IDHS, Division of Mental Health Provider Briefing: Changes to Provider Monitoring April 3, :30pm April 6, :30am

Speakers Jackie Manker, LCSW – Associate Director of Community Services, DHS/DMH Lee Ann Reinert, LCSW – ASO Clinical Policy Manager, DHS/DMH Cathy Cumpston – Chief, DHS Bureau of Accreditation, Licensure and Certification (BALC) Aissa Bell – Director, Provider Relations, IL Mental Health Collaborative for Access and Choice Rusty Dennison, MA, MBA – President, Parker Dennison & Associates, Ltd.

Introduction Beginning in FY09, DMH incorporated Post Payment Reviews (PPR) into DMH/Collaborative provider monitoring site visits Current DMH/Collaborative site visits include: - Post Payment Reviews - Clinical Practice and Guidance Reviews - Fidelity Reviews (PSR in FY09) DHS BALC is still performing Certification reviews

Introduction DMH reviewed and approved all policies, forms, and training materials implemented by the Collaborative for PPR At the time PPR was implemented, DMH instituted managerial oversight of the Collaborative’s practices Weekly meetings with reviewers as well as the Collaborative’s Provider Relations Director Made available DMH clinical staff and BALC staff to consult with the Collaborative’s reviewers in the field Involved DMH Regional Contract Managers in reviews

Introduction Consistent with continuous quality improvement, DMH asked Parker Dennison to evaluate our provider monitoring process in February 2009 Parker Dennison completed this analysis and has provided DMH with recommendations DMH has considered these recommendations and has begun to implement changes to the process Find the Parker Dennison report on the DMH website at:

BALC Coordination with DMH/Collaborative PPR Participation in development of PPR/monitoring model Participation in Collaborative’s PPR staff and provider training Participation in weekly PPR Collaborative/DMH coordination and problem solving calls

PPR vs. Certification: Differences? Example~ Post Payment Review Finds 50% of claims reviewed have no current ITP in record Outcome: provider will lose value of those claims Certification Review Finds 5 of 10 records reviewed (50%) have no current ITP Outcome: provider will lose 42 points on certification As a result will have 422 of 464 points on their certification for a total score of 91%

Parker Dennison Assessment of Post Payment Review Assessment conducted in January/February 2009 Information sources included: Focus group with 25 providers statewide Feedback from other stakeholders Review of policies, forms, training materials, protocols Review of Federal OIG reports from IL and other states Review of applicable state and Federal rules Analysis of audit results through 12/31/08 Included 3,070 claims and audits from 32 providers

Parker Dennison Report: Focus of Post Payment Review All PPR elements consistent with those found in other OIG reports Some elements found in OIG reports are not present in IL PPR Federal OIG does identify some elements that can be deficient, need correction but not recoupment This is inconsistent even within different OIG audits Recommendations include: DMH should periodically rotate in new/different elements (annually review/update) DMH can consider a limited amount of ‘procedural’ designations, at least as a transition

Parker Dennison Report: Training & Communication Provider training was adequate compared to other states but not best practice Training was provided regarding Rule 132 (basis of PPR) Training was provided regarding the PPR tool and protocol Recommendations include: Detailed interpretive guidelines On-going Frequently Asked Questions (FAQs) On-going feedback to providers about aggregate results, common problems, recommendations

Parker Dennison Report: Audit Staff Resources All Collaborative reviewers are LPHAs, including two who are also Certified Recovery Specialists Represents the highest standard of practice in audits Overall feedback was positive regarding professionalism and clinical knowledge Recommendations include: Expand inter-rater reliability monitoring of reviewers Involve DMH contract managers for cross training where feasible Include reviewer competency training in training for new reviewers

Parker Dennison Report: Post Payment Review Process Unannounced reviews are problematic Some inconsistency on provider staff involvement Lack of public interpretive guidelines Recommendations include: Discontinue unannounced reviews (unless there is a provider- specific reason) Clarify provider staff involvement protocol and be consistent Include interpretive guidelines in provider training materials More detail on PPR report to providers

Parker Dennison Report: Analysis of PPR Results (12/31/08) Key statistics: 32 providers 3,070 claims Avg. of 55% of claims unsubstantiated Value of unsubstantiated claims (no extrapolation) = $101,937 Avg. unsubstantiated claims per provider (no extrapolation) = $3,186 Average of two deficiencies per unsubstantiated claim Overwhelming majority of deficiencies confined to 7 elements on PPR tool Only these 7 fell below 95% compliance level All 7 elements were cited in other Federal OIG reports

Parker Dennison Report: Analysis of PPR Results (12/31/08) Lowest compliance %: Q2 – (66.87%): MHA contains all required elements Q10 – (81.14%): Note contains description of interaction w/consumer including response and progress toward ITP goal(s) All other questions had compliance of 92% or greater Remediation of top 7 deficiencies would reduce statewide average to 12% unsubstantiated claims (from 55%) No data demonstrating an inter-rater reliability issue

DMH Response Pleased with the overall assessment results of the Post Payment Review process Appears to be identifying targeted areas for improvement in moving the system forward Identified areas for improvement can be addressed in training Validates the risk and need for continued efforts for continuous improvement in compliance Will continue the established managerial oversight practices

DMH Changes to the Process Announce site visits (began 3/20/09) Improve communication with providers Post interpretive guidelines to website Provider alerts with summaries of issues and trends Analyze and use provider post-review survey feedback Collect provider questions through the address Post provider FAQs to website Ensure reviewer consistency Strengthen inter-rater reliability and monitoring Continue weekly reviewer check-ins with DMH, BALC, and the Collaborative

DMH Changes to the Process (cont.) Change Post Payment Review scoring Split claim status into two parts: claims disallowed and procedural deficiencies Begin requesting plans of improvement based on compliance (including all claims findings) Begin tracking the individual parts of the Mental Health Assessment in the database Allow some types of claims to be corrected Begin scoring changes going forward and re-score those already reviewed this fiscal year [see the separate document “Claims Guide”]

Feedback and Questions Available to Answer Your Questions—Thanks! Jackie Manker, LCSW – Associate Director of Community Services, DHS/DMH Lee Ann Reinert, LCSW – ASO Clinical Policy Manager, DHS/DMH Cathy Cumpston – Chief, DHS Bureau of Accreditation, Licensure and Certification (BALC) Aissa Bell – Director, Provider Relations, IL Mental Health Collaborative for Access and Choice Rusty Dennison, MA, MBA – President, Parker Dennison & Associates, Ltd.