should be located in the claims department. This position should be responsible for daily auditing of 3%-5% of all claims processed, including any additional focused audits (e.g., emergency room claims, claims over $5,000, etc.). Claims should be validated for complete accuracy, data entry for paper claims, member eligible on the date of service, correct fee schedule with applicable provider and claim payment and accuracy of system edits applied (e.g., duplicate, maximum units per day). Strengths Claims and IT Staffing Claims department in one location. Use of merger staff with experience. Report development with the current staffing levels. Claims Administration System Development Eastpointe will be using the Netsmart Avatar system for claims processing. The prior claims processing systems have been merged, and one system is in place as of July 1, Avatar continues to be developed in preparation for the PIHP implementation; however, much development and testing needs to be completed prior to go-live. MERCER 15

18 The Great Plains accounting system has been in place for many years. An interface has not yet been developed to both electronically submit data to Great Plains and receive check payment by claim back to Avatar. Strengths Claims Administration System Development Disaster planning with the multiple locations, including phone system. Use of the data warehouse for report writing. Eligibility intake and reconciliation with error reports to validate correct Medicaid enrollment needs additional development. This includes how Eastpointe will use the global eligibility file, the 834 eligibility monthly file and the 820 reconciliation file, along with the 270/271 eligibility verification processes. Test processes and reports need to be confirmed. P&P development and finalization of all of the areas associated with Medicaid business needs to be completed. This includes but is not limited to: Retro termination of members Processes for retro notification of members with other insurance Avatar edits and processes Claims processing coordination of benefit steps Processes for Eastpointe when there are Medicaid fee schedule changes and how Eastpointe will handle them (i.e., retro payments, annual updates). There is not a current link between the Avatar claims system and the Great Plains financial system for the electronic transfer of claims information to the general ledger, with the return of check number by claim number with date of payment and amount. This is not only necessary for reporting internally, but is information necessary for the 835 remittance advice or the paper explanation of payment. Eastpointe is planning to use a script tool that they have not tested and do not know if there is known performance with the Avatar system. Internal system claim processing edit codes are not fully developed or tested, nor are they crosswalked to the necessary HIPAA 835 remittance advice code. This would include edits after any MERCER 16

19 Strengths Claims Administration System Development manual processes are performed. Testing has been started, but it very limited. Tables in the test environment are not set up to mirror what will be necessary in the production environment. For testing, diagnosis code is allowed, which would not be allowed under the PIHP plan. Institutional claims will be required to be submitted on the 837I format; however, there was not any evidence of actual testing to show that Eastpointe can accept in the 837I claims data, import the data and accurately process the claims. The outpatient emergency department claims need to collect and report both the revenue code and applicable procedure code per service. Currently, Eastpointe can only receive one or the other of these codes on each detail service line. Testing of ValueOption authorizations needs to be completed to ensure services authorized for periods greater than January 1, 2013 will be able to be addressed and/or apply to claims processed. Voids and adjustments of claim process need to be tested and validated, including how these are reflected in the data warehouse. Tracking of incoming claims (electronic data interchange, claims portal and paper) to ensure all claims are timely processed. Perform additional processes to collect members other insurance information other than the information from the State eligibility files. Timely filing processes include sending claims back by certified mail to providers. All claims need to be captured in the claims system. Update process to perform annual disaster recovery testing. MERCER 17

20 Reporting Eastpointe provided claims analysis reports that analyzed the Medicaid FFS data that were utilized in the capitation negotiation process with the State. These reports are a good starting point to be able to analyze cost and utilization of the PIHP at go-live. However, these are just a starting point, and Eastpointe needs to show substantial progress in report development and writing to ensure functionality at go-live. Strengths Reporting Eastpointe provided claims analysis reports that analyzed the Medicaid FFS data that were utilized in the capitation negotiation process with the State. Ensure reports provide Eastpointe the ability to operate as a PIHP. This includes identification of key clinical and financial reports to identify areas of concern. Key management should discuss the reports to direct change and ensure continued fiscal solvency of the PIHP. Reporting development was at 57% at the time of the onsite, with no outsourcing help in place. Data cube development is recommended for dashboards. This would provide drill down capabilities in reports. Listing of reports completed, in development and future reports with projected completion dates needs to be provided. Reporting requirements gathering with specific details needs to be performed for report development. Report development with validation and testing prior to go-live. Vendor management for contracted report development. Priority-based report development ensuring all critical reports, dashboards and data sources, including tested and production are ready by the go-live date. Continue to analyze the Medicaid FFS data to assess its clinical management plan at go-live. MERCER 18

21 APPENDIX A Local Management Entity PIHP Criteria 1. A proven track record with demonstrated success in operating as a LME, as defined in North Carolina General Statues 122C Demonstrated capacity to operate a managed care program, as exemplified by: Financial and risk management resources to ensure that liquidity and solvency requirements are met. Flexible financial analysis and monitoring tools to identify service utilization and costs in a timely manner. The ability to grow equity and capital resources while providing extended behavioral health benefits to State and county populations. The ability to identify third party resources to ensure that Medicaid is the payer of last resort. Effective fraud and abuse policies and detection mechanisms. A cohesive management structure that meets the requirements to contract with the State. A flexible, responsive customer services approach that is highly ingrained in the organization and that promotes 24-hour access to services. Access to industry standard tools, technology and expertise in mental health/developmental disabilities/substance abuse services MH/DD/SAS. A CM/UR program that is person-centered, emphasizes the principles of recovery, resilience and self-determination and relies on state-of-the-art utilization management protocols and clinical practice guidelines. A well-developed quality management program that has sufficient clinical and technical leadership and data management capabilities to monitor and improve access, quality and efficiency of care. MERCER 19

22 A provider network management program that facilitates the development, support and monitoring of network providers for the delivery of mental health, developmental disabilities and substance abuse services (MH/DD/SAS) provided to children, youth, families and adults. Experience and demonstrated success in implementing program innovations that result in improved administrative and clinical outcomes, such as increased access to care by traditionally underserved populations of all ages, improved community tenure, MH/DD/SAS-physical health integration and integrated assessment and service delivery for both co-occurring mental illness and substance use disorders and co-occurring mental illness and DD. Human resource and management support necessary to effectively recruit and retain clinical and administrative qualified professional staff. A solvent and financially viable organization that has sufficient financial and administrative resources to implement and operate managed care functions specified in the Request for Application (RFA). An automated management information system that is capable of performing all the activity, interfacing and reporting requirements (utilizing electronic data interchange) using HIPAA transactions. 3. Demonstrated capacity and a proven approach to managing systems of care that: Rely on innovative approaches to address the diversity and cultures of the population served, including, at a minimum, contracts with culturally competent providers. Identify and implement the preferences of individuals and families in the design of services and supports through development and utilization of person-centered planning. Facilitate the development of consumer-operated programs and use of peer support, including consumer/family team approaches. Facilitate the development and utilization of natural supports. Facilitate the use of self-management and relapse prevention skills, support stable housing and address the development and maintenance of healthy social networks and skills, employment, school performance or retirement activities. 4. Demonstrated capacity to implement the requirements specified in this RFA through a well-designed and detailed implementation plan that clearly articulates tasks, timeframes and expected results. MERCER 20

23 APPENDIX B Eastpointe Plan of Development The tasks below are considered vital for Eastpointe to address to successfully implement the waivers. Each task must be accomplished before the go-live date in order to help assure a smooth transition as a PIHP. Eastpointe Plan of Development PIHP organizational management tasks Ensure strong, knowledgeable and engaged clinical expertise, including a permanent medical director in place. Complete the critical tasks in the implementation plan including report development and areas in system testing. Contracting and capitation Train staff related to detailed procedures for capitation reconciliation. System development for member-level eligibility and capitation payment reconciliation and related reporting. Provider network development ensuring access to care. Facilities management Ensure staffing hires continue in accordance with the needs of the organization to be ready on go-live. Member services/access Complete hiring needs (seven licensed clinicians and two unlicensed staff). Complete IRR P&P. Clinical CM/UR Complete hiring needs (one I/DD and five MH/SA staff). Use data and planned staffing plan to determine caseload ratios. Determine UR reporting needs and prepare for production. Ensure strong, knowledgeable and engaged clinical expertise, including a permanent medical director in place. MERCER 21

24 Eastpointe Plan of Development Care coordination Complete decision trees and protocols for identification of members in need of care coordination, for assignment to care coordination and for discontinuation of care coordination for MH/SA members. Use data to establish anticipated staffing needs, consistent with national caseload standards for I/DD and MH/SA care coordination. Establish care management documentation expectations and systems that can be audited. Ensure strong, knowledgeable and engaged clinical expertise, including a permanent medical director in place. Network operations/provider relations Complete provider credentialing and execute contracts. Complete geo-mapping to ensure adequate network access and choice. Ensure adequate network to meet unique needs of Robeson County. Quality assurance and quality improvement Clarify the staffing plan and organizational chart for quality improvement, ensuring that resources are sufficient to meet expectations of the program. Complete hiring needs for the quality improvement unit. Finalize all P&Ps. Incorporate medical director signature for P&Ps that are clinical in nature. Determine QM reporting needs and prepare for production. Ensure strong, knowledgeable and engaged clinical expertise, including a permanent medical director in place. Financial management/monitoring General ledger conversion and testing. Review the new financial reporting requirements to ensure that Eastpointe develops its system to meet the State requirements. Report development is just under way and needs to be fully tested and implemented prior to go-live. Testing and validation of financial software applications, system interfaces and reporting processes. Eastpointe has developed some of the required P&Ps that are needed for financial processes. They need to complete the development of the detailed procedures related to critical financial processes related to eligibility reconciliation, capitation payment reconciliation and month-end processing, fraud and abuse, and ensure that report development supports the detailed processes. Ensure finalization of the IBNR P&P, and validate that the estimation is accurate and timely to complete month-end accrual accounting. Load provider contracts in claim system and general ledger to ensure accurate provider payments. Claims and IT staffing Report development with the current staffing levels. Claims administration system development Eligibility intake and reconciliation with error reports to validate correct Medicaid enrollment needs MERCER 22

25 Eastpointe Plan of Development additional development. This includes how Eastpointe will use the global eligibility file, the 834 eligibility monthly file and the 820 reconciliation file, along with the 270/271 eligibility verification processes. Test processes and reports need to be confirmed. P&P development and finalization of all of the areas associated with Medicaid business needs to be completed. This includes but is not limited to: Retro termination of members Processes for retro notification of members with other insurance Avatar edits and processes Claims processing coordination of benefit steps Processes for Eastpointe when there are Medicaid fee schedule changes and how Eastpointe will handle them (i.e., retro payments, annual updates). There is not a current link between the Avatar claims system and the Great Plains financial system for the electronic transfer of claims information to the general ledger, with the return of check number by claim number with date of payment and amount. This is not only necessary for reporting internally, but is information necessary for the 835 remittance advice or the paper explanation of payment. Eastpointe is planning to use a script tool that they have not tested and do not know if there is known performance with the Avatar system. Internal system claim processing edit codes are not fully developed or tested, nor are they crosswalked to the necessary HIPAA 835 remittance advice code. This would include edits after any manual processes are performed. Testing has been started, but it very limited. Tables in the test environment are not set up to mirror what will be necessary in the production environment. For testing, diagnosis code is allowed, which would not be allowed under the PIHP plan. Institutional claims will be required to be submitted on the 837I format; however, there was not any evidence of actual testing to show that Eastpointe can accept in the 837I claims data, import the data and accurately process the claims. The outpatient emergency department claims need to collect and report both the revenue code and applicable procedure code per service. Currently, Eastpointe can only receive one or the other of these codes on each detail service line. Testing of ValueOption authorizations needs to be completed to ensure services authorized for periods greater than January 1, 2013 will be able to be addressed and/or apply to claims processed. Voids and adjustments of claim process need to be tested and validated, including how these are reflected in the data warehouse. Tracking of incoming claims (electronic data interchange, claims portal and paper) to ensure all claims are timely processed. MERCER 23