Behavioral Health Partnership Oversight Council

Transition 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: February 10, 2006
Co-Chaired by: Susan Zimmerman & Dr. Stephen Larcen
(Next meeting: Friday March 10 from 12:30 – 2:30 PM)

Attendees: S. Zimmerman & S. Larcen (Co-Chairs), S. Canning (Anthem), M. Schaefer & R. Ciarcia (DSS), E. Clark (CCPA), E. Collins (YNHH), R. Spencer & K. Colvin (CHNCT), R.Caporaro & J. Olender (Children's Center), D.Glazer (HUSKY VOI), J. Rowell (Clifford Beers CGC), L. Russo (Wheeler Clinic), L.Szczygiel (ASO-VOI), T. Tedeschi (PONE), M.Brochu (CompCare), D. Kochol (Anthem), T.Houston (Health Net), M. McCourt (legislative staff).

Claims/Appeals Process

• Behavioral Health Claims Overview-DSS (please click on icon below for presentation).

Rose Ciarcia (DSS) reviewed the Behavioral Health (BH) medical management and claims responsibilities of MCOs and providers for BH claims for services prior to January 1, 2006. The basis of these responsibilities is contractual provisions between DSS & MCOs and MCO/BH vendors and providers. According to Ms. Ciarcia the contractual requirements need to be met in the resolution of outstanding & run out claims. The timely filing and appeals process of each plan does create a “time crunch” for providers in resolving run out claims. See table below provided by Erin Clark, CCPA:

MCO Behavioral Health Claims – Timely Filing and Appeals Requirements

The Magellan (previous CHNCT BH vendor) contractual responsibility for run out claims is 120 days, ending February 28, 2006. Providers need to inform Rich Spencer (CHNCT) of outstanding issues with Magellan as soon as possible.
The frustration for both parties (DSS/MCO/BH vendors and BH providers) was evident in the claims discussion. The reality of the contractual provisions abuts the providers' experience in sorting out reasons for claims denials and receiving payment for claims that were either “clean” from the provider perspective or rejected by the BH vendor computer system for administrative reasons. The following highlights the issues from the MCO and provider perspective:

• MCO perspective: Rose Ciarcia stated the MCO A/R projects with providers identified claim problems including:
o Resolved claims re-submitted.
o Billing codes are outside the MCO/provider contract
o Commercial claims included in the HUSKY mix
o No record of prior authorization in MCO/BH vendor system.
o Missing/incorrect client/provider identifying information.

• From the provider perspective, the most troubling claim denial reasons include:
o Provider has record of MCO/BH vendor prior authorization (PA), provides the service but the claim is denied because the BH vendor has no record of the PA and then the request falls outside the timely filing period.
o Member ID number changes and claim is denied.
o Plan delays/loss of submitted claims, repeated denials of the same claim for new reasons which places claims outside the plan timely filing/appeal time period.
o There is a disconnect when the main carrier is the payer for BH claims and the BH vendor provides UM.
o Claims may be denied when a PA service falls just outside the approved dates of service because the client had to cancel a scheduled visit or there is a holiday in the time period.

ü Outstanding A/R reported by 6 hospitals show there is about an equal dollar amount for outstanding claims < 60 days ($3.2M) and those outstanding >60 days ($4M). (Report revised from that which was provided at the Transition SC meeting).

ü CCPA will provide an update of their provider survey at the February BHP Oversight Council meeting.

ü While there has been successful (from both the MCO/BH vendor and provider perspective) resolution of some outstanding receivables, the DSS and MCO/BH vendor repeatedly stated they need detailed information from providers owed payment for services.

ü Dr. Larcen stated that claims resolution creates an administrative burden on both the MCOs and providers; although the “burden of proof” for payment is on the provider. The goal of resolving the A/Rs is for providers to recoup as much of the dollars legitimately owed by the MCO/BH plans in order to maintain the financial integrity of BH providers in the BHP program system

ü Below are the MCO claims projects reports to DSS:

CTBHP VOI Report

Lori Szczygiel, CTBHP-VOI reviewed the report of the provider network to date, disruption analysis and timelines for service authorization implementations (please click on icon above for report details):

ü Family Peer Specialists are responding to family calls into VOI and assisting in care management activities in the communities. Families see this as a very valuable support.

ü There has been a net growth in MD providers. In the Disruption Analysis, there are about 302 providers that had been enrolled in the HUSKY MCO program that cannot be located. Of these 91 are MDs, 28 are APRNs that would offer medical management.
o Susan Zimmerman noted that if a family is continuing to receive services, they would probably not know if their provider has enrolled in the Medicaid CMAP system. This may leave the family in limbo regarding continuing treatment. Dr. Schaefer asked what the community is reporting on disruption of services as the call volume to VOI doesn't reflect service displacement. Ms. Zimmerman responded that families may not be calling VOI and that a public service announcement (PSA) would reach more HUSKY families. While Dr. Schaefer stated that money could be used more effectively than PSA, Ms. Zimmerman suggested that this really does need to be considered as HUSKY families may not elect to call VOI or follow up to ensure their provider is enrolled in CMAP.
o Dr. Larcen was puzzled that these providers, licensed in CT, cannot be located. VOI has sought contact information from professional organizations, willbe comparing about 250 of the providers against the DCF contract list and manually checking for other phone contact. Some of these providers may be embedded in group practices (about 10%).

ü Treatment Authorization and Registration Transition phase in (please review this important information in the above document) will begin with residential and group home treatment for new admissions effective 2/1/06.
o Inpatient/acute levels of care new admissions are effective 3/1/06. For members in care at this level, providers must call on the day of discharge of by March 15, which ever is sooner, to receive authorization.
o PHP, IOP UM may start in April, depending on the success with the inpatient process. There are about three times the numbers of members that use these services than inpatient and March has consistently had a spike in utilization of these services.

The next Transition Subcommittee meeting is scheduled for March 10, 2006 from 12:30 to 2:30 PM.