Mid-State Health Network Quality Assurance & Performance Improvement Review Process 2019

MSHN Quality Oversight Policy & Procedures MSHN typically conducts full reviews every other year and partial reviews during the interim years Additional reviews are conducted as necessary MSHN policy and procedures are available on the MSHN website Policy #602 Quality – Monitoring & Oversight Monitoring & Oversight of SUD Service Providers Procedure CMHSP Participant Monitoring & Oversight Procedure Policy #611 Quality- Medicaid Event Verification Medicaid Event Verification Procedure

Monitoring and Evaluation Components Desk Audit: This component will consist of a pre-review of select policies, protocols, documents and other resource materials submitted by the CMHSP Participant/SUDSP to the PIHP for review prior to an on-site visit. On-Site Audit: This component will consist of an on-site visit to the CMHSP Participant/SUDSP Participant to review and validate process requirements. This component may include staff interviews. Consumer Chart Review: The PIHP shall pull a random sample (of consumer records to ensure compliance with specific program requirements, Person-Centered Planning requirements, enrollee rights, and documentation requirements. Data Review and Analysis: This component includes analysis of CMHSP Participant/SUDSP performance and encounter data trends.

Types of Quality Assurance Reviews Full QA Review- A full review is conducted, at minimum, once every two years. Review includes various components including administrative (policies and procedures), utilization management, clinical, and MEV. This type of review is a combination of site and desk. Partial QA Review– A partial review is conducted during the interim year or as necessary. The review process will focus on any elements of the previous year findings in which compliance standards were considered to be partially or not fully met. This review can be conducted via desk review, site visit, or a combination of both. Medicaid Event Verification (MEV) Review- This review is specific to Medicaid Event Verification and is conducted annually for SUD providers and bi-annually for CMHSPs. MEV visits review a sample of claims submitted by the provider to ensure validity. This review is primarily site visit. QIP Review: Quality Improvement Plan is utilized by MSHN when a provider is considered high risk or is has been identified as needing additional assistance to become compliant. QAPI staff makes the determination as to when a QIP is necessary and oversees the QIP process and progress.

MSHN SUD Quality Assurance Tools Treatment Program Specific – Review of the Michigan Department of Health & Human Services (MDHHS) Program Specific Requirements, Department of Licensing and Regulatory Affairs (LARA) and Mid-State Health Network Contract Delegated Managed Care Functions – Review of the delegated managed care functions and how those are implemented Chart Review – Review of screening, assessment, individualized treatment plan, enrollee rights and clinical documentation. Staff Training & Credentialing – Review of the credentialing and re- credentialing process, primary staff qualifications and annual training SUDSP Corrective Action Plan Review of reporting requirements (as applicable)

MSHN SUD Quality Assurance Templates Site Review Checklist- assists provider with QA review preparation Agenda- provides timeframe for all areas reviewed while onsite Case Selection Template- Lists the cases and charts that MSHN has chosen to review during QA visit Summary and Compliance Summary- Provides final summary of QA visit Corrective Action Plan Template – The template will be available to providers in REMI. Providers will respond to areas requiring corrective action utilizing REMI. For guidance, click on the “Help option in REMI and choose “Provider- How to Respond to Audit” MSHN SUD Quality Assurance Templates

Navigating Box- MSHN Secure File Sharing Website MSHN Audit Documents Folder includes Delegated Function monitoring tool and individual monitoring tools used by MSHN Staff, file selection document indicating sample selection chosen for review. Additionally, draft final reports are stored in this folder until they are determined as final- at which point they are moved to the Final Report folder. This link is sent to the provider 30 days prior to the scheduled QA review. Provider Supporting Documentation folder includes sub-folders related to the sections within the MSHN monitoring tools. Providers upload related documentation/evidence in the corresponding folders. Additionally, the folder includes the Site Visit/QA Checklist and agenda. A hyperlink to the folder is provided in the notification emails to providers. Chart Review Documents Folder includes the completed chart review monitoring tools for each chart. MEV Review Documents Folder includes MEV Review tools, relevant provider documents, and relevant MSHN documents. Final Reports Folder includes the final summary of each review conducted including MEV, Clinical File, DMC completed tool, and CAP (if applicable). This link is sent to the provider in the final report email which includes information regarding the CAP process. Other Folder Annual Plan folder

QA Review Timeline and Process MSHN creates annual monitoring calendar 45 days prior to a review, MSHN develops a sample list of cases to review 30 days prior to site review, MSHN will send provider a checklist to prepare for review 15 days prior to review, MSHN will email a draft agenda and list of cases for review MSHN will conduct and entrance conference and an exit conference during the site review 30 days from conclusion of review, final report and survey sent to provider Once a provider receives the checklist, they should begin gathering documents and uploading to Box. Providers must have cases selected ready for review onsite. Entrance conferences review the MSHN process while onsite. Exit conferences summarize the visit for providers from MSHN perspective. Final report will include request for Corrective Action Plan if applicable.

Corrective Action Corrective Action Plan (CAP) shall be submitted by provider within 30 days of receiving final report utilizing the template in REMI. Plan shall include: A detailed action plan which addresses steps to be taken to assess and improve performance Measurement criteria (i.e. how will the PIHP know the objective/outcome will be achieved) Timeframes and responsible individual for completing each improvement plan. When access to care to individuals is a serious issue, the CMHSP Participant/SUDSP may be given a shorter period to initiate corrective actions, and this condition may be established, in writing, as part of the exit conference If, during a MSHN on-site visit, the site review team member identifies an issue that places a consumer in imminent risk to health or welfare, the site review team would invoke an immediate review and response by the CMHSP Participant/SUDSP, which must be completed within seven (7) calendar days. Once a provider receives final report, they have 30 days to complete CAP and return to MSHN (by uploading in Box) Chart Review POC required when overall section results >85% May result in technical assistance, quality improvement plan, ongoing documentation. Once a provider receives final report, they have 30 days to complete CAP in REMI and submit. If MSHN has determined additional documentation is needed, MSHN will request from provider and the provider will have 15 days to respond. MSHN will review the 2nd submission within 15 days.

Summary of 2019 Tool Updates Delegated Function Tool Program Specific Tool Chart Review Tool Medicaid Event Verification Grievance and Appeal

Delegated Functions Tool Access & Eligibility ~ 1.4 – Initial & provisional screening requirements ~ Must complete on REMI Warm handoffs must occur, if/when applicable. Information, Enrollee Rights & Protections, Grievance & Appeals, Quality & Compliance Sections – no changes/minor wording changes Individual Treatment Planning – 6.2 – Services identified (amount, scope, duration) and provided as planned. 6.12 – Signature requirements Coordination of Care – 7.1 – Added in communication expectations, i.e. Transferring consumers 7.2 – PCP Requirements/Expectations 7.6 – Deleted Credentialing – 8.9 separated due to REMI character limitations (1 Standard is now 3 Standards)

Delegated Functions Tool - Continued Attestation of Changes/No Changes – Providers do not need to upload policies/procedures if there are no change(s) since last review. Delegated Functions Tool – Monitoring policy/procedure. Evidence should be available in the provider Operation Manual. Provide location of information: hyperlinks are great, page number, paragraph, etc. Tip: Sources are next to the standard & will provide specific language for policy/procedural requirements.

Program Specific ASAM – No changes Residential – Enhanced provider evidence column 2.2 – Enhanced direction Case Management – No Changes Peer Recovery Support Services – 4.2 – Deleted Women’s Specialty Services 5.1 & 5.2 – Delete. This is verified via Treatment Team in required reports. MAT – No Changes

Program Specific Recovery Residences 7.1 – Enhanced to include tenant-inclusion in decision- making regarding co-tenants, Screening, Application 7.5 – Deleted 7.8 – Deleted as information reviewed via credentialing tool 7.9 – Deleted, reviewers do not have expertise to attest/confirm/validate 7.14 – Enhanced. Eligibility – must have SUD with evidence of housing need(s), ongoing requirements (active in treatment), etc. 7.15 – New – 24/7/365 Staffing 7.16 – Housing goal, SMART criteria 7.17 – New – Rules for Documentation Program Specific

Chart Review Screen/Admission/Assessment 1.1 Screen(s) Added word Accurate (Data should match, i.e. Record & REMI info the same) PI Information Requirements (Date of initial contact, cancellation information/no show/etc.) ASAM LOC – this MUST be completed at time of initial contact 1.2 Information Collection Medical info enhanced, SUD History Added 1.6 – FASD ~ Please ask now vs. later. 1.7 – New Standard added to ensure assessments occurring with clinical requirements, i.e. Clinical Summary Gambling Disorder – REMI (treatment planning & discharge) PCP 2.1 – Revised and enhanced (amount/scope/duration) of authorized services 2.3 – Moved SUD to top – MUST have SUD goal(s) for SUD payments Goals & Objectives – Use SMART criteria Gambling D/O in plan, if applicable

Chart Review Record Documentation & Progress Notes 3.1 – Enhanced to include progress note requirements (tie back to plan, provided as specified in the plan, document progress) 3.2 – Reworded Coordination of Care – expanded for provider clarity Discharge Rationale – Enhanced 5.1, Combined 5.2 & 5.3 New – Added Gambling D/O requirements Residential – be sure to include the required hours based on consumer’s ASAM Determination MAT – Deleted pseudo-addiction rule out Housing & WSS – minor changes, wording, etc. Chart Review

Medicaid Event Verification Technical Requirement Medicaid Managed Specialty Supports and Services Concurrent 1915(b)/(c) Waiver Program FY19-Attachment P6.4.1- Medicaid Services Verification-Technical Requirements Mid-State Health Network Medicaid Event Verification Policy and Procedure Attributes Tested Code submitted for billing is approved under the contract Beneficiary is eligible on the date of service Service was provided as authorized and included in the treatment plan Documentation of services agrees to the date and time Service was provided by a qualified individual and documentation of the service provided falls within the scope of the service code submitted Amount paid does not exceed contractually agreed upon amount Modifiers are used in accordance with the HCPCS guidelines

Medicaid Event Verification Common Findings Service is provided as authorized and included in the plan Documentation of services agrees to the date and time Service was provided by a qualified individual and documentation of the service provided falls within the scope of the service code submitted Modifiers are used in accordance with the HCPCS guidelines Required Compliance score Technical Requirement Requires 90% or higher If 90% is not reached a review of more claims is required Findings Recoupment Corrective Action Medicaid Event Verification

Grievance and Appeal Each provider must have a system in place for enrollees that includes: a grievance process an appeal process Which includes the State Fair Hearing process after a local appeal

QAPI Team Goals & Outcomes Ensure quality care & assist provider’s with compliance Utilize data for regional planning Connect providers to resources Trainings, Technical Assistance, Support Partnerships to strengthen provider network SUD Advisory Committee Questions, Feedback, Recommendations Wanted Surveys

Resources MSHN Website State of Michigan Medicaid Provider Manual MSHN Provider Manuals MSHN Website- Policy and Procedures State of Michigan Medicaid Provider Manual SOM Department of Licensing and Regulatory Affairs MSHN Box File Sharing/Storage MSHN Provider Newsletters QAPI Email Contact: QAPI@midstatehealthnetwork.org