HARMONIZING & STANDARDIZING BEHAVIORAL HEALTH CLAIMS, DATA COLLECTION AND REPORTING REQUIREMENTS Xpio Health Behavioral Healthcare and Medicaid System specific technology consulting firm Meaningful Use technical and regulatory expertise in Medicaid program across 15 states and multiple EHR s including CA. EHR Technical Support for the small counties in CA under CiMH contract Expert Panel for Washington State HCA on Medicaid Meaningful Use rollout Xpio Health, LLC Thad Dickson, CEO thad@xpiohealth.com Definitions MITA 3.0 Definition Harmonize Looking for the prevention or elimination of differences in the technical content of standards having the same scope. Harmonization looks at differences between process standard, and sets bounds to the degree of their variation. Standardize Standardization means creating uniform business processes across various divisions or locations. The expected results are processes that consistently meet their cost and performance objectives using a well-defined practice. The Medicaid Information Technology Architecture (MITA) is an initiative of the Center for Medicaid & State Operations (CMSO), and is aligned with the National Health Infrastructure Initiative (NHII). Office of the National Coordinator for Health Information Technology (ONC) Federal Health Information Technology Strategic Plan 2011 2015 California State Medi-Cal Health Information Technology Plan September 9, 2011 1
Conceptual Construct of MITA MITA Goals and Objectives MITA Artifacts Why it Matters? DHCS, office of HIPAA compliance just released a $1.3 million RFO for MITA. CA-MMIS Health Enterprise will support DHCS move towards HIE/HIT by improving health outcomes and quality services for Medi-Cal beneficiaries DHCS conducted a MITA State Self-Assessment (SS-A) for the Medi-Cal program in 2008 and will implement the SMHP consistent with MITA 2.0. DHCS is using the SS-A 3.0 today to support major projects such as its MMIS replacement 2
Why it Matters? Why it Matters? Upcoming MITA activity will create a roadmap for moving Medi-Cal to a service-oriented program The MITA Transition and Implementation Plan (M-TIP), which will document how DHCS intends to advance along the maturity continuum, is currently under development and will incorporate HIT planning efforts Health Information Technology In accordance with 42 CFR 438.204(f), DHCS information systems directly support the departmental and MMCD quality strategies. As part of the advancement of the information architecture, DHCS is working aggressively on: completing all conversions from local codes to HIPAA compliant codes; a project to convert the specifications for file transmissions from the current 35-C format to a HIPAA consistent 837 format for data coming from the Plans to DHCS; and development of data models that will improve consistency between data dictionaries. Better health for people, better health for populations, and better value for consumers Activities Supported by MITA and ICD-10 that help Achieve the NQS National Quality Strategy VBP* Care Management * Value-Based Purchasing Coverage (e.g. Drug Coverage) Person-Centered Benefits (e.g. HIX) Program Integrity (e.g. Deterrence of Fraud, Waste, and Abuse) Health Information Technology (HIT) Eligibility & Enrollment ICD-10 MITA Benefits & Coverage Payment 3
CMS Quality Strategy aims to promote safe, effective, patientcentered, timely, efficient, and equitable care. Evidence Based Care Promote Reimbursement through incentive structure Adopt electronic health records and new network to link health records nationwide Partnerships with external quality organizations are encouraged to refine quality measurement and reporting 13 CMS Quality Strategy Reduce Health Disparities Quality & Value Disseminate best practices for managing health disparities ICD-10 Impact/Opportunity Physician Quality Reporting System (PQRS) (Medicare Only) Accountable Care Organizations (ACO) Hospital Outpatient and Hospital Inpatient Measures Reduce care fragmentation and unsafe transitions, and to compare outcomes and costs for patients discharged to post acute care (e.g., ESRD) Monitor and evaluate the quality of rehabilitation services provided to Medicare beneficiaries in IRFs Facilitate best practices and forums for sharing information BEHAVIORAL HIT LANDSCAPE Change Agents in the HIT Landscape 1. ARRA, HITECH, HIPAA, and ACA 2. Primary Care and Behavioral Health Integration 3. HL7 Behavioral Health Continuity of Care Document 4. Managed care, case rates, capitation, and evolving financial models 5. Accountable Care Organizations and PCMH 6. HIE, PHR s, EHR s, and patient engagement 7. Privacy and Security 8. Meaningful Use Stage 1, 2, 3 9. ICD-10 10. DSM 5 EXISTING CHALLENGES 4
As Is condition Business Process Challenges for Counties 1. EHR s are complex, and when bent to meet unique standards or requirements, often break. Extensive internal testing and payer testing environments are needed. Also consider root cause of complexity. 2. Requirements need to be harmonized and standardized. Common frameworks should be prenegotiated by sending and receiving parties before systems are developed. 3. HIPAA and HL7 compliant and ACA standards and constructs need to be included. Cross walk engines baked in to handle ICD 10, DSM 5, SNOMED. New system should avoid being constructed around old rules. As Is condition (Infrastrucure) Business, Application, and Technical Architecture 1. Manual Processes 2. Siloed Programs 3. Batch file interfaces 4. Partially adopted standard data model 5. Fragmented stores 6. Legacy systems 7. Encapsulated subroutines 8. Standalone applications As Is condition As Is condition 5
MITA Maturity Model BUSINESS NEEDS AND OBJECTIVES INFORM AND DRIVE TECHNICAL DESIGN MITA BPM MITA 3.0 CONSTRUCT 6
MITA 3.0 Business Architecture Key Changes The MITA Medicaid Enterprise Maturity Model modified to accommodate Enhanced Funding requirements Modifications to procedures and business rules More clarity for maturity levels Business Process Model Ten (10) business areas Eighty (80) business processes Business Capability Matrix expanded to performance measures definitions FEA FHA Legend:: Other Payer Other Agency Provider CDC State Unemployment Agency CMS MITA Business Process #1 MITA Business Interface Process #2 Benefit Manager MITA Business Process #3 Department of Homeland Security License Board SURS or Fraud Contractor RHIO ONC Standards Organization 25 MITA guidelines apply; FFP 26 available Entity encouraged to follow MITA guidelines May exchange information; may influence MITA or vise versa Community Based Collaborative Care HL7 COMMUNITY BASED COLLABORATIVE CARE Mission The Community Based Collaborative Care (CBCC) Work Group facilitates development and use of HL7 standards that support and integrate the provision of HHS (health and human services) in community and non-acute care residential settings. We engage experts and other stakeholders to identify, clarify, and validate (by consensus) information system requirements with an emphasis on privacy protection. 7
Community Based Collaborative Care Community Based Collaborative Care Opportunities for California Align technology with current MITA 3.0 standards Integrate Behavioral Health into the core infrastructure Focus on an outcomes based and data driven model Create a system that is harmonized with ACA, Behavioral Health and Primary Care Integration constructs, Patient Centered Care, the BH CCD Framework, HIPAA, HL7, Meaningful Use Stage 1, 2 and 3 Support exchange, interoperability, and payment models with efficient reimbursement, along with robust auditability. Create a national role model for State and County collaboration QUESTIONS / DISCUSSION 8
Meaningful Use Affirmations for Mental Health - AIU MEANINGFUL USE, MR. MIYAGI, AND WHY WE ARE ALL GRASSHOPPERS NOW 1. You DO (most likely) have a certified EHR 2. You DO (most likely) Qualify via Eligible Professionals 3. You DO (most likely) have adequate volume via Group 4. You CAN start in 2013 5. You CAN receive $21,250 per EP in Year 1 6. You CAN receive $63,750 per EP in 6 Years 7. This WILL require some effort 8. but it s worth it. Organization Meaningful Use Medicare and Medicaid MU Framework Medicare EHR Incentive Program Medicaid EHR Incentive Program Year 1 options Must demonstrate meaningful use in year 1 Adopt/Implement/Upgrade option in Year 1 Who is eligible? 3 5 types of EPs, subsection (d) hospitals, and Critical Access Hospitals (CAHs) 5 types of EPs, acute care hospitals, including CAHs, and children's hospitals Important dates Last year to begin participation is 2014 Last payment is in 2016 Last year to begin participation is 2016 Last payment is in 2021 MD and ARNP Benefit Re-assign Medicare payment adjustments Meaningful use definition 4 Begin in 2015 for EPs that are not meaningful users of EHR technology Definition of meaningful use for Medicare is standard None States can adopt their own definition (based on the Federal Medicare definition) Who will implement? Federal government (will be an option nationally) States, on a voluntary basis 9
AIU in 2013 Timeline 6 Years 2021 End ORGANIZATION MU ELIGIBILITY ANALYSIS I.E. SHOULD WE BOTHER? Organization - Analysis and Process Analysis and Process PECOS System Access EP Analysis of Prior MU IT Systems Overview Organization MU Program Viability Organization Initiatives Facility NPI and Billing 1. Program Overview and Organization Structure 2. Organization Initiatives and Opportunity Overlap 3. Facility NPI and Billing Relationships to EP s 4. EP Credentialing and PECOS Enrollments 5. Analysis of Prior EHR Incentive Enrollments 6. 3 rd Party Registrant Process 7. Medicaid Group Proxy Volume Estimates 8. Program Viability Determination EP Credentialing 10
Eligible Professional MU Program for Organization Medicaid 10 Potential Eligible Professionals 5 Validated Eligible Professionals 2013 Low Estimate = $ 106,250 2013 High Estimate = $ 212,500 CMS APPLICATIONS 3 RD PARTY PROCESS IN 3 STEPS Step 1 - EP Re-assignment of Benefit for Audit File Step 2 Send Access Request to NPI of EP 1) Have all participating EP s re-assign EHR incentive to Organization 11
Step 3 EP Approves Access Request Step 3 EP Approves Access Request from EP Account Begin CMS Registration From CMS to California Medi-Cal SLR 12
CA Express Attestation CA Express Attestation Medi-Cal SLR Account Creation CA Group Registration 13
Delegation of Authority CA Group Volume CA Group Volume CA Group Volume 14
Manage Providers Upload Documentation Group Express Attestation Submit Application 15
First collect and analyze NOW FOR THE FUN PART! Next Visualize Next Realize the benefits 16
QUESTIONS / DISCUSSION 17