MONITORING GRIJALVA 2005 Patricia Hokenson, RN, MSN, Region IX Centers for Medicare & Medicaid Services November 9, 2005

OBJECTIVES Review Grijalva Final Rule Provide Results of CMS 2005 Grijalva Monitoring Review CMS Grijalva Monitoring Worksheets Identify Opportunities for Improvement

Review Grijalva Final Rule

GRIJALVA HISTORY 1993 Class action lawsuit Challenged adequacy of notice and appeal rights Final regulation published in April 2003 Implementation of provider notices January 2004

GRIJALVA REGULATION New notification for termination of provider services (SNF, HHA and CORF) 42 CFR 422.624 and 422.626 Expanded grievance process 42 CFR 422.564 Revised process for disputed termination of inpatient hospitalization 42 CFR 422.620

REQUIRED CMS NOTICES Notice of Medicare Non-Coverage (NOMNC) Detail Explanation of Non-Coverage (DENC)

Provide Results of CMS 2005 Grijalva Monitoring

CMS MONITORING REVIEW Review Period: January 1, 2005 to November 1, 2005 Review of 11 MAOs in Region IX

CMS MONITORING REVIEW GUIDE ELEMENTS OP10: Termination of Provider Services: Notice of Termination of SNF, HHA, or CORF Services (Timeliness) OP11: Termination of Provider Services: Notice of Termination of SNF, HHA, or CORF Services (Notice Content)

CMS MONITORING REVIEW GUIDE ELEMENTS OP12: Detailed Explanation of Non-Coverage of Provider Services (Timeliness) OP13: Detailed Explanation of Non-Coverage of Provider Services (Notice Content) OP14: Effectuation of QIO Decision Reversals

OP10: Termination of Provider Services: Notice of Termination of SNF, HHA, or CORF Services (Timeliness)

OP11: Termination of Provider Services: Notice of Termination of SNF, HHA, or CORF Services (Notice)

OP12: Detailed Explanation of Non-Coverage of Provider Services (Timeliness)

OP13: Detailed Explanation of Non-Coverage of Provider Services (Notice)

OP14: Effectuation of QIO Decision Reversals

Review CMS Grijalva Monitoring Worksheets

CMS MONITORING REVIEW Work Sheets OP4 Work Sheet: Evaluates elements OP10 and OP11 OP5 Work Sheet: Evaluates Op12, OP13 and OP14

Identify Opportunities for Improvements

Notice Issues Invalid NOMNCs Late DENCs Integrity of Notices (NOMNCs and DENCs)

Chapter 13 Revisions 10/1/05 Valid Delivery of NOMNC Delivery of DENC Authority of QIO To Request Enrollee Records

BEST PRACTICE FOR ISSUING NOMNCs IN NON-DELEGATED NETWORK Linda Keenan, RNC, NMCC Health Services Director Hometown Health (Part of Washoe Integrated Health Network) November 9, 2005

Best Practice for Issuing NOMNCs In A Non-Delegated Network Product Evaluation Linda Keenan, RN, C NMCC Director, Health Services Hometown Health Reno, Nevada November 9, 2005

Grijalva Regulation – First Steps Understand the regulation Identify participating providers affected by ruling Develop policy and procedure for issuing NOMNCs and DENCs Develop educational plan for participating providers Designate Hometown Health staff to administer “Grijalva Regulation” Develop and maintain monitoring and audit mechanism

Detailing the Process Understanding the Regulation Review CMS guidelines for Grijalva Format NOMNC and DENC to Hometown Health logo Develop process for ongoing monitoring of NOMNC and DENC amendments Establish information necessary to initiate an NOMNC Establish mechanism necessary to ensure delivery of appeal rights Establish key contact at Hometown Health Monday – Friday and on-call

Detailing the Process Identification of Participating Providers Participating providers designated in the provider directory Establish additional providers via: Information Resources Utilization Repot Rural non-contracted provider utilization history Non-contracted out of area providers are monitored by the RN Home Health Case manager via the concurrent authorization process

Detailing the process Development of Policies and Procedures Policy and Procedure developed for: SNF Home Health (No CORF in Northern Nevada) QI0 Appeal Request for NOMNC form (attached) Includes: Delivery of NOMNC Delivery of DENC Provider Accountability Hometown Health Accountability QI0 on-call accountability 24/7

Detailing the Process Provider Education Establish date for completion of provider education On-site and telephonic conferences Discussion of ruling and implementation plan Overview of handouts (in person or via fax) Policy and procedure for NOMNC administration Use of “Request for NOMNC tool” Consistent follow up by Hometown Health for further education and correction of delinquencies

Detailing the Process Designation of staff to administer “Grijalva Regulation” Clerical Receipt of NOMNC request tool Initiation of NOMNC Entry of data onto NOMNC audit log Logs returned NOMNC for filing Certifies mail for follow-up notification RN On-site delivery of NOMNC in SNF setting Monitoring of concurrent authorizations for SNF & Home Health Backup for Director for QI0 Director Audit log reviewed monthly Ongoing education 24/7 contact person for QI0

Detailing the Process Monitoring and Audit Mechanism Development of Excel log/spreadsheet and on-line letter database Inclusion specifically of: Date NOMNC to be given Date termination of service date Reason for denial Date copy of letter received in office Accountability on behalf of provider to return letter within 48 hours and certification notice as applicable Accountability on behalf of Hometown Health to have designee contact provider if outside of 48 hours receipt timeline Daily review of log to establish delinquencies Monthly audit of log with contact to providers to correct any delinquencies

BEST PRACTICE FOR ISSUING NOMNCs IN DELEGATED NETWORK Louise MacDonald, RN, BSN Director QI, UM, CCM SCAN Health Plan November 9, 2005

Our Mission and Vision SCAN will become the leading geriatric-focused health management enterprise in the country. Its mission is to continue to find innovative ways to enhance seniors' ability to manage their health and to continue to control where and how they live. We will achieve this mission by developing partnerships that allow us to deliver the right healthcare, in the right setting, and at the right cost while maximizing the seniors' ability to remain independent.

Network Relationships Health Plan Physician Organizations Contracted Ancillary Vendors SNF HH CORF

Network Relationships Successful partnerships – essential to success with compliance How to help one another succeed?

Network Relationships Health Plan and Physician Organization Partnership Health Plan is ultimately responsible for CMS regulation compliance Physician Organization is responsible for issuing and delivering the NOMNC and DENC

Physician Organization and SNF/HH Partnerships Decisions to be made by the Physician Organization and the SNF/HH Who completes the NOMNC? Who delivers the NOMNC? Who is responsible for the documentation of the NOMNC delivery Who completes and delivers the DENC?

Focus on Success SCAN Health Plan’s Focus Compliance Success for our Business Partners Compliance Success for ourselves Compliance everyday

Actions for Success SCAN Health Plan Audit Identify Areas for Improvement Education Communication Tools Incentive

Actions for Success Audit By SCAN Health Plan Monthly CMS audit worksheets CMS audit methodology CMS scoring method

Actions for Success Identify Areas for Improvement For each Provider Organization For non compliant elements Provide monthly reports that include Compliance scores for each element For non-compliant elements the regulation citation Corrective Action (canned text) Corrective Action specific to the Notices audited

Actions for Success Education Monthly individual telephone in-services for non-compliant elements On site in-services as needed Annual Network Inservice hosted at SCAN

Actions for Success Communication New/revised regulations Revised Notice templates Quarterly Newsletter “Service Denial Update”

Actions for Success Tools Provide tools to facilitate compliance ICE web site www.ICEforhealth.org SCAN tools SCAN Ancillary Provider Operations Manual Coaching – SCAN Denial Oversight and Appeals staff are available to answer questions

Actions for Success SCAN Network Management Provider Service Interventions Working with Physician Organization Management staff and contracted SNFs to resolve barriers to success

Actions for Success Physician Organization Incentive Program Monetary reward for compliance with Denial Notices

NOMNC and DENC Templates

Notice of Medicare Non-Coverage (NOMNC) ICE Template approved by CMS Central Office and CMS Region IX

Notice of Medicare Non-Coverage (NOMNC) pg. 2

Attachment (Optional) (to assist with documentation)

Detailed Explanation of Non-Coverage (DENC)

TOOLS For electronic copies email to qmumdepartment@scan healthplan TOOLS For electronic copies email to qmumdepartment@scan healthplan.com subject: tools

Notice of Medicare Non-Coverage From SCAN Ancillary Provider Operations Manual. Provides a brief description for NOMNC valid delivery.

NOMNC / DENC Instructions From SCAN Ancillary Provider Operations Manual. Provides a narrative description of NOMNC and DENC process including documentation needed for an appeal.

NOMNC / DENC Instructions pg. 2

Telephone Notification Check List This checklist could be used to document valid delivery of the NOMNC.

Acknowlegements On behalf of myself and SCAN we would like to acknowledge the three Physician Organizations that were selected by CMS for the 2005 audit. SCAN extends its gratitude and appreciation for their stellar performance. Alamitos IPA Axminster Family Seniors

Best of Health Regards, SCAN Health Plan

Best Practice for Effectuation of QIO Decision Reversals Susan Tenorio, BSN, RN Director, Health Services Inter Valley Health Plan Pomona, California November 9, 2005

Effectuation of the QIO Decision Reversals Communication Assessment of Decision Reasons for Overturning Documentation Notice of Reinstatement Letter Process Improvement Evidence Process Flow

Communication Verbal notification from Lumetra Plan informs group Written notification from Lumetra - usually within one week Written notification forwarded to group

Reasons for Overturn Technical Reasons Continued Skilled Need Non-compliant submission timeframes Non-Compliant language in NOMNC Poor documentation of verbal notification to member’s representative Continued Skilled Need Patient clearly needs to continue SNF Patient not fit to be discharged

Assessment of Decision Merits of decision analyzed Technical Reasons Non-compliant timeframes Wrong language in NOMNC Administrative issues Medical Necessity/Continued Need for Skilled Patient clearly shows need to continue SNF Medical necessity

Documentation Technical Reasons resulting in QIO reversal Notify group Request group to re-submit NOMNC Medical Necessity/Continued Need resulting in QIO reversal Group contacted with a request to provide re-instatement letter to member with copy to Plan and QIO

Notice of Reinstatement Letter

Process Improvement All appeals tracked in plan’s transaction application (FACETS) All QIO overturns logged in same system for reporting Tracking and trending reasons for overturns Common or recurring issues identified and addressed with group Training opportunities

Evidence Appeals database to track and trend appeals, nature/types, and decisions Case File reposed and maintained by Health Services Department

Process Flow

QUESTIONS???