Tackling Compliance in a New Health Plan: Integration of Compliance and Quality via Audit

Transcription

1 Tackling Compliance in a New Health Plan: Integration of Compliance and Quality via Audit Vanessa Skawski Regulatory Affairs Compliance Manager ArchCare Community Life The ArchCare Organization - Overview ArchCare Community Life (ACL) is one of the health programs offered by the ArchCare organization ArchCare is the Continuing Care Community of the Archdiocese of New York Mission: provide faith based holistic care to frail and elderly people unable to fully care for themselves Provider of: Long term residential care Short term rehabilitation Nursing home alternatives Home health services Health plans End of life care Specialized care 1

2 TOPICS Background: ACL and the changing Medicaid landscape ACL s challenge: How to approach compliance in a new program ACL s solution: Situate a compliance auditor in the quality department Quality/compliance process flow The views expressed herein are my own and do not necessarily represent the views of ArchCare Community Life or the ArchCare organization. Background: The Changing Medicaid Landscape 2

3 Medicaid changes Source: Medicaid in an Era of Health & Delivery System Reform: Results from a 50-State Medicaid Budget Survey for State Fiscal years 2015 and 2015, KFF.ORG Managed Long Term Services and Supports (MLTSS) What is MLTSS? State pays contractor a capitated amount Contractor delivers long term services and supports Expands home and community-based services Variation from state to state Populations enrolled Services included in the capitation rate Mandatory vs. voluntary enrollment 3

4 Managed Long Term Services and Supports (MLTSS) Managed Long Term Services and Supports (MLTSS) 370% increase 4

5 26 States with MLTSS as of 11/2015 Source: National Association of States United for Aging and Disabilities, State Medicaid Integration Tracker, November 2, 2015 How does ArchCare Community Life (ACL) fit into the changing Medicaid landscape? 5

6 MLTSS in New York Three plans developed in New York Program of All Inclusive Care for the Elderly Provides all the care and services covered by Medicare and Medicaid Distinguished by plan s adult day center Members visit primary care doctor and get other services Members participate in social activities Plan arranges for transportation to the center Medicaid Advantage Plans Covers all Medicaid home care and long term care services Also provides Medicare services from the plan. Partially Capitated Managed Long Term Care Plans (MLTC) Covers Medicaid home care and long term care services ACL is an MLTC What does ACL cover? Adult day health care Hearing aids Case Management CDPAS Dental services Home care Home delivered meals DME Medical supplies Medical social services Medical transportation Nursing home Nutrition Optometry Personal Care PERS Podiatry Private Duty Nursing Prostheses Rehabilitation therapies Respiratory therapies Social day care Social/Environmental supports 6

7 The basics: how does ACL work? Care team model SOCIAL WORKER NURSE MEMBER SERVICES REPRESENTATIVE Who is eligible? Mandatory enrollment: Dual eligible Over 21 Need community based long-term care services for more than 120 days Reside in the counties of NYC, Nassau, Suffolk or Westchester. Voluntary enrollment: Dual eligible 18 through 21 years of age Need community based long term care services for more than 120 days Assessed as nursing home eligible OR Medicaid eligible Over 18 years of age Need community based long term care services for more than 120 days Assessed as nursing home eligible. 7

8 Why does ACL have a story to share? Mandatory enrollment Auto-assignment into MLTCs Rapid growth Mandatory Enrollment in MLTCs Source: United Hospital Fund, Mandatory Managed Long-Term Care in New York's Medicaid Program: Key Eligibility and Enrollment Issues 8

9 ACL s challenge: How to approach compliance in a new program ACL s Challenge: How to approach compliance in a new program Inherent risks for any new plan New procedures Changing regulations Rapid growth 9

10 Challenge 1: New Procedures Procedures that were created to follow a new set of regulations should be evaluated ACL s experience: Mandatory enrollment in New York brought a new set of regulations Policies and procedures were created to meet these requirements before plan launched Considerations once the plan is operational: Do these policies work? Are they being followed? Is there compliance on a day-to-day basis? Challenge 2: Changing Regulations Frequent updates to regulations require corresponding changes in practices Changes to eligibility criteria Updates to marketing guidelines Change in assessment instrument New procedures for prior authorizations 10

11 Challenge 3: Rapid Growth Rapid growth increases the importance of monitoring and transparence ACL s experience 0 to 1800 members in less than 18 months Do existing procedures meet increased demand? Are existing internal controls adequate? ACL s solution: Situate a compliance auditor in the quality department 11

12 ACL s Solution : Situate a compliance auditor in the quality department Reporting Structure VP of Compliance, ArchCare Director of Quality, ArchCare Community Life ArchCare Community Life Auditor Benefits of the compliance/quality relationship Benefit 1: Forward-looking approach Undiluted resource dedicated to audit Proactive vs. reactive tone Issues identified sooner Issues corrected sooner 12

13 Benefits of the compliance/quality relationship Benefit 2: Targeted issue identification Quality issues identify audit topics More effective risk assessment Anecdotal reports assist in prioritization Amendments to annual schedule when needed Benefits of the compliance/quality relationship Benefit 3: Facilitation of knowledge transfer Risks in being a team of 1 Mitigated via placement on an existing team 13

14 Benefits of the compliance/quality relationship Benefit 4: Workflow efficiency Compliance and quality goals overlap Audit provides relevant results to both groups Duplicate work is minimized Relevant information is not siloed Benefits of the compliance/quality relationship Benefit 5: A chain reaction of improvements Addressing noncompliance improves quality Corrective actions increase quality and compliance 14

15 Quality/Compliance Process Flow Process Flow Risk Assessment Reaudit Tracking Audit Schedule Development Post Audit Review Responsible Departments Pre-Audit Meeting Post Audit Review Compliance and Quality Audit 15

16 Quality/Compliance Workflow Step 1: Risk Assessment Auditor and Quality Director Sources: OMIG Workplan Feedback from department heads CMS Audit readiness checklist for other MLTSS products Quality/Compliance Workflow Step 2: Audit Schedule Development 6 intensive audits Auxiliary audits as time permits Format sample Month Description Objective January Marketing To ensure MLTC s marketing plan and activities comply with MLTC Contract requirements, internal policies, and New York State Department of Health Policy To ensure assessment timing is in line with contract requirements, Not Taken Under Care forms are used properly, and there are no signs of cherrypicking. March Claims File Claims files containing all claims received by MLTC for a given member will be audited against authorizations to ensure that authorized services are being provided as specified and all members are receiving qualified community based long term care services. 16

17 Quality/Compliance Workflow Step 3: Pre-Audit Meeting of Compliance and Quality Review: Scope Methodology Process Discuss timing Quality/Compliance Workflow Step 4: Audit Create an audit-specific tool 17

18 Quality/Compliance Workflow Step 4: Audit Write the report Format Objective Methodology Scope Discussion Illustrate findings with charts and graphs Include policy audit as attachment Quality/Compliance Workflow Step 5: Post-Audit Review with Compliance and Quality Deeper dive on certain results? Who to include in next step of audit review? What could work as corrective actions? 18

19 Quality/Compliance Workflow Step 6: Final Audit Review with Relevant Department Heads Template used to facilitate meetings NOTE: DATA ABOVE IS SIMILATED. ACTUAL DATA WAS NOT USED. Quality/Compliance Workflow Step 7: Reaudit Tracking of Compliance Indicators COMPLIANCE INDICATOR ORIGINAL AUDIT January February March April MAY Type of Requirement All members are assessed. Noncompliant 90% assessed Compliant 100% assessed Compliant 100% assessed Decline 93% assessed Compliant 100% assessed Compliant 100% assessed Regulatory Assessments are completed timely. Noncompliant 90% timely Noncompliant 90% timely (9 of 10) Improvement 91% timely (10 of 11) Improvement 94% timely (15 of 16) Compliant 100% timely (15 of 15) Compliant 100% timely (14 of 14) Regulatory Mediture files contain 9 required enrollment documents. Noncompliant 7 docs 100% present 2 docs 90 % present Noncompliant 7 docs 100% present 2 docs 90 % present Improvement 8 docs 100% present 1 doc 90 % present Stable 8 docs 100% present 1 doc 90 % present Compliant 9 docs 100% present Compliant 9 docs 100% present Internal requirements imposed via New York Staterequired and approved Enrollment Procedures NOTE: DATA ABOVE IS SIMILATED. ACTUAL DATA WAS NOT USED. 19

20 Questions? 20