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Managed Care: Contract Oversight and Monitoring Enrique Marquez Chief Program & Services Officer
Stephanie Muth State Medicaid Director June 20, 2018
Network adequacy is influenced by many factors: • Provider density, • Provider capacity, • Program administrative complexity, and • Payment rates.
These same issues are common to commercial insurance plans and Medicaid programs nationally.
2
Provider Access Landscape
3
Network Adequacy Oversight Approach
Program Operations
• Streamline provider credentialing
• Simplify and expedite provider enrollment
Contract Monitoring and Oversight
• Monitor time, distance, and appointment availability standards
• Review provider directories quarterly
• Enforce contract remedies
Routine and targeted data analytics support activities.
Quality and Program Improvement
• Conduct EQRO studies: Appointment Availability and PCP Referral
• Implement Pay-4-Quality, Performance Improvement Projects, and quality measure standards
• Survey members
Care coordination helps members access the services they need.
Cross-functional approach to monitoring and improving network adequacy.
PCP: Primary Care Physician EQRO: External Quality Review Organization
4
Network Adequacy Standards
Long Term Services and Supports (LTSS) and Pharmacy standards proposed to be implemented in the September 2018 managed care contracts. Metro = county with a pop. of 200,000 or greater, Micro = county with a pop. between 50,000-199,999, Rural = county with a pop. of 49,999 or less.
Distance in Miles Travel Time in Minutes
Provider Type Metro Micro Rural Metro Micro
Rural
Behavioral Health-outpatient 30 30 75 45 45 90
Cardiovascular Disease 20 35 60 30 50 75 ENT (otolaryngology) 30 60 75 45 80 90 General Surgeon 20 35 60 30 50 75 Hospital - Acute Care 30 30 30 45 45 45 Nursing Facility 75 75 75 - - - OB/GYN 30 60 75 45 80 90 Occupational, Physical, or Speech Therapy 30 60 60 45 80 75
Ophthalmologist 20 35 60 30 50 75 Orthopedist 20 35 60 30 50 75 Prenatal 10 20 30 15 30 40 Primary Care Provider 10 20 30 15 30 40 Psychiatrist 30 45 60 45 60 75 Urologist 30 45 60 45 60 75
Distance and Travel Time Standards
“Secret shoppers” call enrolled providers to see how long it takes to get an appointment. Actions • Corrective Action Plans (CAPs) have been imposed on all the
managed care organizations (MCOs) in at least one service area for not meeting appointment availability standards.
• EQRO will repeat the studies over 2018 and 2019. 5
Network Adequacy Appointment Availability Study
Level/Type of Care Time to Treatment
Requirements Urgent Care (child and adult) Within 24 hours
Routine Primary Care (child and adult) Within 14 calendar days Preventive Health Services for New Child Members
No later than 90 calendar days of enrollment
Initial Outpatient Behavioral Health Visits (child and adult)
Within 14 calendar days
Preventive Health Services for Adults Within 90 calendar days
Prenatal Care (not high-risk) Within 14 calendar days
Prenatal Care (high-risk) Within 5 calendar days Prenatal Care (new member in 3rd trimester)
Within 5 calendar days
Oversight Requirements • Quarterly monitoring process using provider
reconciliation files and member eligibility files. No longer using MCO self-reported data.
• MCOs who do not meet 75 percent compliance with standards are issued a CAP.
• In January 2019, this requirement will increase to 90 percent compliance and issuance of both CAPs and liquidated damages (LDs).
• Implemented Provider Directory requirements in the Spring of 2016.
6
Network Adequacy Oversight
Network Adequacy Next Steps
• Ramp up standards and remedies for time, distance, and appointment availability requirements.
• Perform targeted analysis of access to specialty services, including STAR Health psychiatry services and PCP referral study.
• Strengthen linkages between data analytics and program oversight and operations.
• Identify opportunities, in collaboration with stakeholders, to expand alternative service delivery models, such as telemedicine, telehealth, and remote monitoring.
• Promote quality and access through the Pay-for-Quality program, Performance Improvement Projects, and quality measure standards.
• Examine provider directory data issues. • Analyze claims data to identify and address inactive providers that are not delivering services.
• Lead cross-functional workgroup to identify network adequacy issues and solutions.
7
MCO Member Complaints Two Areas of Focus
#1 is resolution
• No wrong point of entry
• HHSC resolution specialist assigned until case is closed
• Resolution timelines in contract requirements
Note: FFS complaint process varies
• Analysis of MCO member complaints to pinpoint trends that indicate: ̵ Operational issues ̵ Needed policy clarifications
• Adding additional resources to strengthen analytics and focus on real time data
#2 is oversight
8
Future Improvements
• Cross-divisional workgroup to standardize and improve on data collection.
• Contract oversight escalation team. Analyze complaints to determine root cause
of issues presented and identify needed actions
• Flexible data portal. Support data visualization Faster extraction of complaints analysis Facilitate strategic oversight of health plans
• Improvements will allow HHSC to use complaints data to identify risks, increase program transparency, and inform areas for improvement.
9
Complaints Trending and Analysis
10
Operational Reviews Current Activities / Next Steps
• HHSC strengthened contract oversight by adding onsite operational reviews of MCOs in September 2017. Team of 20-25 subject matter experts conduct
onsite monitoring of one MCO per month.
• Onsite comprehensive review of MCO performance across a series of critical indicators, including: Claims processing, Prior authorization, Utilization management, and Encounter submissions.
• Continue to refine the process and add modules
Additional staffing resources will support this effort
• Results of operational reviews inform contractual enforcement and training and technical assistance needs.
11
Long-term Services and Supports Utilization Reviews Current Activities / Next Steps • Created by S.B. 348, 83rd Legislature, Regular
Session, 2015. • Provides oversight of STAR+PLUS Home and
Community Based Services (HCBS) program in order to ensure: MCOs are correctly enrolling members in
HCBS through assessment and justification of service need; and
MCOs are providing services according to their assessment of service needs.
• Additional resources allocated to provide
oversight of STAR Kids and STAR Health Medically Dependent Children’s Program (MDCP).
12
MCO Oversight Next Steps
Rider 61(b) Recommendations In July 2018, Deloitte will complete their independent assessment of contract review and oversight for Medicaid and CHIP managed care contracts, including: • Effectiveness and frequency of audits; • Data necessary to evaluate existing contract
requirements and enforcement including penalties; and
• Need for additional training and resources for effective contract management.
Appendix
An Evolving Landscape Rapid Growth of Managed Care Model
-
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
3,500,000
4,000,000
Fee-For-Service Managed Care
Exceeded 60% of
caseload
92% of caseload
+1.2MM in 10 years
Source: HHSC Financial Services, HHS System Forecasting FY 2017 is incomplete/not yet final
# o
f M
edic
aid
Clie
nts
STAR Kids
STAR Health statewide
STAR expansion (MRSAs) Pharmacy carve in
STAR+Plus inpatient hospital Children’s Dental statewide
14
STAR expansion
STAR STAR+PLUS expansion
STAR+PLUS expansion
STAR+PLUS statewide IDD acute care carve in
NF carve in Mental health services carve in Dual demonstration program
An Evolving Infrastructure Supporting Managed Care
Managed Care Programs
CHIP STAR STAR+PLUS & MMP
STAR Kids
STAR Health Dental
MCO
s pe
r pr
ogra
m
Prod
uct
lines
and
su
ppor
ting
cont
ract
s
Uniform Managed Care contract 21 total contracts, 3 product lines
STAR+PLUS expansion contracts (4)
STAR+PLUS Medicaid Rural Service Area
contracts (4)
CHIP Rural Service Area contracts (2)
Dental Services contracts (2)
STAR Health contract (1)
STAR Kids contracts (10)
MMP contracts (5)
17 18 5 10 1 2
15 Contract numbers are subject to change. Current as of February 2018.
16
Contract formation with clear terms
• Set standards for reported financial data
Principles Timing Templates
• Cap administrative expenses
• Limit profits
Management by specialized expertise
• Reconcile and validate financial data
• Define scope of annual financial audit based on compliance
• Manage other additional financial audits & reviews
Non-compliance discoveries enforced as established in the contract, including liquidated damages or recovery of the Experience Rebate
(i.e. recovery of “excess profit”).
Example: Financial Oversight
Strength in Oversight Starts with Contract Formation
Audits annually & as needed
• Conduct annual audit by two independent contractors for additional data validation
• Conduct supplemental audits or reviews based on other identified issues
17
Financial Oversight Timeline for Managing Compliance
Year start
Q2 FSR
Q3 FSR
Q4 FSR
HHSC validates data
Audit starts
Audit ends
6 – 8 months to conduct
Final Report
HHSC remedies compliance issues for that year.
An 18-20 month audit process post-year end.
FSR = Financial Statistical Report
Year end 1
Q1 FSR
Year end 2
12 months for claims to run out
Fin
al b
ooks
clo
se
Init
ial bo
oks
clos
e
18
Administrative Expenses
Capped by program
Profit
Contract Financial Structure Safeguards to Ensure Fiscal Responsibility
Net income MCOs keep
profit to <3%
Experience Rebate
If profit is HHSC recovers 3% < 5% 20% 5% < 7% 40% 7% < 9% 60% 9% < 12% 80% 12% or greater 100%
Excessive profit
Major components are caps on administrative expenses, conversions to income, and rebates on
excessive profit.
Expenses in excess of admin cap
Provider Relations
Call Center Functioning
Complaints/ Appeals
19
Operations Oversight Tools HHSC and External Auditors
HHSC onsite biennial operational reviews
Claims Processing
Critical indicator focus
Prior Authorization
Process
Website Critical
Elements
Utilization Management
Encounter Data
Targeted area(s) may vary. Examples include:
3rd party biennial performance audits (or more frequently as determined by risk)
Can inform the focus of the 3rd party audit or the need for an incremental one.
Two areas of focus
MCO self-reported data
Operational processes
+ Additional modules under development
- MCO Hotlines - Complaints and Appeals
- Claims processing
- Subcontractor monitoring (including PBMs)
Like financial oversight, operations has multiple monitoring perspectives.
20
Services Oversight Tool Utilization Reviews
Utilization Reviews (UR) are conducted by nurses and overseen by the Office of the Medical Director.
To ensure MCOs are correctly enrolling members in HCBS through assessment and justification of service need To ensure MCOs are providing services according to their assessment of service needs
1
2
Overall purpose
MCO on-site visit
UR components
Records request
Desk reviews
Client home visits
Complaint referrals
Reporting of results
Findings inform Needed policy and
contract clarifications
MCO consultation or training topics
Internal process improvements
Necessary MCO remedies
Ongoing training, consultation, and technical assistance to MCOs
HCBS = Home and Community Based Services
21
S t a g e 1
S t a g e 2
S t a g e 3
S t a g e 4
S t a g e 5
Plans of Action
Corrective Action Plan (CAP)
Liquidated Damages (LDs)
Suspension of Default Enrollment
Contract Termination
$
Multiple stages to address non-compliance discovered via oversight and monitoring.
Increased levels of impact for MCOs.
Remedy issued is contingent on type of non-compliance and not necessarily sequential.
Addressing Non-Compliance Graduated Remedy Process
S t a g e 1
S t a g e 2
S t a g e 3
S t a g e 4
S t a g e 5
Plans of Action
Corrective Action Plan (CAP)
Liquidated Damages (LDs)
Suspension of Default Enrollment
Contract Termination
Financial Impacts
S t a g e 1
S t a g e 2
S t a g e 3
S t a g e 4
S t a g e 5
Plans of Action
Corrective Action Plan (CAP)
Liquidated Damages (LDs)
Suspension of Default Enrollment
Contract Termination
22
2016 Q1-Q3 2017
Q1-Q3 LDs*: $27.4MM
2015
LDs: $2.4MM
2014
LDs: $2.1MM
2013 2012 2011 2009 2010
LDs: $5.2MM
LDs: $2.9MM
LDs: $1.6MM LDs:
$1.1MM LDs:
$900K
Liquidated damages (LDs) increasing with ongoing strengthening of oversight practices.
Financial Impact Stage Liquidated Damages Issued
*Q3 2017 LD dollar amount of $17.7MM is not final. All dollars are based on state fiscal year. All numbers are rounded.
LDs: $4.9MM
23
Utilization Review Liquidated Damages Matrix
Managed Care Utilization Review Liquidated Damages (per day) Matrix
Risk of Harm Impact Tiers
Covered Service Administrative Service
Isolated Systemic Isolated Systemic
4 - significant harm $ 5,000 $ 7,500 $ 3,000 $ 5,000
3 - actual harm $ 3,500 $ 5,000 $ 1,750 $ 3,500 2 - no actual harm, imminent risk for more than minimal harm to member
$ 1,500 $ 2,500 $ 750 $ 1,500
1 - no actual harm, imminent risk for minimal harm to member
$ 500 $ 1,000 $ 250 $ 500