MCPP HEALTHCARE CONSULTING CBS Managed Care Workgroup RFP

MCPP HEALTHCARE CONSULTING

CBS Managed Care Workgroup RFP Development Kick-Off

Work Session

May 13, 2003 9:00 a.m. – 12:15 p.m.Sacramento, CaliforniaDale Jarvis CPA

PAGE 2MCPP HEALTHCARE CONSULTING

Agenda

Introductions & Agenda Review The State of Managed Care in the US What does Managed Care mean to

California Counties? An Evolving Vendor Environment Current Scope of Work for our Workgroup Managed Care - RFP Content Ideas Next Steps Choosing Workgroup Lead & Backup


The State of Managed Care in the US American Academy of Family

Physicians


The State of Managed Care in the US Insurance companies are responding to physician,

hospital, consumer, and legislator pressure. “If you hate managed care, so be it. We’ll move

out of the access and utilization management business and go back to our original mission – using actuaries to price policies and then managing the flow of payor premiums and payor claims.”

This is resulting in commercial insurance premium increases this year in the 20% – 30% range.


The State of Managed Care in the US Behavioral Health Managed Care Companies have

been in a huge state of flux. Magellan Behavioral Health acquired almost all of

their competitors and is now is bankruptcy. Most MBHO’s have gotten out of the Public Sector: Magellan has had contracts pulled. United Behavioral Health has close

to zero remaining public sector contracts.

Value Options has scaled theirpublic sector division back andalso has fewer contracts


What does Managed Care mean to California Counties?

View 1 – Historical Responsibilities Management of Organizational Providers Management of County Operated Programs Inpatient Consolidation – Management of

Institutional Providers Outpatient Consolidation – Management of

Individual Providers & Small Groups



View 2 – Functional Responsibilities Call Center Crisis Tracking and Management Authorization and Utilization Management Care Management (Outpatient and 24 hr

Svcs) Provider Relations and Management Claims Processing


Flow 1: Initial Client Contact - Outpatient

CallfromNew

Client

Log CallCall Log Form

Check SS# to seeif in the system

Check Current/Historical Eligibility

Open an Eqisode

Triage Decision

No $, No Insur,Coverage requires

other provider (LOC =1A)

Refer toCommu-nity Re-source

Contactfront

desk tosetupappt

Meets criteria tobe seen by

internal provider(including level of

care > 1A)

Meets criteria to referto private provider

(LOC = 1A)

Search forProvider

Assign Cert # &authorize XX

sessions

Packet to Client Packet to Provider

Enter chart note

Aid code, shareof cost,

demographics..

Most recent 12months' elig

history

ClientScreening

Initial Assessment/Referral Form

City, Licensure,Gender,

Specialty (up to 3categories)

Look at Status,Comments and

Ratings

If Kaiser, refer to them, open anepisode, put some brief info in; If

Medicare, authorize & tell provider to billMedicare first.

Assign provider type (IP or OP), visit cluster (e.g. any typeof group therapy), # of visits, start date, comments


Flow 2: Client Service - Outpatient

ReturnPaper-work

Referral toPsychiatrist

PsychiatricMedical Evaluation

Non-MedicalReferral

Enter Paperwork

Need MoreCare?

Yes, Non-MD

ProvideService

No

Enter clinicial noteand reason for

closing

Denial Letter

Cert Letter (toProvider)

Referral Made

Assessment andCare

Recommendation

Outpatient TxProgress Report Closing Summary

Report

ApproveRecert?

Yes, fully No CareMgr

review

Care Mgr enterclosing status and

date

Yes, MD

Enter clinicial noteEnter clinicial note

Notice of ActionForm

Assign Cert # &authorize XX

sessions

Yes, partially


Notice of ActionForm

Sections included: Risk, Chemical Dependency,Mental Status Eval, Medications, Diagnosis,

Proposed Treatment Plan


Flow 3: Inpatient Case ManagementClient Admitto Hospital,

call fromHospital

Log Call Call Log Form

Check SS# to seeif in the system

Open an Eqisode(cert #, admit date,

location, auth 3days)

DevelopTx Plan,Provide

Svc

Enter chart note, ifnecessary, & initial

clinical info

CaseReviewevery 2-3 days

Need MoreCare?

Yes No

Close Episode,enter date and

chart note

Inpatient TxProgress Report

ApproveRecert?

Yes No

Denial Letter


Create new certwith more days

Client Admitto Hospital,

fax fromCrisis

HospitalAdmission Form

Assign aCareMgr

Enter toIP Log

Inpatient Log

Check eligibility

Enter chart note, ifnecessary

2x weekreview allcases w/MedicalDirector

Enter dischargeplan from Hospital

phone call


Flow 4: Claims Processing

Send toAuditor

VerifyAuthorization

IMD, SNF Claim(residential)

Enter Claim

Set up RetroEpisode

Adjudicate Claim

Okay to Pay?Yes

MailEOBand

Check

Generate EOB

Denial Letter

Approved?

HCFA 1500 fromOP Provider

EOB

Create Check

UB92 fromHospital

Out of Area Claim

No

Responsible?Yes No

Assign Cert #

Authorize XX days,sessions

Denial Letter (forout of county or

non-MH diagnosis)

NoYes

Send toCareMgr

EvaluateClaim

Approved? NoYes

Setup or CorrectEpisode

Denial Letter

eligibility, placement,reimbursement rate

Enter providerinformation

Enter client &clinical information

CheckClaim

Okay?Yes No

Sendbackwith

coverletter


Flow 5: Provider RegistrationCallfromNew

Provider

Query Nat'lProvider Databank

Provider Packet

Approved?

Sendout a

ProviderPacket

ReceiveMatls

Setup Provider Letter to Provider

Packet to Provider

Renewal Report(malp insur,

license, DEA #)

VerifyMalpInsur

VerifyEducat

VerifyLicense

Credentialing

CommMeet

Yes No

Update Letter toProvider

OpeningAvailable?

Openings for that type ofprovider or geographic

location?NoYes

Informprovider

NeedmoreInfo

RequestmoreInfo Annual

Updates

Bi-Annual recredentialing withproviders, similar packet to initial

provider packet


Flow 6: Calls from Provider or Client

? aboutAuth

Check ClaimScreen

Check AuthScreen

Check ProviderScreen

Contact claimsstaff to look for

claim form

No record?Have

providerresendclaim

Check to see ifpaid

? aboutClaim

(contractprovider)

? aboutCredenti

aling

Wrong $?Request

correction

Paid? Tellprovider

voucher #,date paid

Provideinformation

Provideinformation

Check EligibilityScreen

? aboutEligibility

Provideinformation

Claim to beResearched Form

Add new Providerto System

? aboutProviderChoice

Call client,provider

Approvealternateprovider?

DeniedClaim

Valid Denial?

Make a note inclaims screen

Yes No

Callprovider,

inform no $coming

Contactclaims to

makeadjustment

EOBDenial(non-

contractprovider)

Informprovider of

neededpaperwork

Maybepayable?

Yes No

Callprovider,

inform no $coming

1 2 3 4 5

6



Question: How do your workflows differ?



Software Implications for Views 1 & 2 Software has to match the workflows of these

responsibilities and activities. Software has to “roll with the punches”; different

counties do this work differently and have different business rules.

Software needs to support both clinical activities and business activities.

Software should promote “paperwork reduction initiatives” and make life easier rather than harder for staff.

Software should improve the quality of client care.


An Evolving Vendor Environment 1998 to Now

Cavion - CNR HealthMilwaukee, WI 800 654-5160Managed CareCNR is a managed care company that has becoming a software vendor for the managed care product they’ve been using in-house. The system runs on SQL Server and they are working on adding Oracle. The software manages about 2,000,000+ lives.

Diamond Health Systems Design1330 Broadway Oakland California 800 995-6285Managed CareThis is a healthcare system. A number of counties in California are using it for their healthcare needs and three are using it for mental health. They have a character-based version and a Windows version. They have integrated their product with SMS.

Emcee Managed Care Info System - Mariner Systems2336 Canyon Boulevard, Suite 201 Boulder, Co 80302 (800)242-8845Managed CareThey have a newish managed care product that was built for medical and is starting to be installed in a number of mental health settings. They have the right technology and have started to make links into provider systems and accounting systems.


An Evolving Vendor Environment 1998 to Now

Blackberry Technologies135 West 50th St, Suite 1950 New York, NY 10020 (212) 246-7200 Managed CareThey have managed care software. Folks at OTG have spoken with them before about their product. Their system is supposed to be an odd design because they don’t have deep mental health experience and listen to what their clients need, regardless of how strange the request may be. They have the right technology and are a talented bunch.

In-Net - Aurora CMHCAurora, Colorado (303)617-2300 Managed Care and Practice ManagementThis group came out of a consortium of two hospitals and several CMHCs in Colorado who funded the development of managed care and provider systems using new technology. I don’t know if they have the infrastructure to be viable.

Ecura - InfoMC 2250 Hickory Road, Ste 400, Plymouth Meeting PA 19462 (484) 530-0100Managed CareYou know these guys…


An Evolving Vendor Environment The success stories are now coming in related to electronic

medical records (EMR) projects: Seventh Annual Davies CPR Recognition Award

The Ohio State University Health SystemUniversity of Illinois at Chicago Medical CenterHeritage Behavioral Health Center, Inc.

Sixth Annual Davies CPR Recognition AwardHarvard Vanguard Medical Associates/Harvard Pilgrim HealthcareDepartment of Veterans Affairs: Puget Sound Health Care SystemSt. Vincent's Psychiatric Hospital

Fifth Annual Davies CPR Recognition AwardThe Queen's Medical CenterKaiser Permanente Rocky Mountain Region


An Evolving Vendor Environment Software

vendors are learning that past problems haven’t been due to “problem clinicians”, but to hardware and software products that were just too “clunky”.


An Evolving Vendor Environment


An Evolving Vendor Environment We are now seeing second and third

generation solutions and tools that “really work” and are being used by more and more clinicians.


Current Scope for Managed Care Workgroup

2.0 Functional Requirements Each section of the functional requirements will have: One or more descriptive paragraphs Numbered, high-level functionality components that

should exist in most well designed software packages.

Numbered, more detailed California County-specific functionality components.

Limiting the number of components that should be in most packages is the key to a "right-sized" RFP.



2.1 Access/Call Center (To be completed by the Managed Care Workgroup) This section contains functionality related to how the “front

door” needs to be managed including call logging, provider referral, crisis triage, etc.

2.2 Eligibility Verification (To be completed by the Billing/Accounting Workgroup) This section contains info on the variety of ways that

eligibility should be verified, following how InSyst does this as well as future improvements.



2.3 Payor/Provider Management (To be completed by the Managed Care Workgroup) This section describes functionality related to how county

and external providers are set up in the system, how provider credentialing is managed, as well as how external claims are processed.

2.4 Utilization and Care Management (To be completed by the Managed Care Workgroup) This section focuses on describing the use of

authorizations in a manner that provides enough flexibility so that they will meet the varying needs of all the counties.



Question: How do we want to change the Outline to better map to our needs?

• Call Center• Crisis Tracking and Management• Authorization and Utilization Management• Care Management (Outpatient and 24 hr Services)• Provider Relations and Management• Claims Processing

2.1 Access/Call Center2.3 Payor/Provider Management2.4 Utilization and Care Management


Managed Care - RFP Content Ideas


Managed Care - RFP Content Ideas General Needs (to be found in other parts of the

RFP)1. Custom Forms: The system has the ability to allow

for the development of custom forms for Managed Care - Client Services, Managed Care - Payor/Provider Relations; Practice Management - Client Services. The forms will allow for the creation of new fields. They will support validation checks for all new and existing fields and user-defined determination of entry rules (e.g. required, warning, not required/no warning). Each field will have various field types: text, radio button, checklist, and fields populated by user-defined lookup tables.



RFP)2. System Navigation: Provides the ability throughout the

system to either go back to the menu to move to another screen or to have user-defined buttons on the screen that will prompt the user to go to another form. The system allows for all information relating to a particular client, provider, care manager, member, etc.. to be easily accessed from any screen in the system where such data exists (e.g. be able to go to authorizations or call logs or screening forms from service entry or progress note entry). 3. Provides the ability throughout the system to either go back to the menu to move to another screen or to have user-defined buttons on the screen that will prompt the user to go to another form.



RFP)3. Custom Reports: The system can generate any number

of custom forms that can be place on menus in user-defined locations. Has the capability of reporting on any group of data fields in the entire BHIS including user-defined fields; can perform multi-layered sorts and selects; has the ability to utilize wild cards in any data position of a field to select items; has the ability to compute on any field or group of fields. Has a report designer to design how reports will look and support a number of reports including columnar, cross-tab, mailing labels, form letters, graphs, etc. Has the options of outputting reports on an manual or automated basis to the screen, printer, standard ASCII file format and PC application formats (XLS, WK*, MDB, DIF, etc.)


Managed Care - RFP Content Ideas General Needs (to be found in other parts of the RFP)

4. Tickler Engine: A system that allow for fields to be added in any form that allow the user to specify if follow-up is needed and when ("in xx days", or "on xx date. In addition a tickler attribute can be added to most fields throughout the system whereby a user can set a value for that field (e.g. "a billed item has had no payment action in 45 days" or "it has been 7 days since the form that holds this item was filled out but this required field is still blank"). The tickler engine can be set to run at specified intervals (e.g. "every night at 1am" and when it finds a record that meets the tickler threshold the engine will initiate a predetermined action that was originally set up. These actions include: Send an email to the case manager or designated billing person or the supervisor, etc. Add the item to a report that is automatically printed at the end of the process, sorted by type of tickler item. Add the item to a report that is manually run by various users (e.g. "the scheduling person runs the report of all appointments from the previous day that have not had some action entered")


Managed Care - RFP Content Ideas Call Center

Call Logging: All calls are logged into a user-defined online form that gathers information on the nature of the call and basic caller data such as name, phone number, language requirement, etc. If the call is not a request for service, basic information is collected regarding the type of call and disposition. If the call is about a complaint, compliment or grievance, all relevant data is recorded on the online form. Recording and reporting of disposition is included in all cases.

Pre-Registration: Provides user-defined online pre-registration forms to gather initial client demographic and financial resources information for individuals requesting service. If the client becomes registered for service this information can be forwarded to Registration so that duplicate data entry is not required. If the client is already registered as a client in the system this should be flagged.


Managed Care - RFP Content Ideas Call Center

Intake Screening: Provides user-defined online client screening forms to assist in the determination of whether the client requires services from the crisis system, hospitalization, referral for outpatient services, or referral to other community resources. Includes access needs information, presenting problems and other relevant clinical information.

Referral Database: Contains detailed information about the practices of clinicians in the provider network (including county staff clinicians) and facilitates the matching of client to clinician through the selection of criteria in the provider database. This includes information about provider location, specialties, non-English language capability, etc.


Client Screening


Client Screening



Call Center Case Notes: Supports the entry of case notes for

clients that can become part of the chart (as opposed to a call log record)

Call Center Other: Other: Other:


Managed Care - RFP Content Ideas Crisis Tracking and Management

Crisis Plan: Supports the development of an online Crisis Management Plan that is prepared for clients of the service delivery system. If a client goes into crisis this plan is available to provide guidance to staff.

Crisis Intake: Provides user-defined screens for tracking key crisis service data including date and time of initial request, date and time of first contact, referral source, location of service, and type of service as well as clinical notes about the crisis including user-defined checklists and text-based crisis notes that allow for the recording of diagnosis, level of functioning and other relevant clinical data.


Crisis Plans


Managed Care - RFP Content Ideas Crisis Tracking and Management

Crisis Investigation: Supports the tracking and reporting of data elements related to the involuntary detention law.

Crisis Referrals: Supports the referral of clients to inpatient facilities, crisis respite, walk-in outpatient care, and assignment to an outpatient authorization.

Other: Other: Other:


Managed Care - RFP Content Ideas Authorization and Utilization Management

Authorizations: Allows for the issuance, tracking and closing of a variety of authorization types (e.g. acute inpatient, IMD, intensive outpatient) that constitute discreet episodes of care. Can support several methods of setting service limits for each type of authorization including number of visits or days, number of client or clinician service hours, number of days or weeks, or specific dollar limits. As service is provided actual services are compared with authorized amounts and the system has multiple ways of notifying providers and utilization managers of remaining balances.

Authorization Letters: Generates user-customizable authorization letters for providers and clients. Transmits authorization information to providers in a variety of ways including notification to users of the system, EDI, fax, email, as well as generating hard copy referrals. Can transmit a single authorization to multiple individuals and/or organizations.



Authorization Limits: Can be configured to use authorization limits for information reporting purposes, to generate alerts for care managers and providers, and to stop payment of claims. These options can be applied globally, to specific classes of providers, or to individual clinicians.

Authorization Tracking: Tracks authorizations in a number of ways including individual and aggregate services authorized, services utilized, and service balances. Generates reports to notify care managers or providers of upcoming authorization end dates and/or authorizations that are approaching their limits.


Authorization & Referral Tracking



Caseload and Utilization Reporting: Provides reports for individual clinicians and supervisor roll-ups that report caseload statistics and services provided to those clients.

Ad Hoc Analysis: Supports various ad hoc utilization management activities including random chart pull selection, online chart review, identification of utilization outliers, etc.


Clinician Caseload TrackingABC Mental Health Clinician: Joe Smith

Clinician Caseload Report Report Date: Jan-2000

Level Auth. Start Auth. End Level of Care Hour Range Actual Act. Hrs as Auth TimeClient Name of Care Date Date Average Low High Hours % of Avg % Used

1 Bob Jones 2 7/1/1999 6/30/2000 18 10 49 6 33% 59%2 Beth John 1 8/1/1999 7/31/2000 4 1 9 2 50% 50%3 Bill Jack 2 8/15/1999 8/14/2000 18 10 49 3 17% 46%4 Louis Wise 3 12/1/1999 11/30/2000 58 50 100 14 24% 17%5 Dale Wirst 3 11/15/1999 11/14/2000 58 50 100 12 21% 21%6 Dawn Ent 1 10/2/1999 10/1/2000 4 1 9 2 50% 33%7 - - - 8 - - - 9 - - -

10 - - - Total 161 122 316 39 24% 38%

Level 1 Clients: 2 Level 2 Clients: 2 Level 3 Clients: 2



Care Management Inpatient Tracking and Management: Provides

user-define screens for tracking key inpatient data including date of admission, referring provider, inpatient case manager, outpatient authorization type, outpatient case manager, and date of discharge, admit and discharge diagnosis, legal status, etc.

Admission and Census Reporting: Supports the production of daily census reports and bed statistics reports.


Admission Tracking


Census Tracking


Managed Care - RFP Content Ideas Care Management

Allows for the development of user-defined data fields to automate the individual treatment and discharge plans.


Treatment Planning


Service Review & Discharge Planning



Care Management Other Other Other


Managed Care - RFP Content IdeasProvider Relations and Management

Contracts: Support multiple contractor agreements that include services funded by multiple payors with differing benefit designs and multiple reimbursement systems (e.g. case rate, fee for service, capitation, fixed fee payments).

Clinician Characteristics: Has user-defined screens to register, track and report on internal and external clinicians, including such information as location, licensure, language, days and times worked, specialties, etc.

Credentialing: Allows for the credentialing of individual clinicians (internal and external) and the certification of provider facilities.



Provider Relations and Management Expiration Alerts: Has user-defined alerts and tickler

systems to support the notification of expiring licenses, recredentialing deadlines and other time-sensitive information.

Provider Notes: Has the ability to record and track communications with provider organizations and individual clinicians including provider requests and complaints and includes a tickler system for ensuring follow-up of outstanding items.


Managed Care - RFP Content Ideas Provider Relations and Management

Inpatient Consolidation Managed Care: Supports the per diem payment structure for inpatient services provided by participating and out of area inpatient facilities. Needs to support multiple contract agreements for per diem and pro fees. Supports tracking and management of benefit limits, copays, deductibles, covered and non-covered services, and multiple fee schedules. Supports management of multiple payor contracts. Captures insurance benefit rules. Other

Outpatient Consolidation Managed Care: Supports the external network fee-for-service system for individual clinicians who contract with the Counties. Needs to support multiple contract agreements. Supports tracking and management of benefit limits, copays, deductibles, covered and non-covered services, and multiple fee schedules. Supports management of multiple payor contracts. Supports multiple reimbursement systems (fee for services, case rate, capitation). Captures insurance benefit rules.



Provider Relations and Management Other Other Other


Managed Care - RFP Content Ideas Claims Processing

Claims Receipt: Allows for the entry of HCFA 1500s and UB92s from network providers (including billed amounts, copays, deductibles, and reason codes) through easy to use data entry screen(s).

Claims Adjudication: Adjudicates claims on a per claim basis. Claims are screened for proper eligibility including whether other insurance plans are primary, the existence of an appropriate authorization, coverage for the specific service under the authorization and service by an authorized provider.

Pending/Denying Claims: Can be configured to allow for pending claims for review or to deny the claims if they do not have an appropriate authorization in the system. The user can choose to include or exclude denials and pended claims from Explanation of Benefit (EOB) reports.


Managed Care - RFP Content Ideas Claims Processing

EOBs: Generates Explanation of Benefits (EOB) reports that detail the disposition of the current claims that have been processed. The EOBs will include all claims entry information (including billed amounts, copays, deductibles, allowed amounts and reason codes) and claim line numbers and unique EOB numbers.

Claim Reports: Can produce claim reports that are user defined to include or exclude paid, pending and denied claim information for specific providers or facilities or ranges of providers/facilities.

Claim Adjustments: Can support the entry of claim adjustments where claims that have been entered, adjudicated, approved and paid can be reversed. These adjustments will also be included in the EOBs for specific providers/facilities.



Claims Processing Other Other Other


Next Steps

Email any follow-up ideas. Decide how to gather feedback from colleagues

inside your organization and your provider network.

Get ready to review andcomment on your RFPSections.

Begin thinking aboutdemo scenarios.

MCPP HEALTHCARE CONSULTING

Choosing a Workgroup Lead

Documents

MCPP HEALTHCARE CONSULTING CBS Managed Care Workgroup RFP