Behavioral Health Partnership Oversight Council

Operations Subcommittee

Legislative Office Building Room 3000, Hartford CT 06106
860) 240-0321 Info Line (860) 240-8329 FAX (860) 240-5306
www.cga.ct.gov/ph/medicaid

Meeting Summary: September 8, 2006
Co-Chairs: Stephen Fahey/Stephen Larcen & Lorna Grivois
(Next meeting: Friday October 6, 2006 @ 12:30 in LOB RM 1C)

Stephen Fahey was welcomed back to the subcommittee and Council. He and Stephen Larcen will co-chair the meetings along with Lorna Grivois, over the next several months after which Stephen Fahey will resume co-chairing the subcommittee meetings.

ValueOptions/CTBHP Report
Lori Szczygiel presented the CTBHP/VO report (click on icon below for presentation).

Key discussion items:
• Web registration for outpatient services is required as of September 1, 2006.

o Average registration time for the abbreviated form is 4 minutes.
o VO will be offering several more provider training programs in September (check www.ctbhp.com web site for upcoming dates).
o Provider feedback regarding the web registration security platform prompted system changes effective August 31. Providers (hospitals) that continue to encounter problems have been provided with an interim process while these problems are resolved.
o WinFax is available in the interim for practitioners (34) without web access.

• Utilization Management

o Service by level of care data: highest percentage is for residential treatment facilities (>35%) with IOP as the second highest (20%) used service. Inpatient psychiatric facility use is 10%.
o Discharge delay status (pg 5) shows that 21% of children in an acute inpatient setting have defined discharge delays with 50% awaiting residential/PRFT placement. Valid reasons for discharge delay are derived from inpatient census reports (see reason codes Pg 5). VO has assigned two intensive case managers to children awaiting Riverview placement. 'Children awaiting discharge' reports by local DCF region will be shared with that region when the BHP agencies are sure of the accuracy and completeness of the reports. Initially only DCF-involved children will be addressed at the managed service system (MSS) meetings. Managing access policies under Medicaid and HIPAA may, in the future, allow appropriately shared information on non-DCF involved children. VO system managers and ICM staff will be attending these local meetings. The goal of the reports is to ensure that children receive needed services. The tracking process for service disposition delays is parallel to Medicaid “medical necessity” in that when the member no longer meets the Level of Care criteria for a service the concurrent review process will assess the discharge plan and discuss reasons for delay of transition to a lower level of care with the providers of the higher level of care.
o ED discharge delay report shows no unanticipated ED delay calls in August. VO has been calling EDs daily, M-F, regarding members “stuck” in the ED. Since VO began these routine daily calls, the number of cases has doubled, but the average length of stay in the ED has decreased from 3.5 to 1.1 days (delays defined from the VO point of contact with the ED). It was discussed that it would be helpful to track total elapsed time in ED, especially for Friday and Saturday ED admissions not called until Monday.

• 63% of types of 'service connect inquiries' are now coming from members.
• VO will undertake two clinical studies, reviewed and approved by the Quality Access & Management SC (pg 11).
• Internally VO has fully integrated the system manager, intensive care management and peer/family services.

Department of Social services
BH Claims resolution under managed care
Each managed care organization reported on the status of the outstanding claims projects:

ü Anthem has no outstanding issues; consensus was reached with Clifford Beers, Natchaug, CHR and Bristol.
ü CHNCT coordinated resolution for VO and Magellan outstanding claims for 20 providers. All but 2-3 providers have been paid; the unpaid claims were based on the 'ground rules' initially set by DSS and agreed to by the Council. Checks have gone out with several waiting for provider clarification of the name to be put on the check.
ü Health Net had 23 projects, now have 6 unresolved.
ü WellCare/PONE has resolved 12 of the 17 projects. Three of the five open cases (CHR, Bristol & Lower Naugatuck) have not responded to date with additional claims information.

Dr. Schaefer thanked Anthem and CHN for their work in completing these projects and indicated that they would not need to attend future committee meetings given that coordination of care issues are addressed in another committee. Health Net and PONE will be asked for a status report in October. Overall both plans and providers found the claims projects to be a collaborative process.

BHP Claims: administrative denial trends and issues (click on icons below for presentation with revised denial reasons last icon)

Dr. Schaefer reviewed the reporting trends, noting that the reasons for denial of 30% of claims in July/August is unclear, although this percentage increase may be related to provider location codes that EDS has fixed. Denial by reason report (3^rd icon) shows the denial indicator trends. There was discussion related to technical issues that providers have experienced such as different DOS on the ASO vs. EDS authorization look-up, different authorization numbers between ASO letter and EDS files, interpreting provider manual, coding issues. Providers asked BHP to waive the timely filing requirement for claim denials/resubmission related to implementation issues. (Addendum: The BHP timely filing changed to 120 days September 8, 2006 (see attached provider bulletin) with extensions for claims resubmitted from the previous claim adjudication decision date.) The following are provider resources for help in resolving denied claims that may reduce some of the burden on the provider:

• EDS site to validate authorizations, view claims status, access provider bulletins, etc: www.ctmedicalprogram.com Phone contact: 1-800-842-8440

• BHP Rapid Response Team: request information if claims denials seem incorrect and/or unclear as this may represent system issues. Providers are encouraged to contact the teams as soon as possible when they see unexplained claims denial patterns:

o Paul Piccone (DSS) at 860-424-6160
o Best contact method would be to email him- paul.piccone@po.state.ct.us

With the claim ICN # or the client ID, DOS, provider ID number, example of the problem.

• ValueOptions for provider procedures/information: 860 263-2000

BHP rate adjustment recommendations
Dr.Schaefer (DSS) stated the MCO 3.88% rate adjustment, about $3-4 million, will be applied to
the BHP program for enhanced care clinics (ECC) and toward other proposals recommended by
the Council.
.
• The costs for the ECCs (free-standing and general hospital) will be covered; payments may be retroactive from September or October 2006. (RFA response deadline was September 5).
• Dollars left could be used for program proposals such as:

o Add E&M codes for 1-2 psychiatric medical visit consultations.
o Add E&M codes for rapid access to prescribing providers, paid at 85-95% Medicare rates.
o CM T1016 rate is insufficient for SED children; BHP proposes enhancing the rate, perhaps by increasing rates by provider type.
o Dr. Larcen identified another program proposal for Council consideration: increase rates for lower base rate IOP providers.

These proposals and the 23-hour hospital observation rate will be discussed and recommendations to the BHP will be made at the BHP OC meeting September 13, 2006.