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LOUISIANA MENTAL HEALTH REHABITATION Pelican Project

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LOUISIANA MENTAL HEALTH REHABITATION Pelican Project

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    1. LOUISIANA MENTAL HEALTH REHABITATION Pelican Project Joe Kopsa, MA, JD Section Chief Program Integrity DHH Privacy Officer & James Hussey, M.D. Program Director Mental Health Rehabilitation Services 6/10/2012 1

    2. Rules of the game Part 1 6/10/2012 2

    3. Rules, Objectives, Players Applicable Rule & Regs MHR Program Purpose MHR Services MHR Providers MHR Stakeholders 6/10/2012 3

    4. Applicable Rules & Regs Optional Service Federal Rules 42 CFR §4450.130 State Plan Amendment (SPA) Any Willing Provider State-wideness Freedom of Choice State Rules Promulgated Rule (MHR State Regulation) Provider Manual Program Integrity Regulation (SURS Rule) 6/10/2012 4

    5. The MHR Program Purpose Intensive Outpatient Services for adults with serious mental illness and youth with emotional/behavioral disorders. Medically Necessary Behavioral Health Services that are Recovery and Rehabilitative in nature. Stabilize acute symptoms. Assist with coping of symptoms. Minimize aspects that make it difficult to live independently. Recovery & Rehabilitation Focus 6/10/2012 5

    6. The MHR Program MHR Services: Screening & Assessment for Medical Necessity Community Support Counseling (Individual, Group, & Family) Psychosocial Skills Medication Management Parent/Family Intervention (Intensive) Psychosocial Skills Training –Group (Adult) 6/10/2012 6

    7. The MHR Program Agency Providers: Owners (Public or Private) Managers Clinical Service Delivery Staff Licensed Mental Health Professional (LMHP) Mental Health Professional (MHP) Mental Health Specialist (MHS) 6/10/2012 7

    8. Program Stakeholders Recipients (approximately 7,000 recipients prior to reform effort) Providers (approximately 131 providers at peak enrollment) CMS Department of Health and Hospitals Louisiana Medicaid Louisiana Office of Mental Health Program Integrity SURS DHH Legal Professional Boards Legislature Advocacy Center 6/10/2012 8

    9. The Problem Part 2 6/10/2012 9

    10. The Problem(s): Uncontrolled Program Costs & Growth Few Demonstrable (positive) Outcomes Advocacy Center Concerns Critical Media Angry Providers Sympathetic Legislators Limited Budget Optional Program 6/10/2012 10

    11. Uncontrolled Program Costs & Growth Program Cost Per Year $38,890,461 $49,053,440 +21% $57,874,936 +16% Two year growth rate +31% Recipient Growth Per Year 4,824 6115 +21% 7164 +15% Two year growth rate +33% 6/10/2012 11

    12. Programmatic Issues Yearly Cost per recipient 2003 $8,061.87 2004 $8,021.81 2005 $8,071.17 September 2003 Advocacy Letter Mental Health Advocacy Group Complains to Secretary MHR Agencies blame Medicaid Rates 6/10/2012 12

    13. Summary of Advocacy Center Complaints September 2003 Many providers fail to provide effective, individualized services. Clients’ needs often are not met by the MHRS Program. Some high need individuals are rejected, terminated, or “timed out” of the program. Others are exploited within it. Community mental health professionals are reluctant to refer clients to these programs. Restrictive admission criteria and capitated payment structure result in insufficient services to children. MHRS consumers lack awareness of rights and/or fear to exercise them. 6/10/2012 13

    14. Summary of Advocacy Center Complaints Continued Many providers fail to meet standards for services. Many providers have unqualified and untrained staff. Monitoring process is ineffective in ensuring quality services, and imposes inconsistent remedies. OMH has insufficient staff for annual monitoring & follow-up. DHH has failed to impose legally required restrictions upon providers during appeal of suspensions. DHH & the A G’s Medicaid fraud units have failed to protect consumers by fining or closing down fraudulent providers. Louisiana has an acute, growing need for a quality MHR program to serve individuals with serious mental illness in the community. 6/10/2012 14

    15. Initial Solution 6/10/2012 15

    16. Pelican Project Conduct a 100% review of all MHR Providers Monitoring Reviews Payment and Record audits 6/10/2012 16

    17. The Tasks Monitor and Audit 131 MHR Providers Pre-Pelican Monitoring of Providers was two years behind schedule MHR Monitoring Process Detailed and lengthy review (30+ days/50+ pages) Onsite review and copying Provider and recipient interviews Staff Resource Issues 6/10/2012 17

    18. The Task Pre-Pelican Project MHR Treated like all other provider types Only 10 MHR Providers under active PI audit Program Integrity Audit Review Process MHR treated the same other provider types Complaint Data Mining Two year review of 20 record sample 6/10/2012 18

    19. Obstacles Part 3 6/10/2012 19

    20. Obstacles Program Organizational Complexities Cumbersome & Overly-inclusive MHR Administrative Monitoring Process Cultural Issues 6/10/2012 20

    21. MHR Table of Organization 6/10/2012 21

    22. Cultural Obstacles MHRGoals: Preservation of Program Increased Quality, Accountability, & Efficiency Program Improvement Program Operations Goals: Preservation of Program Cost Containment Quality Services Program Integrity Goals: Sanctioning Providers 6/10/2012 22

    23. Cultural Obstacles Approaches MHR Policy & Monitoring Program Operations Policy Program Integrity Backend auditing 6/10/2012 23

    24. Overcoming Obstacles Part 4 6/10/2012 24

    25. Overcoming Obstacles Joint High Level Meetings Secretary’s representative Medicaid Director’s representative OMH Asst. Secretary’s representative MHR Program Operations DHH Legal Provider Meetings 6/10/2012 25

    26. Working Taskforce Weekly Meetings MHR staff Program Operations staff Program Integrity staff DHH Legal staff 6/10/2012 26

    27. Overcoming Obstacles Modifications in monitoring process MHR Monitoring protocols were modified All MHR monitoring reports were sent to Program Integrity upon completion of the Monitoring Report Program Integrity reviewed the monitoring report MHR Providers with Programmatic issues sent back to MHR Monitors MHR Providers with potential fraud and abuse issues were taken over by Program Integrity 6/10/2012 27

    28. Overcoming Obstacles Other Important Program Modifications: Moratorium on Licensing of New Providers Change from Flat Rate to Fee For Service JCAHO, CARF, or COA Accreditation Management/Personnel Changes Physician Experts for Youth & Adults Rule Changes (Staff Quals, Competencies, Enrollment Criteria, Recertification, etc.) Manual Rewrite (Service Definitions, Denial Codes, etc.) Enhanced Provider training Quarterly Meetings with Providers Program Restructure into centralized Administrative Services Organization model Establishment of Internal QM, PI, P&P Establishment of Program Outcome Indicators Bi-Weekly Provider Network Profile Reviews Standardized Processes, Flow Charts & Templates for NOD’s, POC’s, NOS, etc. 6/10/2012 28

    29. Overcoming the Obstacles Modification in Processes Program Integrity Six member audit team dedicated to MHR audits Six month Audit period to determine if expanded audit period should be used. Only ten Recipient records reviewed 6/10/2012 29

    30. Program Integrity Audit Protocols Criminal Fraud – Referral to MFCU Health & Safety – Immediate action to move clients Civil Fraud/Abuse – Full PI Audit Waste – 6 month audit Technical billing errors or minor program violations – Refer back to MHR Monitoring 6/10/2012 30

    31. Program Integrity Audit Findings Undocumented Services Documentation does not support service billed Services not covered or on Service Plan Altered records Unqualified staff Services billed for while Recipient was hospitalized 6/10/2012 31

    32. Part 5 RESULTS 6/10/2012 32

    33. Pre-Pelican Project Results 6/10/2012 33

    34. Pelican Project Results 6/10/2012 34

    35. Results Over Two Year Period Fiscal Integrity Cost Avoidance $64,797,452 180 PI Cases 49 Recoveries $585,604.54 14 Referrals to MFCU Exclusions 5 MHR 5 PI Programmatic Integrity Bi-weekly Meeting MHR, PI, PO and Legal Administrative Service Organization 6/10/2012 35

    36. Network Profile Summary Total MHR Providers: 57 Providers with Isolated Deficiencies: 31 Providers with Open Complaints: 7 Providers with EFT Holds: 0 Pending Administrative Appeals: 0 Providers with possible AG issues: 4 Providers Accredited: 57 Newly Enrolling Providers: 3-6 6/10/2012 36

    37. Part 6 Lessons Learned 6/10/2012 37

    38. Lessons Learned Own the problems. Hold yourself more accountable than the providers. Establish excellent & honest rapport with principal stakeholders. (Providers/Medicaid/Legal//PI/AG/DHH/OMH/MHR) Focus on deficiencies CLEARLY articulated & Supported in Rule. Focus on Health, Safety & Fraud first, then follow up on lesser issues through Administrative Actions. Standardize ALL procedures and processes Summarize and report findings clearly & regularly. Don’t ask for “it” unless you know what to do with “it.” 6/10/2012 38

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