Qualis Health Alaska Medicaid Care Management Overview

Transcription

1 Qualis Health Alaska Medicaid Care Management Overview Grace Ingrim, RN, BSN, CCM Director, Alaska Medicaid Services Eric Wall, MD, MPH Senior Medical Director Advancing Healthcare Improving Health

2 Presentation Objectives Provide an overview of Qualis Health Updates to the State of Alaska, Division of Health Care Services Utilization and Case Management Program (UM and CM Programs) Present useful tips to support UM web based reviews via iexchange system. 2

3 Qualis Health Background Qualis Health is a private, nonprofit healthcare quality improvement and care management organization headquartered in Seattle, with offices in Alaska, Alabama, California, Idaho and Nebraska. Qualis Health has 37 years of experience providing healthcare utilization, case management and quality assessment/improvement services to public and private sector customers. Qualis Health has experience collaborating with healthcare providers in Alaska since

4 Qualis Health: Advancing Healthcare Mission To generate, apply, and disseminate knowledge to improve the quality of healthcare delivery and health outcomes. Vision To be recognized for leadership, innovation and excellence in improving the health of individuals and populations. Values Integrity, professionalism, collaboration and stewardship. 4

5 Qualis Health in Alaska Services Utilization Management (UM) Case Management (CM) Care Coordination Health Information Technology (HIT) Consulting Contracts Medicaid (UM & CM, Mental Health, TEFRA & Waiver, HIT) Commercial (UM & CM) 5

6 Qualis Health Accreditations Quality Improvement Organization (QIO) Accredited by URAC for compliance with nationally recognized standards in Health utilization management Case management Many staff hold certifications / licensure in advance practice areas. 6

7 Program Indicators of Excellence URAC accreditation in health utilization management and case management 2010 Platinum Award for Medicaid Case Management Program 2010 Platinum Award for Utilization Management Program 7

8 Utilization Management 8

9 Utilization Management Review for medical necessity, appropriateness of treatment and select diagnosis and procedures Assure appropriate use of healthcare resources Assist providers and patients with identifying healthcare service alternatives Immediate referrals for case management 9

10 Do I need to submit a Review? Pre-certification list Three-day benchmark Certain maternal/ newborn stays 10

11 Utilization Management Process Review submission via the web using iexchange Clinical review utilizing InterQual or other criteria set Approval or referral to physician reviewer Certification or non-certification Appeals / hearing process for non-certified cases 11

12 Web-Based Utilization Review Submission iexchange is a web-based tool from MEDecision 24/7 submission through the web Review the status of your request online Communicate directly with Qualis Health 12

13 Why Use iexchange State of Alaska requirement Secure access Increased efficiency Efficient communication 13

14 iexchange Benefits to You Ease of entry Immediate feedback Ability to review updates at any time Access to patient s UM review status and history 14

15 iexchange Preview Page 15

16 iexchange Confirmation 16

17 Qualis Health training Qualis Health online manual and videos Local Support Trouble shooting Qualis Health iexchange Helpdesk Phone iexchange Support 17

18 iexchange Web-based Utilization Management To sign up or request user training please contact the iexchange Helpdesk via 18

19 Pre-Service Utilization Review Pre-certification list Select diagnosis and procedures only Tips No review needed if not on pre-certification list/exceeding three-day benchmark Facilities can see reviews submitted by provider office Add days to pre-service if needed Specifics like L4-5 or right/left/bilateral Submit planned admits within one week; urgent within one day 19

20 Updated Pre-Certification List Update 20

21 Pre-Certification List Updates Cranial implantation or replacement of neurostimulator pulse generator Fat grafting procedures Tips Diagnosis Code range Medical admits for psychiatric review 21

22 Pre-Service Approval Timeframe Pre-service authorizations for surgeries are valid for four months from date of approved authorization Transplant pre-service authorizations are valid for six months from date of approved authorization 22

23 Concurrent Review Concurrent reviews for the following situations: The three-day benchmark Facility confinement reaches the review date and discharge is unlikely Changes in clinical status dx/px requires review 23

24 Retrospective Reviews Reviews after services rendered - Retro eligibility - Retro/late review iexchange Tips Submit summary in one week increments Target IQ criteria Avoid split authorization /bill 24

25 Timeframes of Reviews Timeframes for UM review decisions URAC Collaboration for timeliness/efficient reviews iexchange 25

26 Maternity / Newborn Reviews Date of delivery/birth and discharge rather than admission and discharge. 48 hours of inpatient stay following vaginal delivery 96 hours of inpatient stay following cesarean delivery 26

27 Maternity / Newborn Reviews (cont.) Vaginal delivery Cesarean delivery Administrative authorizations Neonatal reviews: 38 weeks 27

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29 Alternatives to Discharge Swing bed days (rural) Administrative wait days (urban) Request to SDS using a long-term care (LTC) authorization form Case management 29

30 Certification Modifications Use iexchange to request changes to the original certification Requested changes may require additional medical necessity review Changes are made and forwarded to Fiscal Agent 30

31 Auth Modification Request 31

32 UM Tips Chemo admits need protocol # Gestation age of infants Pt admitted for a medical reason, and subsequently undergoes surgery Transfer reviews Less is MORE! Retrospective reviews-weekly summaries Specifics like L4-5, C3-5, right/left/bilateral 32

33 iexchange Tips Security/timing out Can add CSR to pre-service Ability to see authorization from MD Passwords reset every 10 minutes DOS older than one year Communication - name and phone number Retrospective review 33

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35 Medical Affairs Department overview Roles and responsibilities Pre-authorization process and tips Appeals process 35

36 Medical Affairs Department Overview 12+ physicians based in Seattle One physician based in Anchorage (behavioral health) Approximately 300 specialist consultants All board certified 36

37 Medical Affairs Department Roles and Responsibilities Medical review of pre-authorization requests Physician-to-physician calls/discussions Clinical consultation for case managers Medical review of appeals (if same specialty) Fair hearings 37

38 One Pre-authorization Perspective 38

39 And Another! 39

40 Pre-Authorization Process and Tips Best case: Reviews are expedited when all necessary information is submitted Physician review of pre-authorization requests when a clinical nurse reviewer is unable to authorize Most pre-authorization requests would be approved if all information provided All potential denials: Advanced notification with offer of MD-to-MD discussion Appeal rights for all denials 40

41 Continued Stay Review Tips Document intensity of services Treatment goals Discharge plans and expected date if possible 41

42 Physician-to-Physician Discussion Offered for Potential Non-certifications Case discussion offered, to be completed at end of the next business day Extenuating circumstances may allow extension of timeframe Prior decisions / recommendations may be overturned in this process Key takeaways: The right information the first time avoids delay The physician calling in should be familiar with the patient/case 42

43 Appeal Reviews Offered for all denied requests Available to providers and recipients Appeals reviewed by specialty peer match (same specialty as requesting physician) Appeals determinations take precedence 43

44 Standard Appeals May be requested any time up to 180 days from date of non-certification notification Qualis Health has 30 days from the date of the request to complete the review process 44

45 Expedited Appeals Case involving urgent / emergent care Patient may be hospitalized or require urgent services Must be requested within two business days from the date of the non-certification notification Qualis Health has one business day from the date of the request to complete the review process 45

46 Second / DHCS Level Appeal Additional appeal process for Providers Request in writing and postmarked within 60 days of the date of the first-level appeal from Qualis Health Submit requests to DHCS 46

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48 Utilization and Case Management Integration Majority of referrals come from UM reviews Auto referral Clinical reviewers may refer a patient to case management to support the discharge plan and the ongoing care needs of the patient 48

49 Qualis Health Website Point to Healthcare Professionals Click Alaska Medicaid Division of Health Care Services alaska-medicaid-division-health-care-services 49

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51 Qualis Health Contact Information Utilization Review Toll-free phone (800) Toll-free fax (800) Utilization Review Hours 6:30 am to 6:00 pm Alaska Time Monday through Friday 51

52 Qualis Health Alaska Office Grace Ingrim, RN, BSN, CCM Director, Alaska Medicaid Services (907) or (877)

53 Questions? 53

54 Lunch 54

55 Case Management Shelia Markley, RN, CCM Nurse Case Manager Advancing Healthcare Improving Health

56 Presentation Objectives Provide overview of case management Share a case example to demonstrate the case management process Provide referral resource information 56

57 Overview of Case Management Team-oriented approach Voluntary case management program utilizing evidence based practices Integrated approach for clients with catastrophic illness and injury Based throughout Alaska and in Seattle, Washington 57

58 Goals of Case Management Promote self/family management Provide evidence-based interventions; including care transition support Improve health status and quality of care Support appropriate health service utilization and cost Improve patient and provider satisfaction 58

59 Case Management Referrals Utilization management Healthcare facilities State agencies Fiscal agent Community providers Families 59

60 Case Management Referrals Who Should be Referred? Must be eligible for Medicaid or Denali KidCare Medically complex, catastrophic illness or injury High health services utilization and cost How can I refer a patient? 60

61 Case Management Process Complete case management assessment Develop plan of care Set goals Identify barriers Implement interventions Evaluate outcomes Assess for case closure 61

62 Case Example 55-year-old single female with CVA Social history: Lived alone; limited community and family support Acute care, rehab Care transitions 62

63 Plan of Care DME Pharmacy Transportation Therapies Waiver Care transition to swing bed / home 63

64 Barriers / Interventions Smooth transitions of care Coordination of home DME / equipment / supplies Coordination of therapies Medication adherence Transportation Waiver / safety Education provided for medications Dental needs / nutrition support 64

65 Outcomes Appropriate resource utilization Treatment adherence Obtained needed supplies and equipment in a timely manner Successful clinical outcome Move to self care 65

66 Referral to Case Management Case Manager Local Toll-free Kristen McDonald (907) (800) Patricia Blossom (907) (877) Shelia Markley (907) (888) Vicki Albert (907) (888) Call Qualis Health at (888) Fax referral form to (877) Refer directly to a case manager Qualis Health website: 66

67 Case Management Referral Form 67

68 Team Approach Enhances Care 68

69 Care Transitions Failed transition leads to substantial costs, morbidity, mortality and reputational risk. Interventions aimed at reliable handoff communication, close follow-up and engagement or activation of patients and families significantly reduce adverse events. 69

70 Evidence Based Interventions Motivational Interviewing (MI) Patient Activation Measure (PAM) Medication Reconciliation 70

71 Case Management Questions? 71

72 TEFRA Overview Lynda Billmyer Administrative Assistant Janet Cordell, RN TEFRA Nurse Reviewer Advancing Healthcare Improving Health

73 What is TEFRA? The Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) is a Medicaid program for children (under 19 years old) with disabilities and significant medical, developmental or psychiatric needs. This Medicaid program was developed with specialized requirements that may allow children, who would not typically qualify for Medicaid (because of family income), to receive Medicaid benefits. 73

74 Who are TEFRA children? TEFRA children are: Children whose parental income is over the Denali KidCare income limits Children who meet a definition of social security disability (if not for parental income/resources they would be eligible for SSI) Children who meet one of three level-of-care (LOC) categories Children whose personal income and resources are within Special Income Medicaid limits 74

75 TEFRA LOC Categories NF Skilled nursing facility LOC Intermediate LOC IPH Inpatient psychiatric hospital ICF/MR Intermediate care facility for mentally retarded 75

76 The TEFRA Team Parent(s) Division of Public Assistance (DPA) Qualis Health Division of Senior and Disability Services (DSDS) Care Coordinators Disability Determination Services (DDS) 76

77 Qualis Health s Role Work with care coordinators, families and state agencies to Provide administrative management and oversight throughout the application and renewal processes Assist participants in completing the application and renewal processes within specified timelines Review documentation for LOC determination (nurse reviewer) for SNF and IPH applications and renewals Physician support and consultation Support the hearing process 77

78 Determining LOC for NF or IPH Application / Renewal What are the care needs? Needs driven not diagnosis driven Not medical cost driven Chronic conditions Mild Moderate Severe Profound 78

79 Determining LOC (cont.) Services performed at home that would typically be rendered in a facility setting such as Hospital Residential psychiatric treatment center (RPTC) Nursing home Other institutional settings (ICF/MR) 79

80 Online Resource 80

81 TEFRA Contacts Cheri Herman Sonia Cornejo Alma Prado Intake Team Maint. Team Grace Ingrim Lynda Billmyer DPA Statewide LTC (907) DPA Coastal LTC Intake Team Supervisor (907) DPA Coastal LTC Maintenance Team Supervisor (907) Director, Alaska Medicaid Services (907) or (877) Qualis Health, Administrative Assistant (907) or (888)

82 Waiver / 3rd Party Review SDS / Medicaid Waivers: CCMC / IDD / OA / AP Independent Review of denied reassessments Nurse and Physician review support Hearing support 82

83 Panel Discussion Difficult Discharges UM/CM Collaboration Eric Wall; MD, MPH Senior Medical Director Qualis Health Panelists Betty Robards, MS Manager, Mental Health Qualis Health Patricia Blossom, RN, CCM, CPUM Case Manager, Qualis Health Advancing Healthcare Improving Health

84 Your Turn Q & A Session Qualis Health Welcomes Your Input Facilitated By Grace Ingrim, RN, BSN, CCM Director, Alaska Medicaid Services Advancing Healthcare Improving Health

85 Thank you for your participation Surveys will be ed tonight Please check your and complete your survey 85