Managed Care Preparedness: A Primer for Agencies Contracting with Medicaid MCOs

1. Managed Care Preparedness: A Primer for Agencies Contracting with Medicaid MCOs Gary Humble Executive Director April 26, 2017

2. Who Is Pinnacle Partners? Non-profit, Shared Services Organization (SSO) originally formed by three (3) Community Behavioral Health Providers: Connections, Signature Health and ORCA House that is devoted to the enhancement of behavioral health services in our communities. Provide external consulting services to the behavioral health community in the areas of revenue cycle management, contracting, credentialing and internal administrative systems development

3. What Other Services Does Pinnacle Partners Provide through its Subject Matter Experts (SMEs)? Through our Subject Matter Experts, we are able to offer additional Administrative Support Services: Accreditation Services Billing services for professional and facility based services (Residential Treatment, PHP, IOP) Clinical Coding Training and Audit Services Grant Writing, Fundraising/Resource Development Planning, and Board Training

4. What Is Pinnacle Partners’ Mission? Pinnacle Partners’ mission is to assist behavioral health organizations to not only survive but thrive in a managed care environment

5. Objectives of this Presentation The Objectives of Today’s Presentation are to: Provide an overview of the current/future changes in our behavioral health marketplace Understand what changes you organization may have to make clinically and administratively in order to be attractive to Managed Care Organizations (MCOs) Introduce your Organization to the MCO Credentialing and Contracting Process Provide practical, “hands on” strategies in working in this new managed care environment

6. What is Driving the Push for Managed Care in the Public Sector Space? One of the overarching messages in health care reform: Bend the Cost Curve As a result, states are contracting with Managed Care Organizations (MCOs) to manage their public sector systems (Medicaid, Dual Eligible, Developmental Disabilities, Child Welfare) With Medicaid expansion and Health Insurance Exchanges, more opportunities/threats exist for community behavioral health agencies

7. What is Driving the Push for Managed Care in the Public Sector Space? In addition, states are beginning to look at different innovations in payment methodologies (Episodic, capitation) moving away from traditional fee for service, there will be pressure to keep patients out of expensive inpatient care Accountability, transparency and demonstrating effectiveness of an organizations’ clinical services will be drivers in our new environment

8. What Does Health Reform Look Like in Ohio? Since the inception of this Department, the Office of Health Transformation has been driving State’s initiative efforts in health care reform to: Modernize Medicaid Streamline Health and Human Services Pay For Value

9. What Does Health Reform Look Like in Ohio’s Community Behavioral Health Space? Ohio Medicaid & Ohio MHAS have engaged stakeholders for well over a year in redesigning Ohio’s Community Behavioral Health Medicaid system As of July 1, 2017, the State will require new code sets, will enforce Medicaid as payer of last resort (TPL), and require NPIs of eligible providers (modifiers for others) on all Medicaid claims

10. What Does Health Reform Look Like in Ohio’s Community Behavioral Health Space? Ohio Medicaid adding new services to the behavioral health service array: SUD Residential SUD Partial Hospitalization Mental Health Day Treatment Intensive Home Based Treatment (IHBT)

11. What Does Health Reform Look Like in Ohio’s Community Behavioral Health Space? Integrate Community Behavioral Health Medicaid services into the private sector Medicaid MCOs in January, 2018 Begin to report on high-cost episodes of behavioral health care Encourages Comprehensive Primary Care (CPC) to collaborate with behavioral health providers

12. What Else is Happening in Our Behavioral Health Markets? In the commercial market, employees/families paying a larger portion of the monthly insurance premiums & deductibles/co-insurance In the Health Insurance Exchange Market (HIE), more Ohioans are signing up for coverage. Most have their insurance premiums subsidized but most cannot afford the care (high deductibles/large out of pocket maximums) With mental health parity, services such as Residential Treatment are now being covered, particularly under the HIE insurance products now offered on the Exchange

13. What is Happening in Our Behavioral Health Market? MyCare Ohio Five (5) Managed Care Organizations in Ohio: Buckeye Health Plan, CareSource, United HealthCare Community Health Plan, Molina and AETNA Better Health of Ohio Behavioral health services are “carved-in” and paid for directly by the five MCOs Beginning the third year of the demonstration project Governor looking to expand MyCare to the rest of the State by July, 2018

14. Contracting with Managed Care Organizations

15. Contracting with Managed Care Organizations Defines each organizations’ responsibility to each other and the common patient/client/member in which they serve Should be a “win-win-win” for all parties involved: the payer, the provider and ultimately, the client Contracting should be approached carefully and with “eyes wide open”

16. Working with Medicaid MCOs: Who and Where are They? Medicaid MCOs* CareSource Buckeye Health Plan (Cenpatico) United HealthCare Community Health Plan (UBH/OPTUM) Molina Health Plan Paramount Health Plan *All Operate Statewide

17. Contracting with Managed Care Organizations Make sure you are prepared to work with the various managed care organizations- the old carpenter adage Measure Twice, Cut Once! Before your organization embarks in contracting with Managed Care Organizations (MCOs), there should be preliminary market research conducted to determine your opportunities Conduct an organizational assessment to see what areas your agency need to be refined/reworked in preparing to work in a managed care environment

18. External Market Research on Managed Care Organizations Identify the Medicaid/MyCare MCO payers (CareSource, AETNA, United HealthCare) in your marketplace Review their websites: Review provider manuals Review criteria for provider participation Clinical medical necessity criteria

19. Preliminary Assessment of Organization’s Internal Capabilities Review your organization’s current clinical services that are eligible for MCO contracting In the case of commercial insurance, identify providers/practice sites that are commercial insurance eligible (If the organization has multiple sites, it is recommended that they focus on their heavy commercial insurance identified sites first rather the shot gun approach). 

20. Preliminary Assessment of Organization’s Internal Capabilities QUESTIONS TO BE ANSWERED: Review the organization's current cost structure (unit costs) to identify what is needed to cover those costs Identify an organizational "champion" in overseeing this process Review your competition. Which agencies will compete for the same services with the same payers? Assess your organization’s capability to become “Managed Care Friendly” administratively, clinically and philosophically (Managed Care Punch List)

21. Managed Care Punch List: Overview Each organization must go through a “punch list” of items from a clinical, financial and administrativeperspective to determine your readiness The following questions must be answered before your organization is ready to contract with any managed care organization:

22. Managed Care Punch List: Clinical CLINICAL Is your organization’s clinical philosophy compatible with managed care philosophy? Do your clinical services resemble a program model vs. individualized treatment model? Down the road, some clinical services will require clinical authorization. Is your organization willing to follow certain clinical criteria that could ultimately determine whether or not the organization is paid?

23. Managed Care Punch List: Clinical CLINICAL Managed care organizations will be interested in basically two questions: • Does the client meet clinical criteria for the level of care they are being treated? • Did the intervention that happened in group/individual session that day directly reflect what is needed in the client’s individual treatment plan?

24. Managed Care Punch List: Clinical CLINICAL Does your organization have the ability to embrace a different clinical philosophy that includes rapid stabilization, brief solution focused therapy and then be able to reconcile this philosophy with your mission? This Philosophy is the most difficult for most organizations to reconcile : Some believe that this model withholds care from their clients and thus, discriminatory Some believe this model conflicts with their agency’s mission and thus, irreconcilable

25. Managed Care Punch List: Finance FINANCIAL What are your service costs and will contracting with a specific managed care organization cover those costs? Does your organization have a policy regarding the collection of client co-payments and deductibles? If yes, how and when is the policy being communicated to the clients? Is your client self-pay bad debt being tracked?

26. Managed Care Punch List: Administrative ADMINISTRATIVE Do you have communication systems in place to contract with managed care organizations to explain those provisions to key staff throughout the organization? Do you have internal administrative systems in place to assist and support your clinical programs in working with managed care companies (revenue cycle management systems)?

27. Managed Care Punch List: Revenue Cycle Management Process Intake Benefit Verification Communication to clinical/administrative staff involved in client’s initial visit Client’s initial visit- Financial Counseling Clinical authorization process, if needed Charge Capture & Billing Billing Follow up (appeals, self pay balances, claims troubleshooting) Management Oversight

28. Managed Care Punch List: Revenue Cycle Management Intake Do Staff gather insurance information at the time of Intake? What kind of information do they collect? Do Staff know what MCOs the agency participates with currently? Do Staff know which individual clinicians participate with MCOs? Do Staff know what services are covered under your MCO contracts?

29. Managed Care Punch List: Revenue Cycle Management Benefit Verification Do staff verify eligible & benefits before the client comes for their first appointment? • Is there an administrative (communication) system in place to make sure that the client, the clinician knows what each may need to do (client-co-pay, PCP referral, clinician-clinical authorization for the next level of care)

30. Managed Care Punch List: Revenue Cycle Management Communication Process Before Client’s Initial Visit Make sure all parties (Intake, Business Office) communicate with each other regarding insurance and authorization requirements Communicate any challenges to the team and ultimately to the client (before the initial visit, if possible) regarding insurance coverage, eligibility issues (children coverage in a divorce/custody situation)

31. Managed Care Punch List: Revenue Cycle Management Communication Process Before Client’s Initial Visit Develop small regular “flash” meetings or “huddles” to discuss new client appointments making sure everyone knows what they need to do (collecting co-pays, obtaining ongoing clinical authorization) Make sure there is a smooth hand off from Intake to the next level of care (IOP) regarding clinical authorization, co-pay responsibility

32. Managed Care Punch List: Revenue Cycle Management Client’s Initial Visit Develop a financial counseling process for all clients receiving services, including reviewing client’s eligibility and benefits on the initial visit Set the expectations around client responsibilities (co-pays, deductibles, obtaining a PCP referral, coordination of benefit issues) Develop Financial Responsibility Form that clearly outlines the client’s financial responsibility

33. Managed Care Punch List: Revenue Cycle Management Client’s Initial Visit Gives staff opportunity to troubleshoot any challenges regarding ability to pay for services Provide resources for additional patient questions Increase financial transparency for clients so they do not feel as though they were duped in a “bait and switch” scheme Able to identify financial issues NOW rather than six months from now

34. Managed Care Punch List: Revenue Cycle Management Utilization Management/Clinical Authorization Is there a communication system in place to make sure clinicians know what services need to be authorized? Is there is a system in place to ensure services are re-authorized? Do clinicians know what Medical Necessity Criteria will be used in attempting to obtain authorization for services?

35. Managed Care Punch List: Revenue Cycle Management Utilization Management/Clinical Authorization Some commercial payers authorize an initial assessment and several follow up visits (3-7 visits at a time) Some payers are very specific about CPT codes, providers and diagnosis codes Do Staff know, in general, what clinical services (IOP, PHP) are covered under your contracts?

36. Managed Care Punch List: Revenue Cycle Management Billing Do staff know what codes (CPT/HCPCs/Revenue Codes) need to be billed for the various MCO payers? Do staff know the contracted per diems/fee schedules for contracted services? Do staff know about client co-pay/deductible responsibility, if applicable? Take advantage of Third Party Payer Technology -when appropriate, bill through their web portals (usually at no cost)

37. Managed Care Punch List: Revenue Cycle Management Billing Follow Up Billing staff should be familiar with Payer’s claims adjudication process (State Prompt Pay laws, contractual requirements) Develop a system for “working” denials Understand when a claim is not paid, it may not be a denial issue Review the information gathered at the Verification Process

38. Managed Care Punch List: Revenue Cycle Management Billing Follow Up • If your organization provides services that are “cutting edge” (treatment for Autism), you may need to incorporate diagnosis code information when verifying eligibility and benefits Troubleshooting other issues: • Coordination of Benefits (COB) issues • Eligibility • Authorization issues • Payment vs. benefit plan design

39. Managed Care Punch List: Revenue Cycle Management Billing Follow Up Do you have administrative systems in place to track managed care authorizations, required forms (managed care clinical criteria), payer activity? What systems are in place to track denials, submit appeals? What systems are in place to track denial write offs?

40. Managed Care Punch List: Revenue Cycle Management Management Oversight Develop Tools to assist staff by establishing a process to monitor denials, authorization & re-authorization of clinical services Establish a process of monitoring performance of the Payers (contracting is a two way street) Monitor denials on a monthly basis and have staff report back on actions taken and results achieved.

41. Managed Care Credentialing & Contracting Process

42. Types of Managed Care Contracts & Credentialing Requirements Individual Contracts Usually for services that are considered “professional services” billed on a CMS 1500 claim form Requires clinician to be individually credentialed Most major payers use the CAQH credentialing tool, a nationally developed standardized online credentialing application

43. Types of Managed Care Contracts & Credentialing Requirements Group Contracts Usually for services that are considered “professional services” billed on a CMS 1500 claim form May require each individual clinician be credentialed before being “linked” to the Group Contract (most payers utilize CAQH application)

44. Types of Managed Care Contracts & Credentialing Requirements Facility Contracts Usually for services billed on a UB04 (Institutional Claim form- Commercial world). Examples include Ambulatory Detoxification, PHP & IOP Most MCOs require accreditation as well as State Licensure, malpractice insurance requirements Typically do not require the individual clinicians to be credentialed Sometimes this type of contract is referred to as Organizational, Facility, Ancillary or Institutional

45. Managed Care Contracting Process Initial contact/solicitation Application & contract review (includes credentialing process by the payer) Rate negotiations Rate & agreement language finalization (signatures) Contract implementation (operational-facility/clinician)

46. Contracting Process INITIAL CONTACT WITH MCO Identify major behavioral health organizations operating in your geographical area (research) Initiate contact with personnel responsible for contracting (provider relations, facility contracting) Send introductory information regarding services your organization offers

47. Contracting Process APPLICATION & CONTRACT REVIEW For higher levels of care (IOP), MCOs typically use an Organizational (facility) application to credential the entire Organization MCOs interested in contracting with individual clinicians mainly use the CAQH web site for their credentialing/standardized contracts/fee schedules for individuals and/or groups Credentialing & Contracting are separate processes, are usually occurring simultaneously

48. Contracting Process APPLICATION & CONTRACT REVIEW A sample contract is sent to the perspective provider for their legal review (usually the most time consuming part of the process) Organization completes the application, attaching the appropriate licenses, accreditations, malpractice insurance, program descriptions for the MCO’s credentialing department Some Managed Care Organizations may require on-site review of your organization (Non- accredited providers)

49. Contracting Process RATE NEGOTIATIONS (Commercial) Rate negotiations take place between the managed care organization & provider (facility) Fees negotiated can be per diem, case rate, percentage of outpatient charge Areas of additional discussion/disagreement usually pertains to what is included (not included) in the per diem (physician fees, drug screens, H&P, aftercare sessions, assessments)

50. Contracting Process RATE NEGOTIATIONS (Commercial) Specify specific Revenue codes/HCPC codes for your programs in the contract: CD IOP Revenue Code 906, HCPCS H0015/90853 Residential Treatment Revenue Code 1001/1002, HCPCS H0018