ALABAMA MEDICAID AGENCY

1. ALABAMA MEDICAID AGENCY INTERQUAL® WORKSHOP

2. HOW WAS THE DECISION TO USE INTERQUAL® MADE? • With the change of payment methodology, Medicaid was required to comply with the Code of Federal Regulations (CFR) requirements of Inpatient Utilization Review (IUR).

3. Currently, Medicaid admissions are reviewed on the SI-IS (Severity of Illness and Intensity of Service) Criteria. This criteria was not as specific as it needed to be to guide fruitful reviews. • It was noted that the hospitals were already using InterQual® for Blue Cross and Medicare.

4. A certified Quality Improvement Organization (QIO) was needed to assess that the quality of care provided to Medicaid recipients met professionally recognized standards of healthcare.

5. An Invitation to Bid (ITB) was issued. The contract was awarded to the Arkansas Foundation for Medical Care (AFMC).

6. THE AFMC TEAM • Jarrod McClain, RN, CPUR, Project Manager is the lead on the AMA contract and main person of contact. Kenya Harbin, RN, CPUR is the Vice President of Reviews. There are also two other RNs who are assigned to AMA reviews.

7. THE REVIEW PROCESS • A 5% random sample case selection is performed quarterly from the monthly file extracts provided to AFMC by AMA. • The sample consists of a random selection of 5% from within each eligible provider sent in the quarterly query.

8. Case selection lists are currently being sent to individual hospitals via Accellion, a safe and secure HIPAA-compliant encrypted email system. Along with the case listing, record copy submission instructions and time frames for submitting the requested records are included.

9. Providers are given an initial 30 calendar days to submit the requested records.

12. AFMC accepts medical record copies via regular mail, facsimile, CD, or HIPAA-compliant encrypted e-mail. • AFMC also works with individual hospitals that are capable of providing electronic access to the requested records as long as this access is HIPAA compliant.

13. A second request letter is sent after an initial 15 days to all providers whose records have not been received.

16. Upon receipt, the Review Coordinator performs first-level full case review, comparing chart documentation to Alabama Medicaid’s Adult and Pediatric Inpatient Care Criteria, to determine if the admission and entire length of stay meet medical necessity requirements and to determine the appropriateness of the care provided. If medical necessity requirements are met and no quality-of-care concerns are identified, the Review Coordinator approves the case.

17. Cases that do not meet criteria requirements for admission or continued stay, or that have potential quality-of-care concerns are summarized and referred to Alabama contract physicians for a medical determination regarding the areas of concern. The provider is sent a denial letter with case specific information via Accellion. The provider has an allowed (15) calendar days to submit the additional or new information.

21. If the provider submits additional or new medical information within the allowed (15) calendar days, a reconsideration review is completed by an Alabama licensed physician advisor.

22. Based on the information submitted and reviewed as well as the physician’s medical background and experience, the previous denial can be overturned and the review approved. • If documentation does not support the medical necessity of the admission and/or based on medical experience, the physician can determine that the denial remains upheld.

23. The provider is notified of the final outcome, approval or denial. • Copies of all final denial letters are sent to the Agency on a quarterly basis and also listed on the quarterly report.

24. If the denial is upheld, the hospital is notified via a letter of recoupment (naming the reason and amount).

25. This is the final AFMC determination for this review. If you are dissatisfied with this decision, you may request a fair hearing. A written request for a fair hearing must be received within 60 days of the date of this notification. The written request for a fair hearing should be mailed to the following address.   Alabama Medicaid Agency Office of General Counsel/Fair Hearing PO Box 5624 Montgomery, AL 36103-5624

26. Quarterly Reports • AFMC submits a quarterly report consisting of the following sub-topics: • Total Number Selected for Quarter • Total Charts Reviewed • Approved • Denied • Billing Errors • Currently Suspended • Referred for Decision • Admission utilization concerns • Length of stay utilization concerns • Identified billing errors

27. Continued… • Identified deficiency occurrences • Corrective action plans • Retrospective review concerns • Cases not received • Utilization Review Plans – MCE Study

28. All instances of identified medically unnecessary admissions, medically unnecessary inpatient days, and confirmed quality of care concerns are reported to the Agency each quarter.

29. Records reviewed for payment for dates of service prior to and after July 1, 2010 will be reviewed according to Alabama Medicaid Agency’s established SI-IS criteria. • Records reviewed after July 1, 2010 must capture dates of service not meeting InterQual® Adult and Pediatric Medical Criteria and Alabama Medicaid Local Policy guidelines. (process will be covered in the Billing Powerpoint)

30. Records reviewed by hospitals will be reviewed with criteria based on the admission date of the chart. For example if the patient was admitted on June 29, 2010 and discharged July 5, 2010; the chart would be reviewed based on Medicaid’s Adult and Pediatric (SI/IS) Criteria.

31. Psychiatric and Rehab Services • Inpatient psychiatric and rehabilitation services in an acute care facility will be exempt from reporting dates of service that do not meet InterQual® Adult and Pediatric Medical Criteria and Alabama Medicaid Local Policy.

32. Transition to InterQual® • A workgroup was convened consisting of Medicaid staff, the AFMC Project Manager, AlaHa representatives and hospital care coordinators and quality staff representing urban and rural, child and adult facilities. • This group met several times over the past nine months to develop local policies that will be used to further clarify InterQual® and Alabama Medicaid.

33. continued… • The hospital workgroup representatives also brought up other areas of concern that they felt like Medicaid would need to address.

34. AFMC CONTACT INFORMATION Jarrod E. McClain, RN, CPUR Review Manager Arkansas Foundation for Medical Care 2201 Brooken Hill Drive P.O. Box 180001 Fort Smith, Arkansas 72198-0001 jmcclain@afmc.org Phone: (479) 573-7780 Fax:     (479) 649-0799

35. Website Information • AFMC also has a website set up for Alabama hospitals. The link is:  • http://www.almedicaidreview.com/html/index.aspx • This website also contains the instructions on how to download/incorporate the AMA local policy with the electronic version of InterQual ®

36. Website Information cont’d • The Local Policy can also be found at: • www.alabama.medicaid.gov • Then click on the following tabs/links: • Programs • Hospital Services • Adult and Pediatric Medical Criteria

37. Alabama Medicaid Agency Contact Information: Karen M. Watkins-Smith, RN karen.watkins-smith@medicaid.alabama.gov (334) 353-4945 OR Jerri R. Jackson, RN Jerri.jackson@medicaid.alabama.gov (334) 242-5630