PowerPoint Template - MSHO-standard - UCare
4th Quarter MSHO/MSC+ Care Coordination Training Care Systems & UCare Care Coordinators: December 13th, 2017 Recorded WebEx: December 14th, 2017
Agenda •
Fraud, Waste, and Abuse Overview & Reporting
•
HEDIS 2018 Care Coordination Request
•
Adam Nelson
EW and PCA
•
Robert Burkhardt
MSHO/MSC+ 2018 Formulary Changes
•
Chelsey Doepner
2018 MSHO/MSC+ Benefit Updates
•
Cheryl Witsoe
Esther Versalles-Hester
Care Coordination Updates
Bobbi Jo Glood/Ceil Boesche
Fraud, Waste, and Abuse Overview & Reporting December 2017
Special Investigations Unit (SIU) • • •
•
SIU Manager – Cheryl Witsoe Senior Investigator – Open position Investigators Renee Haynes Larry Ashworth Open position Investigative Assistant Mena Xiong Detects possible issues
Investigates cases
Take necessary Action
Prevents Future issues
SIU assists with the Seven Fundamental Elements of an Effective Compliance Program
1. Implementing written policies, procedures and standards of conduct. 2. Designating a compliance officer and compliance committee. 3. Conducting effective training and education. 4. Developing effective lines of communication. 5. Conducting internal monitoring and auditing. 6. Enforcing standards through well-publicized disciplinary guidelines. 7. Responding promptly to detected offenses and undertaking corrective action
The Work SIU does for UCare 4 Components of SIU work Investigate cases from submitted leads, data mining and referrals to UCare Take action, including overpayment recoveries, terminations, and referrals to law enforcement Fulfilling requests from law enforcement for data & information Working with operations to prevent issues
Fraud, Waste & Abuse Spectrum
Mistakes
Inefficiencies
Bending the Rules OR Physical Abuse
Error
Waste
Abuse
Intentional Deception
Fraud
What should be reported to SIU? •
Anytime you think fraud or abuse may have occurred such as:
A member says they never received services from a clinic or doctor on an EOB (check to see if the service was an affiliated service first) A member thinks someone else is using their UCare ID to get services.
Abuse: ›
Physical negligence of a member • The care coordinator or member should call law enforcement, then report to SIU if possible
›
Abusive billing or service practices • When a provider bills outrageous numbers of times for the same event • When a provider repeats the same service without necessity
Helpful Hints while talking with a member DON’T SAY: • “The fraud department will call you.” BETTER: • “I will have someone research this concern and call you back if necessary.”
Often, no FWA concern and SIU does not need to speak with the member Members think “there is fraud on my account” and get worried waiting to hear back
DO: •
When reporting to SIU: Provide HOW the member questioned the issue (EOB, or saw something?). Provide the claim number and other details in your report so we understand the problem. Be sure to include the date or documents/examples you have found so we can try to avoid calling you with questions.
What should NOT be reported to SIU? •
Complaints/Grievances:
•
Quality of Care:
•
When a member complains about the service they got. Ex: “The nurse was mean to me”, or “The doctor refused to give me an x-ray”, or “I was injured by the x-ray tech”
A possible billing error (these are grievances):
•
Member complaints about an amount that is overbilled, or errant copay / deductible
A claim that a member thinks should not be billed to UCare (other insurance exists, or should be billed due to an auto accident, etc.) Clinic possibly billing under the wrong member, ex: 2 Mary Anderson at the clinic.
ID Card possibly stolen or lost*:
Direct the member to call law enforcement, and call customer services, who will offer a replacement card with voluntary restriction, and a Health Ride password. *If the member’s card has already been used by another part for sure, then this gets reported to SIU.
The SIU Investigation Process •
SIU receives the lead
•
Triages the lead:
Is there any member safety concerns? SIU will address asap Is it really possible FWA? Do we have enough information to work the lead? Etc.
•
Close the lead if belongs elsewhere OR if not Fraud, Waste, or Abuse
•
OR Open a full investigation
•
Take Action:
Overpayment recoveries, Provider Education, Refer member for restriction, etc. Refer to Regulators, Boards and/or Law Enforcement
SIU Techniques for Investigations
Techniques used to investigate cases: • • • •
• • •
Interview witnesses, providers, and/or members Data analytics On site review Review of provider records, such as • Medical records and other clinical documents • Interpreter or taxi records • Payroll records Use Subject Matter Expertise Contract review Verification of the provider’s eligibility
Things to know about SIU • We can’t usually tell you what’s happening with a case • We may need your help to follow-up with a member involved in a lead or case • We work daily with all operational areas
To work leads and cases Feedback to operations to better our processes / systems, etc. Train staff
To report a concern • Internal staff may report via the “HUB”: Use “Report a Compliance/FWA/Privacy Incident” • Call the Hot Line: 1-877-826-6847 Callers may remain anonymous, available 24/7 • Email: submit a concern to [email protected] • Contact the UCare Compliance Officer: Mary Jo Flynn, 612-294-5529
HEDIS 2018 Care Coordinator Request
Chelsey Doepner, HEDIS Supervisor
What is HEDIS? • 90% of America's health plans use it to measure performance on important dimensions of care and service. • Measures are standardized - HEDIS makes it possible to compare health plans "apples-to-apples.” • HEDIS results are used internally to see where to focus improvement efforts. • Annual data collection time January to May.
HEDIS Measures Requested from Care CoordinationMSHO only 1. Advanced Care Planning Evidence of a document or discussions in the measurement year (2017). Obtained from the Comprehensive Care Plan. 2. Evidence of a Pain Assessment in the measure year (2017). Obtained from the Comprehensive Care Plan. 3. Evidence of a Functional Status Assessment in the measure year (2017). Obtained from the Health Risk Assessment.
4. A Physician, Nurse Practitioner, or PharmD signed Medication List from any time during the measure year (2017.) Remember, COA measures are Star Rating Measures!
How can you help? •
Requests will be sent to counties/delegates for information that supporting measures in about February.
•
Provide the following information: LTCC/HRA completed during 2017 Care plan including completed signature page and date summary sent to PCP. Provide all documents in separate format. Refusal/unable to reach members you can just notify by email. If institutional member provide: › ICCD › MDS Assessment › Signed Medication review › LTCC or POC as above if resided in community at any point during the year.
Timeline for Request and Turnaround •
Initial Request Letter will be sent out on: February 2nd , 2018
•
We need complete documentation or notification of refusal by: February 9th, 2018
•
We know it’s a tight turnaround (1 week), but your support is critical to scoring well on this Stars HEDIS measure! Every piece of information can help!
•
How many members? Some may have none, some may have 2 and some may have 20. The sampling is random and UCare will not know until February.
Questions?
Chelsey Doepner, HEDIS Supervisor [email protected] or [email protected] Phone and Secure Voicemail: 612-294-5674
2018 MSHO / MSC+ Benefits Changes MSHO / MSC+ Care Coordinator Training December 13, 2017
DHS Contract Benefit Changes • Home Health Agency visit - Face to Face encounter with physician, mid-level practitioner required 90 days before or 30 days after (one-time perinatal visit does not require) • Medical Equipment, supplies, appliance need must be reviewed annually by a physician • Initiating Medical Equipment requires face to face documented visit by physician or mid-level - can be telemedicine (all products) 12/14/2017
DHS Contract Benefit Changes Pending Federal Approval: • EW respite care services will include a new provider type: Respite Camps
Camps must be licensed under Minnesota Statutes, Chapter 245D and Certified by the American Camp Association.
Part D Cost Sharing • Annual cost sharing increase Low Income Subsidy Level
Generic Living Situation
1
Specialty
2017
2018
2017
2018
Over 100% FPG, Community
$3.30
$3.35
$8.25
$8.35
2
Community well
$1.20
$1.25
$3.70
$3.70
3
Community with waiver (EW or disability), or Institutional
$0
$0
$0
$0
Additional Benefits
New incentive: $25 for annual exam or inhome visit Will continue to offer in 2018: › Silver Sneakers › $300 Dental allowance › Strong & Stable kit › Preventive care incentives (mammogram, colon cancer screening, etc.) › Community Education discounts › Whole Health Living discounts 12/14/2017
Questions?
MSHO and MSC+ 2018 Formulary Changes
MSHO Formulary Changes • General Formulary Overview
Medicare (CMS regulated) formulary Annual formulary with 1/1 – 12/31 lifespan 6 Pharmacy and Therapeutic Committee Meetings annually Limited opportunities to remove medications throughout the year 1-Tier formulary Cover OTC products
• Summary of Changes
Drug Changes › Additions: 6 › Removals: 21 Prior Authorization Changes › Additions: 10 › Removals: 0
MSHO Formulary Changes • Hepatitis C Drugs
Epclusa, Harvoni, and Zepatier will remain on the formulary. Mavyret and Vosevi added to formulary.
• Minimal impact from removals of drugs for 2018
Metformin ER 1,000 mg notable removal
• HRM PA added to benztropine and phenobarbital • PA added to long acting opioids for new starts only • Medical injectables
Adding PAs to certain cancer drugs and drugs for enzyme replacement Removing PAs for Aranesp, Epogen, and Procrit
• Medicare Preferred Value Network of Pharmacies
Does not apply to MSHO members.
• Expanded OTC coverage by 1,425 NDCs
MSHO Adherence Programs • Late to refill letters sent to members monthly • Medication Therapy Management (MTM)
Vendor remains OutcomesMTM for 2018 Improve completion rates of comprehensive medication reviews (CMRs) for Medicare members
• Medicare STARs measures
Improve adherence to diabetes medications, RAS antagonists, and statins
• Promote 90-day fills of medications • Add Screen Rx through Express Scripts (ESI) for 2018
Uses predictive modeling to detect risk of nonadherence. Outreach completed by pharmacists to members and prescribers. Combination of calls and mailed letters.
MSC+ Formulary Changes • General Formulary Overview
Medicaid (DHS regulated) Formulary Not an annual formulary 6 Pharmacy and Therapeutic Committee Meetings annually Able to remove medications throughout the year 2-Tier Formulary
• Summary of Changes
Drug Changes › Additions: 15 › Removals: 44 Prior Authorization Changes › Additions: 36 › Removals: 0
MSC+ Formulary Changes • Hepatitis C Drugs
New drugs Mavyret and Vosevi will be preferred. Epclusa, Harvoni, and Zepatier will be non-preferred.
• Additions, removals, prior authorizations
Adding Lyrica and rosuvastatin with prior authorizations (PA). Adding PAs to certain drugs (mostly oncology drugs). Significant formulary removals include Metformin ER 1,000 mg and Alprazolam ER
• Medical injectables
Adding PAs to certain cancer drugs and drugs for enzyme replacement. Removing PAs for Aranesp, Epogen, and Procrit.
Both Formulary Changes • Diabetic Testing Supplies
Changing to all OneTouch (Johnson & Johnson) diabetic testing supplies for 2018. Notification letters sent to members and prescribers. Members able to start transitioning to OneTouch now. Does require a prescription from prescriber. MSHO members will be eligible for transition fills in 2018.
Questions?
EW and PCA Updates
EW DTR
HCBS/LTSS Services • •
The purpose of these programs is to promote community living and independence with services and supports designed to address each person’s individual needs and choices. In the case of EW, the additional services go beyond what is otherwise available through Medical Assistance (MA).
Examples; PCA, Homemaking, PERS, MOW, Transportation, CDCS, ADS, CL and equipment and supplies. •
UCare requires authorization for all EW services, therefore if services are terminated reduced or denied a DTR is required.
When to Issue a EW DTR Most common DTR reasons and codes.
1. Based on annual LTCC assessment, member no longer meets criteria for EW.
Reason Code: 1622
2. When reducing EW services 1.
Reason Code: 1616
3. Member has or will be in institutional setting for more than 30 days. 1.
Reason Code: 1621
4. Member is requesting that EW services be terminated. 1.
Reason Code: 1602
5. Member is requesting that EW services be reduced. 1.
Reason Code: 1615
6. Can not locate member to conduct face to face annual LTCC. 1.
Reason Code: 1614
Reminder regarding DTR Process • •
A 10 business day notice is required on all DTR’s. EW DTR form must be completed in its entirety.
Failing to do so results in delay of processing and service delivery.
•
When denying EW services, a DTR is required for each service or event.
•
Ucare issues a DTR to the member and provider ( preferably faxed to provider). Extended PCA: DTR is processed via the CC communication form. Keep an eye out for duplicative services
• •
i.e. Member previously receiving homemaking services, was just assessed for PCA, therefore homemaking will be reduced or terminated – DTR is required, we can not let the EW services continue at the higher level.
Resources DTR Form https://www.ucare.org/providers/CareCoordinators/Pages/FormsMSHO.aspx Reason Codes https://www.ucare.org/providers/CareCoordinators/Pages/FormsMSHO.aspx UCare Provider Manual Chapter 24 https://www.ucare.org/providers/ResourcesTraining/Provider-Manual/Pages/ProviderManual.aspx
WSAF Reminders • Two new codes have been added for ICLS services. • Dates and e-mail contact for CM added to form. • Reminders › › ›
To prevent potential HIPPA violations, please check and confirm the correct provider UCare legacy prior to submitting to UCare. Discrepancies identified on the WSAF will be returned back to the case manager for correction. EW WSAF data entry will be transitioned to a new Intake team. There will be no changes to the fax number
DHS EW Budget Increase • • • • • •
•
DHS Bulletin 17-25-10 Increase to Elderly Waiver (EW) and Alternative Care (AC) Monthly Budget Limits The Minnesota Legislature authorized the following increase to monthly limits and caps provided on or after Jan. 1, 2018. The 1.74% increase applies to: Alternative Care (AC) and Elderly Waiver (EW) monthly case mix limits AC and EW Consumer Directed Community Supports (CDCS) budget caps EW service rate limits for customized living (CL), 24-hour customized living (24-hour CL), and residential care services For MMIS instructions related to this change, please see Bulletin #17-2510. Please visit the Elderly Waiver Residential Services webpage to access the latest version of the Residential Services Tool (RS Tool) for planning for services in customized living, 24-hour customized living, and residential care settings. UCare will be implementing the September 1, 2017 DHS rates effective January 1, 2018.
PCA Updates/Reminders Provider contract termination
UCare Intake is assisting with this initiative by reaching out to member via phone call. UCare will email the CS to f/u with the member in identifying a new PCA agency.
Reassessments
Reminder to adhere to the DHS guidelines as they relate to ADL dependency definitions. Early PCA reassessments can be conducted if there has been a change in members health or level of care or change in caregiver status. › Please consult with UCare prior to an early PCA reassessment that does not meet the criteria above.
Questions………? PCA related inquires • Call 612 676-6705 option 2, option 4 to speak to a representative regarding PCA EW related inquires • Contact the CLS Liaison via e-mail at [email protected]
Care Coordination Updates
Measureable Goals and Outcomes Collaborative Care Plan – SMART goals
What is a SMART Goal • • • • •
S – Specific M – Measureable A – Attainable R – Realistic T – Time-Bound
SMART Goals • Specific – Specifically define the goal for the member using action verbs–what member will do or maintain, and how.
• Measurable – Identify how the member’s success will be measured – how will we know if they met the goals or not?
• Attainable – Make sure the goal is realistic and possible for the member to reach.
• Relevant – The goal should be relevant to the member and reflect member wants and/or needs.
• Timely – Establish and STATE a realistic time frame for achieving the goal.
Member Centric Language • Continue to write goals in first person language
“I will…” “My needs…”
• It is important to balance the need for member centered language and SMART goals as both are required components to goal writing
Goal Category
Member Goal
IADLs/ADLs
I will become more independent in walking
Intervention
Examples of goals Goal Category
Member Goal
Intervention
IADLs/ADLs
(A/R) I will become more independent in walking as demonstrated by my (S) (M) ability to walk with my cane or walker within the next 3-6 months. (T/A)
I will continue to work with Physical Therapy 2 days a week to strengthen my legs and increase my ability to ambulate safely.
Goal Example Goal Category
Member Goal
Intervention
Pain Management
I will not have pain. Take measures to control pain.
Goal Example Goal Category
Member Goal
Interventions
Pain Management
My pain will be (A/R) controlled as evidenced by my report, (T) at my next assessment, of (S/M) a pain rating of less than ##, on the 0-10 pain scale rating.
I will schedule a clinic appointment to discuss pain management. (Is this Time Bound?) (How could it be improved?)
Goal Example Goal Category
Member Goal
Intervention
Fall Risk
I will reduce my falls risk by (S/R/A ) using my walker) each time (T/M) I ambulate greater than (M) ## feet and report (M) no falls in a (T) 6 month time span.
I will utilize adaptive equipment consistently and notify CM or Primary Care Provider if service or equipment not meeting needs. I will accept services in my home (homemaking, PT/OT home safety eval, lifeline) to secure my safety. My Care Manager reviewed environmental concerns r/t falls risk with me (i.e. scatter rugs, keeping walkways clear, etc.) My Care Manager will order a falls prevention kit.
Goals and Outcomes Goal Category
Goal
Interventions
Outcomes
Falls Risk
I will (R/A )reduce my falls risk by (S)using my walker (T) (M) each time I ambulate greater than (M) ## feet and report (M) no falls in a (T) 6 month time span.
I will utilize adaptive equipment consistently and notify CM or Primary Care Provider if service or equipment not meeting needs. I will accept services in my home (homemaking, PT/OT home safety eval, lifeline) to secure my safety.
At 6 month check-in, I have used walker at least daily for most walking activities. I have had no falls in last 6 months.
My Care Manager reviewed environmental concerns r/t falls risk with me (i.e. scatter rugs, keeping walkways clear, etc.) My Care Manager will order a falls prevention kit.
I am currently receiving homemaking services, which help so I am not on my feet all day. I have a falls prevention kit and use the tub grips in my tub.
Put Goals to the SMART Test • • • •
Review goals at each assessment/review. Do they fit the SMART format? Make changes as needed. Outcomes should answer the question – was the goal met? What was the outcome of the specific, measureable goal? Was it met or not?
Questions?
MSHO/MSC+ members in 90 day grace period
• UCare expects care coordination delegates to continue with care coordination services for MSHO members in the 90-day grace period, and to monitor MSC+ members during this 90 day time frame, as outlined in the MSHO/MSC+ requirements grid located on the UCare website.
MSHO/MSC+ members in 90 day grace period continued For UCare’s MSHO members, care coordinators must: • • • • • •
Continue care coordination per usual for 90 days. Complete the annual reassessment and any ongoing care management as needed if annual reassessments are due during the 90-day term window. Retain the completed assessment documents in each member’s file and enter the DHS form #3427 into MMIS when a member’s MA is reinstated. Enter the assessment date on the Monthly Part C Assessment log. For EW members only: Provide the county with the DHS #6037 transfer form and all supporting documentation for members whose MA is not reinstated, resulting in disenrollment from the health plan. MSHO members that are in the 90-day grace period are identified on the Care Coordination Enrollment rosters with a specific end date provided vs. 12/31/999.
MSHO/MSC+ members in 90 day grace period continued For MSC+ members, care coordinators must: • •
•
•
•
Monitor members’ MA status for 90 days and complete activities as stated in DHS 6037a scenario #10. If their annual reassessment is due during the 90-day term window, complete the annual reassessment, POC and OBRA Level I, and retain the completed assessment documents in the member’s file. Enter the DHS form #3427 into MMIS when members’ MA is reinstated. For EW members only: If the member’s MA is not reinstated, resulting in disenrollment from the health plan, provide the DHS #6037 transfer form and assessment to the county. Refer to DHS Bulletin # 15-25-10 for CC requirements. MSC+ members that are in the 90-day grace period are identified on the monthly MSC+ term report that is sent out around the 1st of each month.
Care Coordination Enrollment Rosters Please remember to review your care coordination enrollment rosters each month. As a reminder: • The “Changes Tab” (1st Tab) identifies changes with a member’s status:
i.e. Care Coordinator Change, Clinic Change, New Member, Product Change, Rate Cell Change, and Termed Members. ›
Full definitions of the changes are located on the “Definitions” tab (3rd tab).
• The “All Tab” (2nd Tab) identifies all the members you should be providing Care Coordination for. ›
›
Please reconcile your care coordination enrollment rosters quarterly at a minimum. This includes ensuring that every member is assigned to a care coordinator and is being actively managed. Please notify [email protected] with any discrepancies.
Primary Care Clinic/Care Coordination Change Process When Care Coordinators identify members who have a primary care clinic or care coordination change, please keep the following in mind:
If the current CC delegate has not confirmed the new PCC with the member, the current CC will be responsible for care coordination until the new PCC is confirmed. If a member states they plan to establish care with a new PCC, UCare expects the receiving CC delegate to work with the member in scheduling the appointment to establish care. PCC/Care Coordination change request forms are to be submitted to UCare by the current CC delegate only. Please refer to the PCC/Care Coordination Process flow chart located on the UCare website.
Primary Care Clinic/Care Coordination Change Process continued
PCC/Care Coordination change request form must be completed in its entirety and must be received prior to the 15th of the current month for the change to happen in the current month. Communication of the care coordination change will be sent to the current CC delegate as well as the new CC delegate. The member will show as a transfer on next month’s care coordination enrollment roster.
Primary Care Clinic/Care Coordination Change Process continued
PCC/Care Coordination change request forms received after the 15th of the month will be processed with an effective date for the 1st of the following month. Communication will be sent to the current CC delegate indicating that the care coordination change will happen the following month.
The member will show as a transfer on the next month’s care coordination enrollment roster.
UTF paperwork UCare receives Process for UTF paperwork that is received by UCare from a non-delegate (FFS): • CM Intake will review all UTF’s as they come to determine the correct delegate • CM Intake will then push out all UTF information to delegates within 2 business days of enrollment posting • After the UTF information is pushed out, if the delegate changes due to PCC change, the delegate should send the UTF information to the new delegate
DHS Bulletin 17-25-10 Increase to Elderly Waiver (EW) and Alternative Care (AC) Monthly Budget Limits
The Minnesota Legislature authorized the following increase to monthly limits and caps provided on or after Jan. 1, 2018. The 1.74% increase applies to: Alternative Care (AC) and Elderly Waiver (EW) monthly case mix limits AC and EW Consumer Directed Community Supports (CDCS) budget caps EW service rate limits for customized living (CL), 24-hour customized living (24-hour CL), and residential care services For MMIS instructions related to this change, please see Bulletin #17-25-10. Please visit the Elderly Waiver Residential Services webpage to access the latest version of the Residential Services Tool (RS Tool). UCare will be implementing the September 1, 2017 DHS rates effective January 1, 2018.
DHS Bulletin #17-25-08: Policy and MMIS Screening Document Changes for Managed Care
Effective September 1, 2017, all MSHO/MSC+ activity must be entered into MMIS via the newly created H screen or via the current L screen.
In addition to H screen entries, DHS also added a new assessment result value 50 – person not located for HRA and a new referral reason 21 – PCA or health care.
H screen entries • Rate cell A/Community Well, no services (No PCA) • Person not located/Missing Member (new assessment result value 50) Continue to use assessment result value 39 for refusal members • Product changes for members on a waiver/nonwaiver • Transfers from fee-for-service or other health plans • Change in care coordinator document (for rate cell A/community well without PCA and members on CADI, CAC, DD or BI)
L Screen entries • EW members • Members receiving PCA services • Change in care coordinator document (for EW and PCA members) • Exit document (exiting from waiver)
Clinical Liaisons
Clinical Care System Liaison 612-294-5045
[email protected]
Agenda •
Fraud, Waste, and Abuse Overview & Reporting
•
HEDIS 2018 Care Coordination Request
•
Adam Nelson
EW and PCA
•
Robert Burkhardt
MSHO/MSC+ 2018 Formulary Changes
•
Chelsey Doepner
2018 MSHO/MSC+ Benefit Updates
•
Cheryl Witsoe
Esther Versalles-Hester
Care Coordination Updates
Bobbi Jo Glood/Ceil Boesche
Fraud, Waste, and Abuse Overview & Reporting December 2017
Special Investigations Unit (SIU) • • •
•
SIU Manager – Cheryl Witsoe Senior Investigator – Open position Investigators Renee Haynes Larry Ashworth Open position Investigative Assistant Mena Xiong Detects possible issues
Investigates cases
Take necessary Action
Prevents Future issues
SIU assists with the Seven Fundamental Elements of an Effective Compliance Program
1. Implementing written policies, procedures and standards of conduct. 2. Designating a compliance officer and compliance committee. 3. Conducting effective training and education. 4. Developing effective lines of communication. 5. Conducting internal monitoring and auditing. 6. Enforcing standards through well-publicized disciplinary guidelines. 7. Responding promptly to detected offenses and undertaking corrective action
The Work SIU does for UCare 4 Components of SIU work Investigate cases from submitted leads, data mining and referrals to UCare Take action, including overpayment recoveries, terminations, and referrals to law enforcement Fulfilling requests from law enforcement for data & information Working with operations to prevent issues
Fraud, Waste & Abuse Spectrum
Mistakes
Inefficiencies
Bending the Rules OR Physical Abuse
Error
Waste
Abuse
Intentional Deception
Fraud
What should be reported to SIU? •
Anytime you think fraud or abuse may have occurred such as:
A member says they never received services from a clinic or doctor on an EOB (check to see if the service was an affiliated service first) A member thinks someone else is using their UCare ID to get services.
Abuse: ›
Physical negligence of a member • The care coordinator or member should call law enforcement, then report to SIU if possible
›
Abusive billing or service practices • When a provider bills outrageous numbers of times for the same event • When a provider repeats the same service without necessity
Helpful Hints while talking with a member DON’T SAY: • “The fraud department will call you.” BETTER: • “I will have someone research this concern and call you back if necessary.”
Often, no FWA concern and SIU does not need to speak with the member Members think “there is fraud on my account” and get worried waiting to hear back
DO: •
When reporting to SIU: Provide HOW the member questioned the issue (EOB, or saw something?). Provide the claim number and other details in your report so we understand the problem. Be sure to include the date or documents/examples you have found so we can try to avoid calling you with questions.
What should NOT be reported to SIU? •
Complaints/Grievances:
•
Quality of Care:
•
When a member complains about the service they got. Ex: “The nurse was mean to me”, or “The doctor refused to give me an x-ray”, or “I was injured by the x-ray tech”
A possible billing error (these are grievances):
•
Member complaints about an amount that is overbilled, or errant copay / deductible
A claim that a member thinks should not be billed to UCare (other insurance exists, or should be billed due to an auto accident, etc.) Clinic possibly billing under the wrong member, ex: 2 Mary Anderson at the clinic.
ID Card possibly stolen or lost*:
Direct the member to call law enforcement, and call customer services, who will offer a replacement card with voluntary restriction, and a Health Ride password. *If the member’s card has already been used by another part for sure, then this gets reported to SIU.
The SIU Investigation Process •
SIU receives the lead
•
Triages the lead:
Is there any member safety concerns? SIU will address asap Is it really possible FWA? Do we have enough information to work the lead? Etc.
•
Close the lead if belongs elsewhere OR if not Fraud, Waste, or Abuse
•
OR Open a full investigation
•
Take Action:
Overpayment recoveries, Provider Education, Refer member for restriction, etc. Refer to Regulators, Boards and/or Law Enforcement
SIU Techniques for Investigations
Techniques used to investigate cases: • • • •
• • •
Interview witnesses, providers, and/or members Data analytics On site review Review of provider records, such as • Medical records and other clinical documents • Interpreter or taxi records • Payroll records Use Subject Matter Expertise Contract review Verification of the provider’s eligibility
Things to know about SIU • We can’t usually tell you what’s happening with a case • We may need your help to follow-up with a member involved in a lead or case • We work daily with all operational areas
To work leads and cases Feedback to operations to better our processes / systems, etc. Train staff
To report a concern • Internal staff may report via the “HUB”: Use “Report a Compliance/FWA/Privacy Incident” • Call the Hot Line: 1-877-826-6847 Callers may remain anonymous, available 24/7 • Email: submit a concern to [email protected] • Contact the UCare Compliance Officer: Mary Jo Flynn, 612-294-5529
HEDIS 2018 Care Coordinator Request
Chelsey Doepner, HEDIS Supervisor
What is HEDIS? • 90% of America's health plans use it to measure performance on important dimensions of care and service. • Measures are standardized - HEDIS makes it possible to compare health plans "apples-to-apples.” • HEDIS results are used internally to see where to focus improvement efforts. • Annual data collection time January to May.
HEDIS Measures Requested from Care CoordinationMSHO only 1. Advanced Care Planning Evidence of a document or discussions in the measurement year (2017). Obtained from the Comprehensive Care Plan. 2. Evidence of a Pain Assessment in the measure year (2017). Obtained from the Comprehensive Care Plan. 3. Evidence of a Functional Status Assessment in the measure year (2017). Obtained from the Health Risk Assessment.
4. A Physician, Nurse Practitioner, or PharmD signed Medication List from any time during the measure year (2017.) Remember, COA measures are Star Rating Measures!
How can you help? •
Requests will be sent to counties/delegates for information that supporting measures in about February.
•
Provide the following information: LTCC/HRA completed during 2017 Care plan including completed signature page and date summary sent to PCP. Provide all documents in separate format. Refusal/unable to reach members you can just notify by email. If institutional member provide: › ICCD › MDS Assessment › Signed Medication review › LTCC or POC as above if resided in community at any point during the year.
Timeline for Request and Turnaround •
Initial Request Letter will be sent out on: February 2nd , 2018
•
We need complete documentation or notification of refusal by: February 9th, 2018
•
We know it’s a tight turnaround (1 week), but your support is critical to scoring well on this Stars HEDIS measure! Every piece of information can help!
•
How many members? Some may have none, some may have 2 and some may have 20. The sampling is random and UCare will not know until February.
Questions?
Chelsey Doepner, HEDIS Supervisor [email protected] or [email protected] Phone and Secure Voicemail: 612-294-5674
2018 MSHO / MSC+ Benefits Changes MSHO / MSC+ Care Coordinator Training December 13, 2017
DHS Contract Benefit Changes • Home Health Agency visit - Face to Face encounter with physician, mid-level practitioner required 90 days before or 30 days after (one-time perinatal visit does not require) • Medical Equipment, supplies, appliance need must be reviewed annually by a physician • Initiating Medical Equipment requires face to face documented visit by physician or mid-level - can be telemedicine (all products) 12/14/2017
DHS Contract Benefit Changes Pending Federal Approval: • EW respite care services will include a new provider type: Respite Camps
Camps must be licensed under Minnesota Statutes, Chapter 245D and Certified by the American Camp Association.
Part D Cost Sharing • Annual cost sharing increase Low Income Subsidy Level
Generic Living Situation
1
Specialty
2017
2018
2017
2018
Over 100% FPG, Community
$3.30
$3.35
$8.25
$8.35
2
Community well
$1.20
$1.25
$3.70
$3.70
3
Community with waiver (EW or disability), or Institutional
$0
$0
$0
$0
Additional Benefits
New incentive: $25 for annual exam or inhome visit Will continue to offer in 2018: › Silver Sneakers › $300 Dental allowance › Strong & Stable kit › Preventive care incentives (mammogram, colon cancer screening, etc.) › Community Education discounts › Whole Health Living discounts 12/14/2017
Questions?
MSHO and MSC+ 2018 Formulary Changes
MSHO Formulary Changes • General Formulary Overview
Medicare (CMS regulated) formulary Annual formulary with 1/1 – 12/31 lifespan 6 Pharmacy and Therapeutic Committee Meetings annually Limited opportunities to remove medications throughout the year 1-Tier formulary Cover OTC products
• Summary of Changes
Drug Changes › Additions: 6 › Removals: 21 Prior Authorization Changes › Additions: 10 › Removals: 0
MSHO Formulary Changes • Hepatitis C Drugs
Epclusa, Harvoni, and Zepatier will remain on the formulary. Mavyret and Vosevi added to formulary.
• Minimal impact from removals of drugs for 2018
Metformin ER 1,000 mg notable removal
• HRM PA added to benztropine and phenobarbital • PA added to long acting opioids for new starts only • Medical injectables
Adding PAs to certain cancer drugs and drugs for enzyme replacement Removing PAs for Aranesp, Epogen, and Procrit
• Medicare Preferred Value Network of Pharmacies
Does not apply to MSHO members.
• Expanded OTC coverage by 1,425 NDCs
MSHO Adherence Programs • Late to refill letters sent to members monthly • Medication Therapy Management (MTM)
Vendor remains OutcomesMTM for 2018 Improve completion rates of comprehensive medication reviews (CMRs) for Medicare members
• Medicare STARs measures
Improve adherence to diabetes medications, RAS antagonists, and statins
• Promote 90-day fills of medications • Add Screen Rx through Express Scripts (ESI) for 2018
Uses predictive modeling to detect risk of nonadherence. Outreach completed by pharmacists to members and prescribers. Combination of calls and mailed letters.
MSC+ Formulary Changes • General Formulary Overview
Medicaid (DHS regulated) Formulary Not an annual formulary 6 Pharmacy and Therapeutic Committee Meetings annually Able to remove medications throughout the year 2-Tier Formulary
• Summary of Changes
Drug Changes › Additions: 15 › Removals: 44 Prior Authorization Changes › Additions: 36 › Removals: 0
MSC+ Formulary Changes • Hepatitis C Drugs
New drugs Mavyret and Vosevi will be preferred. Epclusa, Harvoni, and Zepatier will be non-preferred.
• Additions, removals, prior authorizations
Adding Lyrica and rosuvastatin with prior authorizations (PA). Adding PAs to certain drugs (mostly oncology drugs). Significant formulary removals include Metformin ER 1,000 mg and Alprazolam ER
• Medical injectables
Adding PAs to certain cancer drugs and drugs for enzyme replacement. Removing PAs for Aranesp, Epogen, and Procrit.
Both Formulary Changes • Diabetic Testing Supplies
Changing to all OneTouch (Johnson & Johnson) diabetic testing supplies for 2018. Notification letters sent to members and prescribers. Members able to start transitioning to OneTouch now. Does require a prescription from prescriber. MSHO members will be eligible for transition fills in 2018.
Questions?
EW and PCA Updates
EW DTR
HCBS/LTSS Services • •
The purpose of these programs is to promote community living and independence with services and supports designed to address each person’s individual needs and choices. In the case of EW, the additional services go beyond what is otherwise available through Medical Assistance (MA).
Examples; PCA, Homemaking, PERS, MOW, Transportation, CDCS, ADS, CL and equipment and supplies. •
UCare requires authorization for all EW services, therefore if services are terminated reduced or denied a DTR is required.
When to Issue a EW DTR Most common DTR reasons and codes.
1. Based on annual LTCC assessment, member no longer meets criteria for EW.
Reason Code: 1622
2. When reducing EW services 1.
Reason Code: 1616
3. Member has or will be in institutional setting for more than 30 days. 1.
Reason Code: 1621
4. Member is requesting that EW services be terminated. 1.
Reason Code: 1602
5. Member is requesting that EW services be reduced. 1.
Reason Code: 1615
6. Can not locate member to conduct face to face annual LTCC. 1.
Reason Code: 1614
Reminder regarding DTR Process • •
A 10 business day notice is required on all DTR’s. EW DTR form must be completed in its entirety.
Failing to do so results in delay of processing and service delivery.
•
When denying EW services, a DTR is required for each service or event.
•
Ucare issues a DTR to the member and provider ( preferably faxed to provider). Extended PCA: DTR is processed via the CC communication form. Keep an eye out for duplicative services
• •
i.e. Member previously receiving homemaking services, was just assessed for PCA, therefore homemaking will be reduced or terminated – DTR is required, we can not let the EW services continue at the higher level.
Resources DTR Form https://www.ucare.org/providers/CareCoordinators/Pages/FormsMSHO.aspx Reason Codes https://www.ucare.org/providers/CareCoordinators/Pages/FormsMSHO.aspx UCare Provider Manual Chapter 24 https://www.ucare.org/providers/ResourcesTraining/Provider-Manual/Pages/ProviderManual.aspx
WSAF Reminders • Two new codes have been added for ICLS services. • Dates and e-mail contact for CM added to form. • Reminders › › ›
To prevent potential HIPPA violations, please check and confirm the correct provider UCare legacy prior to submitting to UCare. Discrepancies identified on the WSAF will be returned back to the case manager for correction. EW WSAF data entry will be transitioned to a new Intake team. There will be no changes to the fax number
DHS EW Budget Increase • • • • • •
•
DHS Bulletin 17-25-10 Increase to Elderly Waiver (EW) and Alternative Care (AC) Monthly Budget Limits The Minnesota Legislature authorized the following increase to monthly limits and caps provided on or after Jan. 1, 2018. The 1.74% increase applies to: Alternative Care (AC) and Elderly Waiver (EW) monthly case mix limits AC and EW Consumer Directed Community Supports (CDCS) budget caps EW service rate limits for customized living (CL), 24-hour customized living (24-hour CL), and residential care services For MMIS instructions related to this change, please see Bulletin #17-2510. Please visit the Elderly Waiver Residential Services webpage to access the latest version of the Residential Services Tool (RS Tool) for planning for services in customized living, 24-hour customized living, and residential care settings. UCare will be implementing the September 1, 2017 DHS rates effective January 1, 2018.
PCA Updates/Reminders Provider contract termination
UCare Intake is assisting with this initiative by reaching out to member via phone call. UCare will email the CS to f/u with the member in identifying a new PCA agency.
Reassessments
Reminder to adhere to the DHS guidelines as they relate to ADL dependency definitions. Early PCA reassessments can be conducted if there has been a change in members health or level of care or change in caregiver status. › Please consult with UCare prior to an early PCA reassessment that does not meet the criteria above.
Questions………? PCA related inquires • Call 612 676-6705 option 2, option 4 to speak to a representative regarding PCA EW related inquires • Contact the CLS Liaison via e-mail at [email protected]
Care Coordination Updates
Measureable Goals and Outcomes Collaborative Care Plan – SMART goals
What is a SMART Goal • • • • •
S – Specific M – Measureable A – Attainable R – Realistic T – Time-Bound
SMART Goals • Specific – Specifically define the goal for the member using action verbs–what member will do or maintain, and how.
• Measurable – Identify how the member’s success will be measured – how will we know if they met the goals or not?
• Attainable – Make sure the goal is realistic and possible for the member to reach.
• Relevant – The goal should be relevant to the member and reflect member wants and/or needs.
• Timely – Establish and STATE a realistic time frame for achieving the goal.
Member Centric Language • Continue to write goals in first person language
“I will…” “My needs…”
• It is important to balance the need for member centered language and SMART goals as both are required components to goal writing
Goal Category
Member Goal
IADLs/ADLs
I will become more independent in walking
Intervention
Examples of goals Goal Category
Member Goal
Intervention
IADLs/ADLs
(A/R) I will become more independent in walking as demonstrated by my (S) (M) ability to walk with my cane or walker within the next 3-6 months. (T/A)
I will continue to work with Physical Therapy 2 days a week to strengthen my legs and increase my ability to ambulate safely.
Goal Example Goal Category
Member Goal
Intervention
Pain Management
I will not have pain. Take measures to control pain.
Goal Example Goal Category
Member Goal
Interventions
Pain Management
My pain will be (A/R) controlled as evidenced by my report, (T) at my next assessment, of (S/M) a pain rating of less than ##, on the 0-10 pain scale rating.
I will schedule a clinic appointment to discuss pain management. (Is this Time Bound?) (How could it be improved?)
Goal Example Goal Category
Member Goal
Intervention
Fall Risk
I will reduce my falls risk by (S/R/A ) using my walker) each time (T/M) I ambulate greater than (M) ## feet and report (M) no falls in a (T) 6 month time span.
I will utilize adaptive equipment consistently and notify CM or Primary Care Provider if service or equipment not meeting needs. I will accept services in my home (homemaking, PT/OT home safety eval, lifeline) to secure my safety. My Care Manager reviewed environmental concerns r/t falls risk with me (i.e. scatter rugs, keeping walkways clear, etc.) My Care Manager will order a falls prevention kit.
Goals and Outcomes Goal Category
Goal
Interventions
Outcomes
Falls Risk
I will (R/A )reduce my falls risk by (S)using my walker (T) (M) each time I ambulate greater than (M) ## feet and report (M) no falls in a (T) 6 month time span.
I will utilize adaptive equipment consistently and notify CM or Primary Care Provider if service or equipment not meeting needs. I will accept services in my home (homemaking, PT/OT home safety eval, lifeline) to secure my safety.
At 6 month check-in, I have used walker at least daily for most walking activities. I have had no falls in last 6 months.
My Care Manager reviewed environmental concerns r/t falls risk with me (i.e. scatter rugs, keeping walkways clear, etc.) My Care Manager will order a falls prevention kit.
I am currently receiving homemaking services, which help so I am not on my feet all day. I have a falls prevention kit and use the tub grips in my tub.
Put Goals to the SMART Test • • • •
Review goals at each assessment/review. Do they fit the SMART format? Make changes as needed. Outcomes should answer the question – was the goal met? What was the outcome of the specific, measureable goal? Was it met or not?
Questions?
MSHO/MSC+ members in 90 day grace period
• UCare expects care coordination delegates to continue with care coordination services for MSHO members in the 90-day grace period, and to monitor MSC+ members during this 90 day time frame, as outlined in the MSHO/MSC+ requirements grid located on the UCare website.
MSHO/MSC+ members in 90 day grace period continued For UCare’s MSHO members, care coordinators must: • • • • • •
Continue care coordination per usual for 90 days. Complete the annual reassessment and any ongoing care management as needed if annual reassessments are due during the 90-day term window. Retain the completed assessment documents in each member’s file and enter the DHS form #3427 into MMIS when a member’s MA is reinstated. Enter the assessment date on the Monthly Part C Assessment log. For EW members only: Provide the county with the DHS #6037 transfer form and all supporting documentation for members whose MA is not reinstated, resulting in disenrollment from the health plan. MSHO members that are in the 90-day grace period are identified on the Care Coordination Enrollment rosters with a specific end date provided vs. 12/31/999.
MSHO/MSC+ members in 90 day grace period continued For MSC+ members, care coordinators must: • •
•
•
•
Monitor members’ MA status for 90 days and complete activities as stated in DHS 6037a scenario #10. If their annual reassessment is due during the 90-day term window, complete the annual reassessment, POC and OBRA Level I, and retain the completed assessment documents in the member’s file. Enter the DHS form #3427 into MMIS when members’ MA is reinstated. For EW members only: If the member’s MA is not reinstated, resulting in disenrollment from the health plan, provide the DHS #6037 transfer form and assessment to the county. Refer to DHS Bulletin # 15-25-10 for CC requirements. MSC+ members that are in the 90-day grace period are identified on the monthly MSC+ term report that is sent out around the 1st of each month.
Care Coordination Enrollment Rosters Please remember to review your care coordination enrollment rosters each month. As a reminder: • The “Changes Tab” (1st Tab) identifies changes with a member’s status:
i.e. Care Coordinator Change, Clinic Change, New Member, Product Change, Rate Cell Change, and Termed Members. ›
Full definitions of the changes are located on the “Definitions” tab (3rd tab).
• The “All Tab” (2nd Tab) identifies all the members you should be providing Care Coordination for. ›
›
Please reconcile your care coordination enrollment rosters quarterly at a minimum. This includes ensuring that every member is assigned to a care coordinator and is being actively managed. Please notify [email protected] with any discrepancies.
Primary Care Clinic/Care Coordination Change Process When Care Coordinators identify members who have a primary care clinic or care coordination change, please keep the following in mind:
If the current CC delegate has not confirmed the new PCC with the member, the current CC will be responsible for care coordination until the new PCC is confirmed. If a member states they plan to establish care with a new PCC, UCare expects the receiving CC delegate to work with the member in scheduling the appointment to establish care. PCC/Care Coordination change request forms are to be submitted to UCare by the current CC delegate only. Please refer to the PCC/Care Coordination Process flow chart located on the UCare website.
Primary Care Clinic/Care Coordination Change Process continued
PCC/Care Coordination change request form must be completed in its entirety and must be received prior to the 15th of the current month for the change to happen in the current month. Communication of the care coordination change will be sent to the current CC delegate as well as the new CC delegate. The member will show as a transfer on next month’s care coordination enrollment roster.
Primary Care Clinic/Care Coordination Change Process continued
PCC/Care Coordination change request forms received after the 15th of the month will be processed with an effective date for the 1st of the following month. Communication will be sent to the current CC delegate indicating that the care coordination change will happen the following month.
The member will show as a transfer on the next month’s care coordination enrollment roster.
UTF paperwork UCare receives Process for UTF paperwork that is received by UCare from a non-delegate (FFS): • CM Intake will review all UTF’s as they come to determine the correct delegate • CM Intake will then push out all UTF information to delegates within 2 business days of enrollment posting • After the UTF information is pushed out, if the delegate changes due to PCC change, the delegate should send the UTF information to the new delegate
DHS Bulletin 17-25-10 Increase to Elderly Waiver (EW) and Alternative Care (AC) Monthly Budget Limits
The Minnesota Legislature authorized the following increase to monthly limits and caps provided on or after Jan. 1, 2018. The 1.74% increase applies to: Alternative Care (AC) and Elderly Waiver (EW) monthly case mix limits AC and EW Consumer Directed Community Supports (CDCS) budget caps EW service rate limits for customized living (CL), 24-hour customized living (24-hour CL), and residential care services For MMIS instructions related to this change, please see Bulletin #17-25-10. Please visit the Elderly Waiver Residential Services webpage to access the latest version of the Residential Services Tool (RS Tool). UCare will be implementing the September 1, 2017 DHS rates effective January 1, 2018.
DHS Bulletin #17-25-08: Policy and MMIS Screening Document Changes for Managed Care
Effective September 1, 2017, all MSHO/MSC+ activity must be entered into MMIS via the newly created H screen or via the current L screen.
In addition to H screen entries, DHS also added a new assessment result value 50 – person not located for HRA and a new referral reason 21 – PCA or health care.
H screen entries • Rate cell A/Community Well, no services (No PCA) • Person not located/Missing Member (new assessment result value 50) Continue to use assessment result value 39 for refusal members • Product changes for members on a waiver/nonwaiver • Transfers from fee-for-service or other health plans • Change in care coordinator document (for rate cell A/community well without PCA and members on CADI, CAC, DD or BI)
L Screen entries • EW members • Members receiving PCA services • Change in care coordinator document (for EW and PCA members) • Exit document (exiting from waiver)
Clinical Liaisons
Clinical Care System Liaison 612-294-5045
[email protected]
