Colorado Access Regional Care Collaborative Organization Reference Guide Accountable Care Collaborative

Transcription

1 2011 Colorado Access Regional Care Collaborative Organization Reference Guide Accountable Care Collaborative Colorado Access 10/19/2011l

2 Contents Content Page Number Accountable Care Collaborative 3 ACC Map 4 Colorado Access RCCO Staff Contact Information 4 Who should I contact 5 Medical Home Model Principles 6 Care Management 7-8 HCPF Web Portal 9 Instruction References Billing Specialist Services Request for PCMP Medicaid Patient List Referral Exclusions 15 Informational Website Links 16 2 P age

3 Welcome to the Accountable Care Collaborative (ACC) The Accountable Care Collaborative (ACC) is a new Medicaid program to improve clients' health and reduce costs. Medicaid clients in the ACC will receive the regular Medicaid benefit package, and will also belong to a Regional Care Collaborative Organization" (RCCO). Medicaid clients will also choose a Primary Care Medical Provider (PCMP). What is a Regional Care Collaborative Organization (RCCO)? The RCCO connects Medicaid clients to Medicaid providers and also helps Medicaid clients find community and social services in their area. The RCCO helps providers to communicate with Medicaid clients and with each other, so Medicaid clients receive coordinated care. A RCCO will also help Medicaid clients get the right care when they are returning home from the hospital or a nursing facility, by providing the support needed for a quick recovery. A RCCO helps with other care transitions too, like moving from children s health services to adult health services, or moving from a hospital to nursing care. What is a Primary Care Medical Provider (PCMP)? A primary care medical provider (PCMP) is a Medicaid client's main health care provider. A PCMP is a Medicaid client's medical home, where he/she will get most of their health care. When a Medicaid client needs specialist care, the PCMP will help him/her find the right specialist. All clients enrolled in the ACC have a PCMP. Source: 3 P age

4 The State s Accountable Care Collaborative has divided the counties across the state into regions called Regional Care Collaborative Organizations (RCCO). The RCCO helps manage care of those ACC members living in the counties within their region. The table below shows the counties served by each RCCO. Colorado s Accountable Care Collaborative Organization Map Colorado Access Regional Contract Managers & Additional RCCO Staff Region 2 Contract Manager & Community Liaison Dave Rastatter [email protected] Medical Director Dr. Mark Wallace [email protected] Region 3 Contract Manager & Community Liaison Molly Markert [email protected] Medical Director Dr. Deb Parsons [email protected] Region 5 Deputy Director, Medicaid & Contract Julie Holtz [email protected] Manager & Community Liaison Vice President, Medical Services & Senior Medical Director Region 5 Dr. Genie Pritchett [email protected] Additional RCCO Staff Executive Director Medicaid April Abrahamson [email protected] RCCO Project Manager Amy Akapo [email protected] RCCO Program Services Manager Drew Kasper [email protected] RCCO Program Services Coordinator Michelle Pryor [email protected] 4 P age

5 WHO SHOULD I CONTACT? 1 5 P age

6 Medical Home Model Principles The Accountable Care Collaborative Program administered by the State of Colorado s Department of Health Care Policy and Financing outlines the following Medical Home Model Principles in their Contract with Colorado Access for the Regional Care Collaborative Organization. The following are the principles of the Medical Home Model: 1) The care provided is: a) Member/family-centered; b) Whole-person oriented and comprehensive; c) Coordinated and integrated; d) Provided in partnership with the Member and promotes Member self-management; e) Outcomes-focused; f) Consistently provided by the same provider as often as possible so a trusting relationship can develop; and g) Provided in a culturally competent and linguistically sensitive manner. 2) A PCMP that is: a) Accessible, aiming to meet high access-to-care standards such as: i) 24/7 phone coverage with access to a clinician that can triage; ii) Extended daytime and weekend hours; iii) Appointment scheduling within: (1) 48 hours for urgent care, (2) 10 days for symptomatic, non-urgent care (3) 45 days for non-symptomatic routine care; and iv) Short waiting times in reception area. b) Committed to operational and fiscal efficiency. The Contractor s PCMP network shall provide for extended hour on evenings and weekends and alternatives for emergency room visits for after-hours urgent care. The Contractor will determine the appropriate requirements for the number of extended hours and weekend availability based on the needs of the Contractor s Region, and submit these requirements to the Department for approval. The Contractor shall assess the needs of the Contractor s Region on a regular basis, no less often than quarterly, and submit a request to the Department to adjust its requirements accordingly. c) Able and willing to coordinate with its associated RCCO on medical management, care coordination, and case management of Members. d) Committed to initiating and tracking continuous performance and process improvement activities, such as improving tracking and follow-up on diagnostic tests, improving care transitions, and improving care coordination with specialists and other Medicaid providers, etc. e) Willing to use proven practice and process improvement tools (assessments, visit agendas, screenings, Member self-management tools and plans, etc.). f) Willing to spend the time to teach Members about their health conditions and the appropriate use of the health care system as well as inspire confidence and empowerment in Members health care ownership. g) Focused on fostering a culture of constant improvement and continuous learning. h) Willing to accept accountability for outcomes and the Member/family experience. i) Able to give Members and designated family members easy access to their medical records when requested. j) Committed to working as a partner with the RCCO in providing the highest level of care to Members. 6 P age

7 RCCO Care Management Categories Category #1: Assessments The primary function of the Assessment Care Management Category is to perform outreach to RCCO patients for the purpose of administering Health Risk Assessments (HRAs). The HRA can help distinguish between RCCO Members who need: Monitoring/Surveillance, vs. Moderate Intervention/assistance, vs. A more intensive level of RCCO Care Management Category #2: Routine and Intensive Care Management The primary functions of Routine and Intensive Care Management Category include: Stratification of RCCO patient population Individual needs assessments Development of individualized care plans Assisting with access to care Assisting members who require coordination (with medical and non-medical services) Intensive Care Management, serving populations such as: o Members with complex medical needs and treatment regimens. o Members who need additional assistance in managing their medical care. o Members having difficulty contacting other physicians or obtaining medical equipment or medications. o Members who lack adequate social support systems. o Members with both physical and behavioral health needs. Category #3: Transitions of Care The primary functions of Transitions of Care involves assistance during care transitions from hospitals or other care institutions to home or community-based settings; Or during other transitions, such as the transition from children s health services to adult health services, or from hospital or home care to care in a nursing facility. Delegation of RCCO Care Management The RCCO-HCPF contract defines certain terms of Care Management delivery that Colorado Access can provide for your RCCO patients. When a PCMP is capable of providing those Care Management functions, as defined in the RCCO-HCPF contract, Colorado Access can delegate those functions to the PCMP. Full Delegation PCMP is delegated for all 3 categories of RCCO Care Management Partial Delegation PCMP is delegated for 1-2 categories of Care Management. Colorado Access does the remaining Care Management categories No Delegation Colorado Access handles all 3 categories of RCCO Care Management 7 P age

8 If I want to pursue delegation of RCCO Care Management, where do I start? PCMP fills out Pre- Delegation Questionnaire and s to Drew Kasper at RCCO (optional step) Dialogue underway. When ready, PCMP fills out their section of the Pre-Delegation Audit Tool and sends to RCCO with supporting documents RCCO reviews information and schedules visit to PCMP site (by Program Services Manager and RCCO Contract Manager), to review the tool and Care Management program in detail. Customized Transition Process Agreement is completed, including designation of Care Management Categories for Delegation, and agreement on transition processes. RCCO reviews the findings of the pre-delegation audit and provides PCMP with a formal follow-up response. While this represents the typical process flow, Colorado Access wants to accommodate your individual practice needs. For instance, we would be happy to walk through the pre-delegation audit tool with you, as a first step, if you prefer. Please let us know, what works best for you. To access the RCCO Care Management Pre-Delegation Questionnaire or Audit Tool, please contact your RCCO Contract Manager, or the RCCO Program Services Manager (Drew Kasper, [email protected], P age

9 HCPF Web Portal Example below shows how a patient of the Accountable Care Collaborative Program appears in the HCPF Eligibility Portal Link to HCPF Legibility Portal: The screen sub-heading that previously read Prepaid Health Plan will now read Accountable Care Collaborative. If the client is enrolled in the ACC program, one of the following phone numbers will be at the bottom of the last screen under the heading Prepaid Health Plan or Accountable Care Collaborative Contact Phone Number : RCCO RCCO RCCO P age

10 Instruction References Billing for Specialist Services August 30, 2011 Dear Primary Care Medical Provider for RCCO Regions 2, 3 and 5: It has come to our attention that there is confusion about billing for specialty services under the RCCO program. We know that all of you have established solid working relationships with medical specialists to whom you refer your primary care patients. We are committed to preserving and enhancing those relationships by providing useful information and technical assistance when issues or questions arise. To that end, we wanted to provide you with guidance on how specialists should bill for the services they provide to your patients: 1. When referring to a specialty provider, please give the specialist your Medicaid billing identification number, along with whatever necessary clinical and medical history information you routinely provide when making a specialty referral. 2. The specialty provider should include the name of the referring physician (the PCMP physician or practice name) in field number 17, Name of Referring Physician or other Source on the HCFA-1500 and the Billing ID Number on Field number 17a, ID Number of Referring Physician. Inclusion of this billing information on the specialist s claim indicates that this referral is being made by a contracted Primary Care Medical Provider under the RCCO program. We have attached a copy of the HCFA form for your reference. 3. There are no other prior authorization or utilization management requirements that must be met in order to make a specialty referral. The specialist will get paid by Fee-for-Service Medicaid for their services so long as the referring provider s billing information is provided on the claim. 4. Please be aware that some medical procedures, equipment and prescription medications require prior authorization. More information on these requirements is available at We will post this information and instructions on our website at under the Provider tab. Please feel free to distribute this information within your practice and to your specialists as needed. As always, don t hesitate to contact any of us on the Colorado Access RCCO team if you have questions or need our assistance. Thank you for your valued participation as a provider in the RCCO program. Sincerely, The Colorado Access RCCO Team 10 P age

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12 Request for PCMP Medicaid Patient List September 12, 2011 Dear RCCO Primary Care Medical Provider: Colorado Access RCCO staff have been working with the Department of Health Care Policy and Financing (the Department) to better understand current and proposed member attribution models and to identify effective means to increase attribution to participating PCMPs. We all share the Department s commitment to enroll ACC eligible Medicaid members in the program and get them well connected to a medical home. We also appreciate your eagerness to provide high quality primary care services to RCCO members. As described in the attached letter dated August 10, 2011, the Department has reviewed a sample of Medicaid patient lists from some of our PCMPs to try and determine the discrepancy between the number of members they believe could be reasonably attributed to them to the number actually attributed. Their findings are described in more detail in the letter and speaks to their commitment to continue to seek better solutions for the attribution process. To that end, Colorado Access has offered some technical assistance to the Department in conducting further analysis of our provider s current lists of Medicaid patients. Our goal is to compile these lists and analyze where our Medicaid members are receiving their primary care services, recognizing that many may have received care with more than one of you in the past year. We have no guarantee that the Department will use our analysis or recommendations for future attribution, however we are hopeful that we may be able to guide continued discussions about how to get members appropriately attributed to a medical home. We have consulted with legal counsel and have confirmed that the exchange of this requested patient information is allowable under HIPAA treatment, payment and operations provisions and under the Business Associate Agreements that Colorado Access has with the Department under our RCCO contracts. If you would like to participate in this effort, we have developed the attached Excel spreadsheet for you to use in providing your current Medicaid patient lists. The initial elements we need for this analysis are the Member s name, Date of Birth and Medicaid ID #. Please do not include those Medicaid members who: 1. Have concurrent Medicare coverage in addition to their Medicaid 2. Are currently institutionalized or incarcerated Please encrypt and password protect the Excel spreadsheet on which you are providing this information and these to [email protected] by October 1, Please do not hesitate to contact your Colorado Access Contract Manager if you have questions or need assistance with this request. We thank you in advance for your assistance with this effort. Sincerely, The Colorado Access RCCO Team 12 P age

13 COLORADO DEPARTMENT OF HEALTH CARE POLICY & FINANCING 1570 Grant Street, Denver, CO (303) (303) Fax John W. Hickenlooper, Governor Susan E. Birch MBA, BSN, RN, Executive Director August 10, 2011 Dear Primary Care Medical Provider: A number of ACC Primary Care Medical Providers (PCMPs) noted a gap between the number of Medicaid members on their panel and the number enrolled in the ACC program. Although the Department did not guarantee enrolling a provider s entire panel, we have been trying to enroll as many attributed clients (clients we can connect to a provider) as possible, up to 75% of the RCCOs population. In order to research the discrepancy between the number of Medicaid members you expect and the number that are assigned to you in our ACC attribution process, we asked providers to submit a list of Medicaid clients who are on their panel. Thank you to those of you who submitted this information. We used that information to research why the numbers we are able to attribute to you are lower than what you anticipated. We identified the following reasons for this discrepancy: 1. Adults v. Children: Currently we are trying to maintain a ratio of two-thirds adults to onethird children. Since the Medicaid population is roughly the reverse of that (two thirds children to one third adults), the pool of potential enrollees is significantly smaller. 2. Duals: Of the adult members on your Medicaid panel, a number have different primary insurance (such as Medicare). We are not currently enrolling anyone with another primary insurer. 3. Not Medicaid Eligible: Of the population you identified as your Medicaid population, a notable percentage are not currently Medicaid eligible. Individuals on Medicaid may lose and regain Medicaid eligibility several times over the course of a year. 4. Attributed to another provider: We attribute members to the provider who they have seen the most. If a patient on your panel has seen another primary care physician more frequently they would be attributed to that provider. We are working to avoid severing existing patient-provider relationships. 5. Outside Focus Community: We are only enrolling members who reside in one of the counties that the RCCO identified as their initial focus community. Patients on your panel who reside outside of those counties cannot be enrolled. Our research found the percentages that fall into the groups listed above are slightly different for each practice. We are currently exploring alternative methods to attribute a higher percentage of your adult patient panel, such as expanding focus community boundaries. We appreciate your patience and partnership as we launch this new program. If you have questions or need additional information please contact one of the ACC contract managers listed below. Sincerely, Kathryn Jantz, RCCO 1 and 4 Contract Manager, , [email protected] Greg Trollan, RCCO 6 and 7 Contract Manager, , [email protected] Curtis Johnson, RCCO 2, 3 and 5 Contract Manager , [email protected] colorado.gov/hcpf 13 P age

14 Medicaid Patient List Practice Name: Date Prepared: Prepared by: Phone number: Patient Last Name Patient First Name STATE MEDICAID ID # DOB Smith Sue Y /1/ P age

15 Referral Exclusions PCMPs may refer Members/Patients to any specialists enrolled in Medicaid or any other Medicaid provider, including those not associated with the Contractor or another RCCO. PCMPs are not required to provide a referral when the Member/Patient receives any of the following services: Emergency care. EPSDT screenings. Emergency and non-emergent medical transportation. Anesthesiology services. Dental services. Vision services. Family planning services. Behavioral health services. Home and Community-Based Waiver services, as defined in the State Plan that the Department has submitted to the Centers for Medicare and Medicaid Services. Obstetrical care. 15 P age

16 Health Care Policy and Financing Informational Web Links: Health Care Policy and Financing website Information about RCCOs ACC Provider Information Colorado Access Informational Web Links: Colorado Access RCCO Colorado Access RCCO Provider Information Colorado Access RCCO Member Information Colorado Access for Our Providers (PCP Reports) 16 P age