IDHS, Division of Mental Health Provider Briefing: Changes to Provider Monitoring April 3, 2009 2-3:30pm April 6, 2009

1. IDHS, Division of Mental HealthProvider Briefing: Changes to Provider MonitoringApril 3, 2009 2-3:30pmApril 6, 2009 10-11:30am

2. Speakers Jackie Manker, LCSW – Associate Director of Community Services, DHS/DMH Lee Ann Reinert, LCSW – ASO Clinical Policy Manager, DHS/DMH Cathy Cumpston – Chief, DHS Bureau of Accreditation, Licensure and Certification (BALC) Aissa Bell – Director, Provider Relations, IL Mental Health Collaborative for Access and Choice Rusty Dennison, MA, MBA – President, Parker Dennison & Associates, Ltd.

3. Introduction • Beginning in FY09, DMH incorporated Post Payment Reviews (PPR) into DMH/Collaborative provider monitoring site visits • Current DMH/Collaborative site visits include: • - Post Payment Reviews- Clinical Practice and Guidance Reviews- Fidelity Reviews (PSR in FY09) • DHS BALC is still performing Certification reviews

4. Introduction • DMH reviewed and approved all policies, forms, and training materials implemented by the Collaborative for PPR • At the time PPR was implemented, DMH instituted managerial oversight of the Collaborative’s practices • Weekly meetings with reviewers as well as the Collaborative’s Provider Relations Director • Made available DMH clinical staff and BALC staff to consult with the Collaborative’s reviewers in the field • Involved DMH Regional Contract Managers in reviews

5. Introduction • Consistent with continuous quality improvement, DMH asked Parker Dennison to evaluate our provider monitoring process in February 2009 • Parker Dennison completed this analysis and has provided DMH with recommendations • DMH has considered these recommendations and has begun to implement changes to the process • Find the Parker Dennison report on the DMH website at: http://www.dhs.state.il.us/page.aspx?item=43483

6. BALC Coordination with DMH/Collaborative PPR • Participation in development of PPR/monitoring model • Participation in Collaborative’s PPR staff and provider training • Participation in weekly PPR Collaborative/DMH coordination and problem solving calls

7. PPR vs. Certification: Differences? Example~ Post Payment Review • Finds 50% of claims reviewed have no current ITP in record • Outcome: provider will lose value of those claims Certification Review • Finds 5 of 10 records reviewed (50%) have no current ITP • Outcome: provider will lose 42 points on certification • As a result will have 422 of 464 points on their certification for a total score of 91%

8. Parker Dennison Assessment of Post Payment Review • Assessment conducted in January/February 2009 • Information sources included: • Focus group with 25 providers statewide • Feedback from other stakeholders • Review of policies, forms, training materials, protocols • Review of Federal OIG reports from IL and other states • Review of applicable state and Federal rules • Analysis of audit results through 12/31/08 • Included 3,070 claims and audits from 32 providers

9. Parker Dennison Report:Focus of Post Payment Review • All PPR elements consistent with those found in other OIG reports • Some elements found in OIG reports are not present in IL PPR • Federal OIG does identify some elements that can be deficient, need correction but not recoupment • This is inconsistent even within different OIG audits • Recommendations include: • DMH should periodically rotate in new/different elements (annually review/update) • DMH can consider a limited amount of ‘procedural’ designations, at least as a transition

10. Parker Dennison Report:Training & Communication • Provider training was adequate compared to other states but not best practice • Training was provided regarding Rule 132 (basis of PPR) • Training was provided regarding the PPR tool and protocol • Recommendations include: • Detailed interpretive guidelines • On-going Frequently Asked Questions (FAQs) • On-going feedback to providers about aggregate results, common problems, recommendations

11. Parker Dennison Report:Audit Staff Resources • All Collaborative reviewers are LPHAs, including two who are also Certified Recovery Specialists • Represents the highest standard of practice in audits • Overall feedback was positive regarding professionalism and clinical knowledge • Recommendations include: • Expand inter-rater reliability monitoring of reviewers • Involve DMH contract managers for cross training where feasible • Include reviewer competency training in training for new reviewers

12. Parker Dennison Report:Post Payment Review Process • Unannounced reviews are problematic • Some inconsistency on provider staff involvement • Lack of public interpretive guidelines • Recommendations include: • Discontinue unannounced reviews (unless there is a provider-specific reason) • Clarify provider staff involvement protocol and be consistent • Include interpretive guidelines in provider training materials • More detail on PPR report to providers

13. Parker Dennison Report:Analysis of PPR Results (12/31/08) • Key statistics: • 32 providers • 3,070 claims • Avg. of 55% of claims unsubstantiated • Value of unsubstantiated claims (no extrapolation) = $101,937 • Avg. unsubstantiated claims per provider (no extrapolation) = $3,186 • Average of two deficiencies per unsubstantiated claim • Overwhelming majority of deficiencies confined to 7 elements on PPR tool • Only these 7 fell below 95% compliance level • All 7 elements were cited in other Federal OIG reports

14. Parker Dennison Report:Analysis of PPR Results (12/31/08) • Lowest compliance %: • Q2 – (66.87%): MHA contains all required elements • Q10 – (81.14%): Note contains description of interaction w/consumer including response and progress toward ITP goal(s) • All other questions had compliance of 92% or greater • Remediation of top 7 deficiencies would reduce statewide average to 12% unsubstantiated claims (from 55%) • No data demonstrating an inter-rater reliability issue

15. DMH Response • Pleased with the overall assessment results of the Post Payment Review process • Appears to be identifying targeted areas for improvement in moving the system forward • Identified areas for improvement can be addressed in training • Validates the risk and need for continued efforts for continuous improvement in compliance • Will continue the established managerial oversight practices

16. DMH Changes to the Process • Announce site visits (began 3/20/09) • Improve communication with providers • Post interpretive guidelines to website • Provider alerts with summaries of issues and trends • Analyze and use provider post-review survey feedback • Collect provider questions through the dhsmh@dhs.state.il.us address • Post provider FAQs to website • Ensure reviewer consistency • Strengthen inter-rater reliability and monitoring • Continue weekly reviewer check-ins with DMH, BALC, and the Collaborative

17. DMH Changes to the Process (cont.) • Change Post Payment Review scoring • Split claim status into two parts: claims disallowed and procedural deficiencies • Begin requesting plans of improvement based on compliance (including all claims findings) • Begin tracking the individual parts of the Mental Health Assessment in the database • Allow some types of claims to be corrected • Begin scoring changes going forward and re-score those already reviewed this fiscal year [see the separate document “Claims Guide”]

18. Feedback and Questions Available to Answer Your Questions—Thanks! Jackie Manker, LCSW – Associate Director of Community Services, DHS/DMH Lee Ann Reinert, LCSW – ASO Clinical Policy Manager, DHS/DMH Cathy Cumpston – Chief, DHS Bureau of Accreditation, Licensure and Certification (BALC) Aissa Bell – Director, Provider Relations, IL Mental Health Collaborative for Access and Choice Rusty Dennison, MA, MBA – President, Parker Dennison & Associates, Ltd.