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: October 6, 2006
Co-chairs: Stephen Larcen/Stephen Fahey & Lorna Grivois
Next meeting: Nov. 3, 2006 at 12:30 at the LOB)

Attendees: S. Larcen & L. Grivois (Co-Chairs), K. Andersson (DCF), M. Schaefer, P. Piccione (DSS), L. Szczygiel (CTBHP/VO), R.Caporaso, T. Houston (HealthNet), T. Tedeschi (PONE), B. MacLachlan, C.Rizzo, L. Russo, J.Benson, (M.McCourt, Leg.staff).

ValueOptions/CTBHP Report (click on icon below for presentation)

Lori Szczygiel (CEO, CTBHP/VO) reviewed the ASO report for September 2006. Highlights of report that elicited Subcommittee comment:
Web registration for Out Patient Services
• 1,743 Provider User ID's have been generated; no response from 498 EDS/Medicaid providers. VOI has followed up with alerts to these providers.
• As of 8/06 13,829 registrations have been completed with the average time per registration 2.5-3 minutes.
• Providers have until October 31 to enter web-registration for 9/1/06 and forward DOS. The 21-day service retro-registration limit starts November 1, 2006.
• All fields for web registration will be required as of November 1, 2006; VOI will send out a provider alert 10/6/06.

Comments:

ü Web registration time can be about 15 minutes/registration, especially in the afternoons. May be related to the provider's server system. Mark Schaefer & Karen Andersson will test this at provider sites to assess problems.
ü One practice is downloading information into a document that a clinic programmer can then enter onto the website. Can the full field registration start date be later than 11/1/06 to accommodate this internal process? VOI will discuss with BHP agencies.
ü Going forward can electronic feed of client information for authorizations be available? This will consolidate provider administrative effort? VOI will do a level-of-effort evaluation. This is currently not in the VOI scope of work; DSS has duly noted the issues and will consider for the existing or future BHP/VOI contract provisions, as this process is consistent with program goals of improving administrative efficiencies and accurateness for both providers and the Administrative Service Organization (ASO).
ü Can providers access registration information for their own practice for quality management? DSS noted this may be feasible if it is within available IT resources. Providers would then receive their own profile with statewide comparisons.
ü The increased number of denials (1,892 as of Sept. 25, 2006) due to 'procedure requires prior authorization', the majority of which are related to outpatient services, reflect providers that didn't register the new or continuing outpatient client as of Sept 1, 2006.

Precert/concurrent reviews
Ms. Szczygiel noted there are anecdotal reports of lengthy reviews up to 45 minutes. VOI's analysis of their phone system shows 17 minutes for pre-cert. VOI response:
• Will assess all screen registration content, compare with contractual provisions for reports to BHP.
• The subacute (PHP, IOP, Home services) registration screens can be more readily modified than the inpatient screens. VOI will meet with CHA to collaborate in making the registration process more efficient.

Dr. Larcen stated he would like the Operations SC to have input into the Quality SC processes on these issues.
Intensive Care Management: referrals increased in September, especially from EDs and inpatient.

Discharge delays: ED delays increased in September to 26 cases, ALOS 2.0 days from point of ED admission, while in August 11 cases were held over in the ED. VOI is meeting monthly with CCMC, DCF and community providers to consider options that would reduce ED stays at CCMC. 17% of children in acute inpatient setting were defined as delayed discharges with more than half waiting residential/PRTF placement. In September the ALOS was 50 days compared to 44 days in August.

Comment:

ü What has happened to the final Local Area Development Plan (LADP) reports? BHP stated they are being released to the regional participants.
ü Concern was expressed that children are placed outside their community for treatment.
o VOI recognizes the importance of arranging treatment close to home so that there is family involvement. The LADP and geo-access report will identify types of services geographically available for the client; VOI can outreach to area providers asking them to consider expanding their expertise for identified needed services.
o Mark Schaefer (DSS) commented that the level of reporting in the BHP program will help build the program on existing strengths. Initially the level of care guidelines had provider input to ensure that mitigating circumstances would provide 'medically necessary' institutional care. Over time, BHP wants to look at alternative care services and parent input into improving levels of care that effectively support the child to be successful living in the community.

Department of Social Services
Managed Care Claims Project
At the September meeting Anthem and CHNCT reported closure of their projects. WellCare/PONE reported at this meeting that the 17-18 projects have been closed; some provider signature are required to finalize a few projects. Health Net reported it is close to completion of two projects – Natchaug and St. Francis. The plan expects to finish these projects over the next 2 weeks.

BHP Claims Report (click on icons below for DSS handouts)

From July 11 through Sept. 26, 2006 reporting periods, the percentage of paid claims began to drop, with the exception of 8/22/06, below 75% and the denied claims rate has crept up to almost 30%. In 9/26/06 the percentage of paid claims was 70.58% and denial percentage was 29.42% (8/8/06 the denial rate was 29.86%). Paul Piccione (DSS Rapid Response Team) noted that a number of outpatient services in the Sept. cycle needed client registration (mandatory as of Sept. 1, 2006) in order to obtain service authorization (see comments under ASO report above). ValueOptions will outreach to the 498 EDS/Medicaid providers not yet registered; those that do register will be able to backdate their claims. The top two denial reasons in the Sept. 26 report were “claim denied, duplicate of a paid claim” (2000 claims) and “service denied – procedure requires prior authorization” (about 11,000 claims). The magnitude of the latter denied reason relates to non-registration of clients for outpatient services.

Subcommittee comments, recommendations:

ü Classifying denial reasons by provider class (i.e. inpatient, IOP, PHP) rather than provider specific may explain claims denial variances related to service type. Steve Larcen noted that Natchaug sees denial codes #294 and #295 as the most common denial reasons in addition to the top 6 identified in the report. Dr. Schaefer (DSS) stated the BHP Rapid Response Team (RRT) is separately reviewing Yale and Natchaug claims issues. The Team's goal is to identify specific providers with claims issues and work with that provider. DSS wants the report to be consistent with provider experience and may refresh the claim denial data if necessary in November.
ü 30% claims denial rate, which is worrisome to providers and DSS, may need a proactive trouble shooting process including provider education, according to Steve Larcen. Dr. Schaefer stated the BHP is not indifferent to the 30% denial rate but recognizes this is the first month that prior authorization was done for 13,000 services, the majority of whom are associated with outpt. registration. About one-third of the denials are related to duplicate billing. When providers find denial patterns, they are encouraged to contact EDS, VOI and/or the Rapid Response Team to resolve the problem.
ü Wheeler Clinic noted that the RRT was most helpful in successfully resolving a small denial trend seen in the clinic.
ü It was suggested that one proactive step to more broadly correct claim/denial problems would be to issue quarterly individual provider 'report cards' that address billing issues as well as other issues such as service access. Dr. Schaefer stated that while the BHP would not rule out issuing such a report, this would involve added out-of-contract responsibility for the ASO for an activity that is within the provider responsibilities. The BHP will discuss this further at the November meeting when more claim/denial data is available.

Other
• BHP was asked about when crisis stablelization services will require web registration. Karen Andersson stated the BHP is looking at this but no current changes for the services are expected.
• Continue authorization process for outpt. services (i.e. beyond the initially approved 26 sessions at client registration) is being reviewed by the ASO through a level-of- effort assessment. Initially VOI planned to do continuous authorizations via telephone, but need to look at staffing demand for this versus a web-based process.