VA Pa&ent- Centered Community Care Provider Network Management Training Deck
Agenda Program Overview Provider Network Implementa&on Appointment Process Medical Documenta&on Care Coordina&on Claims Overview Veteran Complaints / Grievances Review 2
Program Overview
Introduc&on The Pa&ent Centered Community Care (PCCC) program provides eligible Veterans access to care through a comprehensive network of community- based providers when the Veterans Affairs (VA) cannot provide the care in- house Health Net s extensive provider network provides coverage for: - Primary care services - Outpa&ent specialty care - Inpa&ent specialty care - Behavioral health care - Limited emergency care - Limited newborn care 4
PC3 Exclusions The following services are not covered under PC3: Dental care Nursing home care Long Term Acute Care Hospitals (LTAC) Homemaker and home health aide services Chronic dialysis treatments Compensa&on and pension examina&ons If HN receives an authoriza&on request for a non- covered service: Upon receipt HN will return the request via idocs to the referring VAMC and inform the Contrac&ng Officer (CO) / Contrac&ng Officer Representa&ve (COR) of the rejected authoriza&on VAMC reques&ng authoriza&on has the ability to review the authoriza&on request in the idoc queue sensi&ve pursuant to FOIA Exemp&on 4 5
Implementa&on Overview
PCCC Awarded Regions 7
Region 1 Privileged and Business sensitive pursuant to FOIA Exemption 4 8
Region 2 Privileged and Business sensitive pursuant to FOIA Exemption 4 9
Region 4 Privileged and Business sensitive pursuant to FOIA Exemption 4 10
Program Governance
Health Net s Program Management Office Dedicated account management staff for each region focused on collabora&ng with VISNs/VAMCs Understand VAMC priori&es Educate on how the program works Iden&fy VAMC network needs Exis&ng rela&onships with VA in several areas Significant similar experience (TRICARE, MFLC) allows us to draw upon proven approaches/best prac&ces Privileged and Business sensitive pursuant to FOIA Exemption 4 12
Program Management Office Suppor&ng Three Regions Program Manager Donna Hoffmeier Deputy Program Manager, Field Opera&ons Deputy Program Manager, Opera&ons Contract Manager Transi&on Manager Betsy Zande Kevin Rosen Rick Hobson Susan Cunningham Tye Hill Account Manager Region 4 Brian Corleb Account Manager Region 2 Dave Hunter Account Manager Region 1 Transi&on Team Dedicated program management and field staff Primarily using exis&ng staff with VA and/or DoD experience Regional account management suppor&ng Regions 1, 2, and 4 13
Provider Network Management
Network Providers Par&cipa&ng provider network consists of: Preferred Provider Network MHN Mul&plan Lebers of Agreement Providers who par&cipate and receive payment through PC3 must be creden&aled by Health Net or its subcontractors Providers must be Medicare- cer&fied and meet all Medicare Condi&ons of Par&cipa&on and Condi&ons for Coverage 15
Provider Par&cipa&on In addi&on to mee&ng Health Net s creden&aling requirements, the Department of Veterans Affairs (VA) has addi&onal PC3 requirements Par&cipa&ng providers in the PC3 network agree to comply with all Health Net and Department of Veteran Affairs (VA) program rules, policies and procedures, including the PPN Provider Manual and the PCCC Benefit Program Requirements, which is available on the Health Net website, www.hnfs.com under the Department of Veteran Affairs Programs 16
Terms of Par&cipa&on The following prac&ces are required to complete addi&onal documenta&on: Outpa&ent facili&es that perform: Computed tomography, magne&c resonance imaging (MRI), breast MRI, nuclear medicine, and positron emission tomography exams Radia&on Oncology Centers Facili&es that perform: Cancer surgery, cardiac catheteriza&ons and/ or percutaneous coronary interven&ons, and implants cardioverter defibrillators 17
Behavioral Health Providers In addi&on to tradi&onal behavioral health special&es, Health Net provides a network of providers with evidence- based psychotherapies (EBPs) Providers of EBPs are required to have specialized training and experience in EBPs. This includes founda&onal instruc&on on the theore&cal and applied components of the therapy and ongoing supervision or expert consulta&on on the implementa&on of the therapy For example, a Veteran being referred for cogni&ve processing therapy is required to be seen by a provider who has specialized training and experience in that treatment modality 18
Behavioral Health Providers The following is a list of EBPs VA currently uses: Cognitive processing therapy for post-traumatic stress disorder (PTSD) Prolonged exposure therapy for PTSD Cognitive behavioral therapy (CBT) for depression Acceptance and commitment therapy for depression Interpersonal psychotherapy for depression Behavioral family therapy (BFT) for serious mental illness Multiple family group therapy for serious mental illness Social skills training for serious mental illness Integrated behavioral couples therapy for relationship distress CBT for insomnia CBT for chronic pain Motivational interviewing for motivation, engagement, and adherence Motivational enhancement therapy for substance use disorders Contingency management for substance use disorders Behavioral couples therapy for substance use disorders CBT for substance use disorders 19
Behavioral Health Providers Veterans with a history of military sexual trauma (MST), and being treated for a behavioral health problem related to MST, may receive care from a provider their gender choice For both inpa&ent and outpa&ent behavioral health care, par&cipa&ng providers are advised of Veterans Affairs / Department of Defense (VA / DoD) Clinical Prac&ce Guidelines (CPGs) for the diagnosed behavioral health diagnosis found at www.healthquality.va.gov. 20
Where Can Providers Locate Rates? Provider Resources: Provider rates can be viewed online at the Centers for Medicare and Medicaid Providers can download step- by- step instruc&ons at: hbps://hnfs.com/content/hnfs/home/va/home/ provider/providerratesinstruc&ons.html 21
Ordering and Authoriza&on Process
Ordering and AuthorizaDon Process VA will send an authoriza&on when care is not readily available at the local VAMC Informa&on will be included on the authoriza&on form outlining details of the authoriza&on All authoriza&on will have a point of contact on the form Privileged and Business sensitive pursuant to FOIA Exemption 4 23
Eligibility and Authoriza&on VA is responsible for determining eligibility and authorizing care. Eligibility for VA health care is based on Veteran statuses, service- connected disabili&es or exposures, income and other factors Health Net is responsible for coordina&ng all appointments with a provider s office or facility; however, providers are strongly encouraged to contact Veterans with a courtesy appointment reminder Covered services under the PC3 program are limited to those services listed in the authoriza&on Providers must contact Health Net for authoriza&on to provide any services in addi&on to those listed on the authoriza&on PC3 will not issue ID cards Veterans will verify their iden&ty through a government issued iden&fica&on, such as a driver s license or military card 24
Appointment SeGng The Details Health Net s appointment- making process focuses on core components of a successful PC3 program- access, quality, performance, value and sa5sfac5on. Appointment schedulers work directly with Veterans to schedule appointments that meet both the PC3 program and the Veteran s requirements. With empathy and respect, our appointment schedulers make Veteran appointments using VA- provided appoin&ng criteria and access to care standards. Privileged and Business sensitive pursuant to FOIA Exemption 4 25
Appointment SeGng Process Process: Health Net will make appointments for Veterans at VA s direc&on to support health care authorized by VAMC authoriza&on. Step 1: Receive AuthorizaDon Our appointment center receives an authoriza&on request via facsimile, encrypted email, HIPPA- compliant transac&ons or secure website. Enters the authoriza&on into document management system. Step 2: IdenDfy Appropriate Provider Upon retrieval of the authoriza&on, our scheduler will locate appropriate provider using the Veteran s address. Privileged and Business sensitive pursuant to FOIA Exemption 4 26
Appointment SeGng Process Step 2: (Con&nued) Based on the Veteran s address the appointment scheduler limits search criteria based upon the Veteran s geographic distance parameters for Urban, Rural, and Highly Rural areas: Urban within 60 minutes commute &me Rural within 120 minutes commute &me Highly Rural within 240 minutes commute &me Higher Level of care Urban within 120 minutes commute &me Rural within 240 minutes commute &me Highly Rural community standards Privileged and Business sensitive pursuant to FOIA Exemption 4 27
Appointment SeGng Process (Con&nued) Step 3: Schedule Appointment with Provider Upon iden&fica&on of a provider, the appointment scheduler will contact provider to request available appointment &me(s) that fall within 21 calendar day (but not more than 30 calendar day), unless otherwise noted on the authoriza&on. Providers must comply with the following access to care standards: Appointments must be made within 14 calendar days Urgent care appointments must be within 48 hours Office wait &me for appointment must not exceed 20 minutes Privileged and Business sensitive pursuant to FOIA Exemption 4 28
Appointment SeGng Process (ConDnued) Step 4: Contact Veteran to Confirm Appointment Scheduler will contact Veteran and confirm through a one- on- one conversa&on the appointment date, &me and provider. Contact with the Veteran is made within 5 business days of receipt of the authoriza&ons. Calls will be recorded for tracking purposes. Privileged and Business sensitive pursuant to FOIA Exemption 4 29
Appointment SeGng Process (Con&nued) ExcepDons to the Standard Appointment SeGng Process include: ü Appropriate Provider Not in- Network ü Veteran Preferences ü Inability to Contact Veteran within Require Timeframe Rescheduling, Canceling and Modifying Appointments Our Call Center is available toll- free, Monday through Friday from 7:00 a.m. to 10:00 p.m. EST Appointment schedulers are available to assist Veterans, providers or VAMC POC s calling to reschedule, cancel or modify an appointment during this &me. Privileged and Business sensitive pursuant to FOIA Exemption 4 30
Provider NoDficaDon Upon confirma&on of the appointment: Providers will receive a customized no&fica&on packet confirming the appointment and all the details required for trea&ng the Veteran and instruc&ons for return of medical documenta&on prior to the appointment. Cancella&ons, No- Shows or Missed Appointments: Providers may not bill the Veteran, Health Net or VA for cancella&on, no- shows, or missed appointments Providers must report these events to Health Net Privileged and Business sensitive pursuant to FOIA Exemption 4 31
Provider NoDficaDon Civilian providers will be instructed to use the following fax number: (804) 622.3559 to submit: 1. Wriben requests for an extension of an authoriza&on or addi&onal service for a previously referred Veteran 2. Grievances Mul&ple submissions should not be faxed together since the system does not have a separator page to indicate the start of a new document. Privileged and Business sensitive pursuant to FOIA Exemption 4 32
Request for AddiDonal Treatment A request for addi&onal treatment will be ini&ated when a provider determines the need for addi&onal services beyond the ini&al authoriza&on. The Provider No&fica&on packet ini&ally sent to the provider includes a form the provider can use to support the request addi&onal recommended services. This informa&on will be collect and recorded in our system and forward as a report to the VA for determina&on. We will proceed as directed by the VA. Providers need to be instructed not to deliver any unauthorized care. Privileged and Business sensitive pursuant to FOIA Exemption 4 33
Ensuring Medical DocumentaDon Return Required Content of Medical DocumentaDon Required Content of Medical DocumentaDon Veteran s name and sex, the last four digits of his/her social security number, and date of birth Ini&al assessment and, for an episode of care comprising more than one appointment, reassessments regarding the Veteran s clinical condi&on, including but not limited to per&nent medical history, physical examina&on results, an inventory of the Veteran s body systems, and a record of his/her vital signs and perceived pain, using the required 0-10 scale Provider s ini&al and final diagnoses and diagnos&c impressions Therapeu&c goal (both the provider s and the Veteran s goal) Care plans and ra&onale, including provider s ra&onale for diagnos&c and therapeu&c procedures Diagnos&c and therapeu&c procedures and treatments used, as well as tests and their results Any specific care or services provided for the Veteran, including medica&on use and allergies or sensi&vi&es to medica&on Veteran s response to the care and services provided Any safety measures the provider deems necessary to protect the Veteran from injury Veteran s func&onal limita&ons and ac&vity restric&ons related to the care or services provided A list of all medica&ons and recommended/ordered durable medical equipment (DME) or prosthe&cs Instruc&ons provided to the Veteran Provider s recommended follow- up 34
Return of Medical DocumentaDon Recognizing the importance of the VAMC receiving follow up informa&on regarding the Veteran s episode of care with a network provider; Appointment schedulers will contact the provider of service to ensure: Veteran received the care Ensure &mely return of complete clinical informa&on regarding the episode of care through the Medical Documenta&on Return process Medical Documenta&on Return target &me frames: Within 14 calendar days aper the comple&on of all appointments involved in episode of care Hospitals must report admissions with in 24 hours Within 30 days aper discharge of the authorized episode of inpa&ent care, facility required to return medical documenta&on Cri&cal findings within 24 hours of finding Privileged and Business sensitive pursuant to FOIA Exemption 4 35
Appointment Process At a Glance 36
Care CoordinaDon
Discharge Planning / CoordinaDon of InpaDent Services Ensures &mely communica&on with the VAMC on all aspects of Veteran admission and discharge through: Compliant admission / discharge planning process Health Net coordinates with the authorizing VA facility Provider No&fica&on Packet will instruct inpa&ent facili&es on handling post- inpa&ent coordina&on Consistent monitoring of quality of care for the Veteran discharged home with home care or transferred to VAMC Collabora&on with the VA in transi&oning pa&ents between a VA seqng and a community (network) inpa&ent seqng 38
Discharge Planning / CoordinaDon of InpaDent Services (con&nued) Ensures smooth transi&ons for hospitalized Veterans Reduces administra&ve costs for the VA staff and op&mizes use of the VA resources 39
Claims Overview
Claims Overview Quantum Choice (QC) is Health Net s claims and invoice system The system features edits and valida&on checks to ensure: Timely return of medical documenta&on prior to claim submission Consistency in claims coding and Medicare billing and PC3 requirements Accuracy in billing and payments Reimbursement of network providers based on contracted rates 41
Clean Claims A clean claim is a claim that complies with billing guidelines and requirements, has no defects or improprie&es, including: Substan&a&ng medical documenta&on as defined by the provider no&fica&on packet and does not require special processing that would prevent &mely payment. All medical documenta&on must be returned before claims will be paid Veterans have no cost- shares, deduc&bles, or out- of- pocket expenses under the PC3 program Clean claims will be processed within 30 days Timely filing limita&ons 120 days aper the episode of care 42
Veteran Complaints and Grievances
Veteran Complaints / Grievances Collabora&on with the VA to tailor program and improve Simple repor&ng process Report in wri&ng or speak with a scheduler Timely report to CO / COR System controls and alerts to iden&fy / track / trend Analysis, review and inves&ga&on to resolve complaint 44
Clinical Quality Management
Clinical Quality Management Promotes quality of care, service and sa&sfac&on for all Veterans that improves PC3 program experience Defines quality of care as: Medical care that is safe, &mely, appropriate, leading to a posi&ve Veteran outcome Monitors the Veteran quality of care and treatment Iden&fies, analyzes, assess, inves&gate, resolves, and improves Reports to CO / COR for certain types of events Collaborates with the VA on safety / quality commibees to share responsibility Complies with regulatory requirements Meets Medicare Condi&ons of Par&cipa&on and Condi&ons of Coverage 46
Veteran Safety
Veteran Safety Established processes and controls to iden&fy, report, research, and address all Veteran safety events: Veteran safety events will be inves&gated, confirmed and reported to the authorizing VAMC and the CO / COR within 24 hours. Veteran safety events will be resolved through interven&on, feedback and training to prevent reoccurrence. 48
Performance Quality Assurance Plan (QAP) and Quality Assurance Surveillance Plan (QASP)
QASP Performance Monitoring through HN s Quality Assurance Plan In- place processes, systems, and controls are HN s tools to ensure sa&sfac&on of QASP performance objec&ves Performance Standard Review Frequency Monitoring Method Time from receipt of authorization to appointment completion Performance objective = 30 days Enhanced objective 21 days Daily monitoring Monthly reporting Captured by system so 100% of transactions reported in calculation Management tracking facilitated by reporting and alerts in our system Timeliness from completion of the authorized episode of care to return of clinical documentation Daily monitoring and reporting Captured by system so 100% of transactions are reported in calculation Management tracking facilitated by reporting and alerts in our system Timeliness of critical and urgent findings reporting Daily monitoring and reporting Captured by system so 100% of transactions are reported in calculation Management tracking facilitated by reporting and alerts in our system Network adequacy to enable access as follows: Urban within 60 minutes commute time Rural within 120 minutes commute time Highly Rural within 240 minutes commute time Daily monitoring Monthly reporting Health Net s network sizing model serves as an effective tool for identifying potential network gaps and strategic recruiting opportunities to develop the right-sized PCCC network Appointment scheduling management monitors time service reports to identify when appointments cannot be scheduled within requirements due to network adequacy 50
QASP Performance Monitoring through HN s Quality Assurance Plan (Continued) Performance Standard Review Frequency Monitoring Method Network adequacy to enable higher level of care, access as follows: 120 minutes Urban 240 minutes Rural Highly Rural community standard Daily monitoring Monthly reporting Health Net s network sizing model serves as an effective tool for identifying potential network gaps and strategic recruiting opportunities to develop the right-sized PCCC network Appointment scheduling management monitors time service reports to identify when appointments cannot be scheduled within requirements due to network adequacy Timeliness of Veteran safety event reporting Daily monitoring Monthly reporting Sentinel/adverse events, intentionally unsafe acts, and adverse events involving administration of drugs reporting occurs within 24 hours of discovery Monthly deliverable summarizes Veteran safety findings and conclusions Timeliness of response to Veteran complaints/ grievances Daily monitoring Monthly reporting Complaints related to Veteran care tracked through completion Complaints related to quality of service tracked through completion Accreditation, certification, credentialing, privileging, re-privileging, and licensing of facilities and providers Daily monitoring Monthly reporting Credentialing committee 10 times per year Tracking of all provider requirements and completion status performed using internal database Data collected directly from provider and industry resources, including: Council for Affordable Quality Healthcare, American Medical Association, National Technical Information Service, Controlled Dangerous Substances, State Licensing Boards, National Practitioner Data Bank and Health Integrity and Protection Data Bank 51
Puqng It All Together
AuthorizaDon Tracking Process VA Medical Center Clerk Health Net Provider Veteran 53
What Providers Need to Know About the Appointment Appointment Schedulers will call to schedule Veteran appointments A Provider No&fica&on Packet with detailed informa&on regarding Veteran care will be sent once appointment is scheduled Authorized care is outlined in the Provider No&fica&on Packet Veterans will not have an ID card for the program, but must present ID in the form of a drivers license or other state recognized ID Return of Medical Documenta&on is required in order to be reimbursed Providers may not bill Veterans, or request reimbursement from VA or Health Net for no- show, missed or cancelled appointments 54
Addi&onal Informa&on Providers Need To Know Pharmacy Providers must prescribe all medica&ons in accordance with the VA Na&onal Formulary, which includes provisions for reques&ng non- formulary drugs. (hbp://www.pbm.va.gov/pbm/na&onalformulary.asp), Prescrip&ons must be transmibed by fax to VA for processing [Provide Link to Directory]. IMPORTANT: Incomplete prescrip&ons will not be processed and will be returned to the prescribing provider. If there is an urgent need for a Veteran to start a medica&on and it is not possible for the Veteran to obtain the medica&on from a VA pharmacy, a provider may prescribe a prescrip&on for up to a 10- day supply, without refills. 55
Addi&onal Informa&on Providers Need To Know Pharmacy (con&nued) If the medica&on is needed on an ongoing basis, the prescribing provider must send the VA pharmacy or Consolidated Mail Outpa&ent Pharmacy the following informa&on: Provider s name Address Personal DEA number (not a generic facility number) Telephone number Fax number Na&onal Provider Iden&fier 56
Addi&onal Informa&on Providers Need To Know Durable Medical Equipment (DME) Most DME products and medical supplies will be provided by VA. VA will order/procure all DME that is not bundled under other health care services. Excep&ons to this requirement, such as DME for surgeries, require provider coordina&on with the ordering VA facility for approval in advance. 57
Need Assistance? Beginning January 6,2014, providers may call (800) 979.9620 Monday through Friday, from 7:00 am to 10:00 pm, EST for assistance with the following: Ques&ons regarding authoriza&ons Assistance with extensions on exis&ng authoriza&ons Claims ques&ons or inquiries Grievances 58
Addi&onal Requirements
Terms of Par&cipa&on Addi&onal Requirements for Outpa&ent Facili&es All documents available on the Arlington Drive 60
Terms of Par&cipa&on Addi&onal Requirements for Outpa&ent Facili&es 61
Terms of Par&cipa&on Addi&onal Requirements for Oncology Prac&ces 62
Terms of Par&cipa&on Addi&onal Requirements for Clinical Labs 63
Terms of Par&cipa&on Addi&onal Requirements for Surgery Facili&es 64
What s Next for PNM? Systems training: Quantum Choice Role Based Training
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