The New Provider Orientation Handbook
1 Dear Contracted Provider,
Elite Care Health Organization is sharing this provider orientation handbook to ensure that you, the Primary Care Physicians and/or Specialists, are trained on the Medi-Cal Managed Care program and policies and procedures.
According to the State of California’s Department of Health Care Services, new contracted providers MUST be trained within 10 business days of active status.
The information provided will allow you and your staff to gain a broad understanding of our shared mission, the importance of positive customer service experiences, member benefits, and member rights and responsibilities.
Additionally, if you need clarification on any of the information provided, please contact ECHO MSO for further guidance.
Welcome to Superior Choice Medical Group!
2 Medi-Cal Managed Care ...... 4
Claims and Encounters ...... 5
Authorizations ...... 6
Provider EZ-Net Portal Access ...... 8
Seniors and Persons with Disabilities ...... 9
Health Assessments and Provider Toolkits...... 10
Child Health and Disability Prevention ...... 11
Behavioral Health ...... 16
Case Management ...... 17
Managed Long-Term Services and Supports ...... 18
Federal and State Statutes ...... 19
Access and Availability Standards ...... 20
Member Rights and Responsibilities ...... 21
Cultural and Linguistic Services ...... 23
Customer Service ...... 24
3 Medi-Cal Managed Care
Health Plan Delegated Model For more information on NQCA standards and Managed care plans delegate certain authorization and functions, please visit their website at claims processing to some of its contracted Participating http://www.ncqa.org/AboutNCQA.aspx. Provider Groups (PPG's) like Superior Choice Medi-Cal Managed Care provides high quality, Medical Group (SCMG) and Management Services accessible, and cost-effective health care through Organizations (MSOs) like ECHO. Delegation is when an entity gives another entity the authority to managed care delivery systems. Medi-Cal Managed carry out a function that it would otherwise perform, Care contracts for health care services through such as operating within the parameters agreed upon established networks of organized systems of care which between the emphasize primary and preventive care. Managed care plans, have been proven to be a cost-effective use of Managed care plan and Superior Choice Medical health care resources that improve health care access Group (SCMG). and assure quality of care. The National Committee on Quality Assurance (NCQA) holds managed care plans to the following requirements:
• Delegation Agreement - A mutual agreement between Managed care plan and SCMG/ECHO outlining specific delegated functions that meet NCQA standards.
• Oversight and Monitoring – Managed care plans must oversee the delegates to ensure that the delegateis properly performing all delegated functions.
4
Claims and Encounters Claim Forms and Submission Requirements
1. SCMG will not provide Claim Forms. Contracting Provider shall submit Claim Forms within ninety (30) days of date of service to IPA on CMS 1500 forms, or a mutually agreed upon reporting format, unless otherwise specified under the terms of this Agreement.
2. The CMS 1500 form is the required format for billing submission. The following information shall be included with respect to the Enrollee:
1. Full name and address; 2. Identification number (Insurance I.D. number); 3. Date of birth; 4. Sex; 5. Plan affiliation; 6. Diagnostic code and description (ICD-9); 7. Date of Service; 8. Place of Service; 9. Procedures, services or supplies furnished and related current CPT or HCPCS Coding and the charges for those services, procedures or supplies; 10. PHYSICIAN’s name (not name of physician group); 11. PHYSICIAN’s address and telephone number; 12. PHYSICIAN’s tax identification number, and 13. PHYSICIAN’s NPI and charges
Claims forms shall be submitted to:
Superior Choice Medical Group PO Box 910 La Verne, CA 91750 Attn: Claims
Via EDI: Office Ally- SCPR1
5
Authorizations
In order to determine who is responsible for • Routine Women’s health services – a woman can go authorization of services, please contact ECHO MSO or directly to any network provider for women’s health reference your contract with the SCMG for more care such as breast or pelvic exams information. ° This includes care provided by a Certified Professional authorizations and payment of claims for Nurse Midwife/OB-GYN and Certified Nurse those services are usually the responsibility of SCMG. Practitioners For all other services, SCMG/ECHO and the • Basic prenatal care – a woman can go directly to any managed care plan have a contractual document network provider for basic pre-natal care that defines which entity is responsible for a service (e.g., Division of Financial Responsibility and a • Family planning services, including: counseling, Delegation Agreement). For additional information on pregnancy tests and procedures for the termination of what services are paid for by the SCMG or managed pregnancy (abortion) care plan please call ECHO MSO • Treatment for Sexually Transmitted Diseases, includes: testing, counseling, treatment and prevention • Emergency medical transportation
Services That Do Not Require Prior Authorization Services That May Require Prior Authorization Note: As the Prior Authorization process may • Emergency Services, whether in or out of covered vary between PPGs/MSOs, verify with SCMG county but within the continental USA (except for that these services are correct. care provided outside of the United States which is subject to retrospective review) • Non-emergency out of area care (outside covered • Emergency Care provided in Canada or Mexico county) is covered • Out of network care, services not provided by a • Urgent care, whether in or out of network contracted network doctor • Mental health care and substance use treatment • Inpatient admissions, post-stabilization/non- emergency/elective • Inpatient admission to skilled nursing facility or nursing home • Outpatient hospital services/surgery • Outpatient, non-hospital , such as surgeries or sleep studies • Outpatient diagnostic services, minimally invasive or invasive such as CT Scans, MRIs, colonoscopy, endoscopy, flexible sigmoidoscopy, and cardiac catheterization
6 Authorizations (continued)
• Durable Medical Equipment, standard or customized; rented or purchased • Medical Supplies • Prosthetics and Orthotics • Home Health Care, including: nurse aide, therapies, and social worker • Hospice • Transportation (excluding emergency medical transportation) • Experimental or Investigation Services • Cancer Clinical Trials
Hospital and Ancillary Provider Network You managed care plan maintains a network of contracted hospitals and ancillary providers. Please contact SCMG/ ECHO for the most recent list to be utilized for services provided to the managed care plan's Direct members.
7 Primary Care Physician EZ Net Portal Access
Primary Care Physicians through the EZ Net Portal can:
Submit requests for Authorization View status of submitted Referral Authorization Requests View members (please check eligibility with the Health Plan)
For Portal Access:
Please send an email to [email protected] with subject line: EZ Net Portal Access Please include: • Name of organization (as listed in the contract) • Organization address • Full name of person(s) that need access • Job title • Phone number • Email address
Please note all Provider Portal registration requests will be processed within 1 - 3 business days.
Please note Specialists do not have access to the EZ Net Portal.
Please direct all referral authorization requests to the member's PCP.
For Claim status questions please call 888)975-3246 Option 2
Please note Claims Department hours of operation are from 8am-2pm.
For UM/ Referral questions please call 888)975-3246 Option 3
8 Seniors and Persons with Disabilities
Under federal and state law, medical care providers must Examples of reasonable modifications health care provide individuals with disabilities: providers may need to make for individuals with • Full and equal access to their health care services disabilities are: and facilities • Spend additional time explaining individualized • Reasonable modifications to policies, practices, and member care plans to ensure understanding procedures when necessary to make health care services accessible and, • Scheduling an appointment to accommodate a member with an anxiety disorder who has difficulty • Effective communication, including auxiliary aids waiting in a crowded waiting room and services, such as the provision of sign language interpreters or written materials in alternative formats. • Allowing members to be accompanied by service dogs Note: A health care provider cannot require individuals Physical Access who are visually impaired or hard of hearing to Providers must make their facilities, as well as their bring someone with them to interpret or facilitate medical equipment and exam rooms accessible. The law communication. Health care providers cannot charge requires the development and maintenance of accessible members for providing any form of interpreter services. paths of travel to elevators, ramps, doors that open easily, reachable light switches, accessible bathrooms, accessible parking and signage that can assist individuals Procedures for Providing Accommodations Health care providers must: who are blind or have low vision. Additionally, health care providers must provide • Ensure that individuals are informed of their right to accessible equipment, such as exam tables, diagnostic request accommodations equipment and the use of a lift or trained staff who can • Provide individuals with information about the ensure equal access to medical testing. process for requesting accommodations • Provide individuals with information about filing Reasonable Modifications complaints about accommodations with managed The Americans with Disabilities Act (ADA) provides care plan if the provider is in the managed care protection from discrimination for people with all types plan's network, and filing complaints with other of disabilities, including people with physical, cognitive, entities that oversee disability access laws in the communication and mental health disabilities. Health health care context. care providers must make reasonable modifications in policies, practices and procedures when necessary to avoid discrimination on the basis of disability, unless the provider can demonstrate that making the modification would fundamentally alter the nature of the service, program or activity.
9 Health Assessments and Provider Toolkit
Initial Health Assessments Provider Toolkits Primary Care Providers (PCP) are responsible for conducting Most managed care plans maintain accessible toolkits a health assessment screening. All new members must and resources to assist providers in managing the care have an initial health assessment (IHA) within: of our members. Toolkits may include: • Medi-Cal members - 120 calendar days from the date • Appropriate Use of Antibiotics of enrollment with the managed care plan. Managed • Asthma care plans do not mandate utilization of a • Cardiovascular Care standardized form for the IHA. Managed care plan • Childhood and Adolescent Wellness Flyers do require the documentation of specific elements of the assessment. Managed care plans do provide • Chlamydia samples of Well Child Assessment forms. A full • COPD description of the IHA process is available in • Diabetes and Cardiovascular Care managed care plan's Provider Manual. • Obesity Toolkit for Adult and Children • Pre/Post Bariatric Surgery Toolkit • Perinatal Care Staying Healthy Assessments • Tobacco Control and Cessation For Medi-Cal enrollees, managed care plans require • Better Communication, Better Care: A Provider the completion of the Staying Healthy Assessments to Toolkit for Serving Diverse Populations be administered during the IHA and periodically • Behavior Health Provider Toolkit thereafter as the patient enters a new age category. • Behavioral Health Toolkit for PCPs • Depression Provider Toolkit
10
Child Health and Disability Prevention (CHDP)
The CHDP program provides health assessments for the EPSDT Screening Services early detection and prevention of disease and disabilities Screening services provided at intervals that meet for low-income children and youth. standards of medical and dental practice, and at such other medically necessary intervals to determine the CHDP health assessments screenings should consist of existence of physical or mental illnesses or conditions. the following: Screening services must at a minimum include: • health history • a comprehensive health and developmental history • physical examination (including assessment of both physical and mental • developmental assessment health development) • nutritional assessment • a comprehensive physical exam • dental assessment • appropriate immunizations • vision and hearing tests • laboratory tests (including blood lead level taking into account age and risk factors) • a tuberculin test • health education (including anticipatory guidance) • laboratory tests
• immunizations • health education/anticipatory guidance EPSDT Diagnostic Services EPSDT covers medically necessary diagnostic services. • referrals for any needed diagnosis and treatment When a screening examination indicates the need for further evaluation of a child’s health, the child should be appropriately referred for diagnosis without delay. Early and Periodic Screening, Diagnostic and Treatment (EPSDT) PCPs are required to follow-up with the components of the federally mandated Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program for Medi-Cal eligible children and youth. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) are a Medi-Cal benefit for individuals under the age of 21 who have full-scope Medi-Cal eligibility. This benefit allows for periodic screenings to determine health care needs. Based upon the identified health care need and diagnosis; treatment services are provided. EPSDT services include all services covered by Medi-Cal. A beneficiary under the age of 21 may receive additional medically necessary services.
11
Child Health and Disability Prevention (CHDP) (continued)
ESPDT Treatment Services on all Medi-Cal members as part of the IHA, Mental Health and Substance Use Services: periodic, and other preventive health care visits • Treatment for mental health and substance use issues and provide referrals to the Medi-Cal Denti-Cal and conditions is available under a number of Medi-Cal Program for treatment. For children, Denti-Cal uses service categories, including hospital and clinic the periodicity schedule recommended by American services, physician services, and services provided by a Academy of Pediatric Dentistry (AAPD). Also some licensed professional such as a psychologist. Dental benefits for adults 21 and older have been recently restored. To find a dentist, Medi-Cal members Medically Necessary Personal Care Services should be advised to call Denti-Cal at 1-800-322-6384 • Are furnished to an individual who is not an inpatient or visit http://www.denti-cal.ca.gov. or resident of a hospital, nursing facility, intermediate care facility, or institution for mental disease, that are: (A) authorized for the individual by a physician in Vision and Hearing Services accordance with a plan of treatment or (at the • EPSDT requires that vision services be provided at option of the State), otherwise authorized for intervals that meet reasonable standards as determined the individual in accordance with a service plan in consultation with medical experts, and at other approved by the State intervals as medically necessary to determine the existence of a suspected illness or condition. (B) provided by an individual who is qualified to provide such services and is not a member of the • At a minimum, vision services must include diagnosis individual’s family and treatment for defects in vision, including eyeglasses. (C) furnished in a home or in another location • Glasses to replace those that are lost, broken, or stolen also must be covered.
Oral Health and Dental Services: • Medi-Cal vision benefits may be covered by the • Dental care needed for relief of pain, infection and managed care plan. maintenance of dental health (provided as early an age as necessary). • Emergency, preventive, and therapeutic services for dental disease that, if left untreated, may become acute dental problems or cause irreversible damage to the teeth or supporting structures. • Medi-Cal Dental Care and Treatment Services are a carved out benefit for Medi-Cal members through the Medi-Cal Denti-Cal Program. Primary Care Providers are expected to perform dental screenings
12 Child Health and Disability Prevention (CHDP) (continued)
• EPSDT requires that hearing services be provided at The Vaccines for Children (VFC) Program is managed intervals that meet reasonable standards as determined by the California Department of Public Health, in consultation with medical experts, and at other Immunization Branch. A full description of the intervals as medically necessary to determine the program and potential conditions is located at: existence of a suspected illness or condition. • https://www.cdph.ca.gov/programs/immunize/ • Hearing services must include, at a minimum, Pages/HealthProfessionals.aspx diagnosis and treatment for defects in hearing, • http://eziz.org/vfc/overview/ including hearing aids.
California Children Services (CCS) Vaccines for Children (VFC) CCS is a statewide program that treats children The Vaccines for Children Program, established by an under the age of 21 with certain physical limitations act of Congress in 1993, helps families by providing and chronic health conditions or diseases. CCS can free vaccines to doctors who serve eligible children authorize and pay for specific medical services and 0 through 18 years of age. The VFC program is equipment provided by CCS-approved specialists. The administered at the national level by the United States California Department of Health Services manages the Centers for Disease Control and Prevention (CDC) CCS program. Providers are required to refer children through the National Center for Immunization and with certain physical limitations and chronic health Respiratory Diseases. The CDC contracts with vaccine conditions or diseases to a CCS paneled provider or manufacturers to buy vaccines at reduced rates. Enrolled CCS Specialty Care Center for care. VFC providers are able to order vaccine through their state VFC program and receive routine vaccines at no cost. This allows routine immunizations to eligible children without high out-of-pocket costs. Appropriate documentation shall be entered in the member’s medical record. It should indicate all attempts to provide immunizations. A receipt of vaccines or proof of prior immunizations; or proof of voluntary refusal of vaccines in the form of a signed statements by the member (if an emancipated minor) or the parent(s), or guardian of the member, shall be entered in the member’s medical record. Please contact SCMG or ECHO for further details.
13 Child Health and Disability Prevention (CHDP) (continued)
Services for the Developmentally Disabled • Have established risk conditions of known The term developmental disability refers to a severe etiology, with a high probability resulting and chronic disability that is attributable to a in delayed development mental or physical impairment that begins before an • Are at high risk of having a substantial developmental individual reaches adulthood. These disabilities include disability due to a combination of risk factors mental retardation, cerebral palsy, epilepsy, autism, and disabling conditions closely related to mental retardation or requiring similar treatment. Primary Care Responsibilities for Care Coordination with Linked and Carved out Services For an individual to be assessed in California as having PCPs are responsible for Coordination of Care for a developmental disability, the disability must begin Linked and Carved out Services (i.e. CCS, DDS, before the individual’s 18th birthday, be expected to Regional Centers, etc.). continue indefinitely and present a substantial disability. Care Managers at the managed care plan or SCMG are available to assist members, who may need or who Early Intervention/Early Start are receiving services from out of plan providers and/ or A child with or at risk of developmental delay or programs. This service is available to ensure disability can receive an “Early Start” in the State of coordinated service delivery and effective joint case California. Teams of service coordinators, health care management. The coordination of care and services providers, early intervention specialists, therapists, and remains the responsibility of each member’s PCP. parent resource specialists can evaluate and assess an PPG’s and the member’s PCP will monitor the infant or toddler. They can also provide appropriate early following: intervention services to children eligible for California • Member referral to and/or utilization of special Early Start. For more information, please refer to the programs and services section below; • Member referral to and/or utilization of specialty care, “Primary Care Responsibilities for Care Coordination including ensuring consultative notes and summaries with Linked and Carved out Services.” are maintained in the medical home records
Eligibility Criteria • Routine medical care, including providing the Infants and toddlers from birth to 36 months may necessary preventive medical care and services be eligible for Early Intervention services through • Provision of Initial Health Assessments including the documented evaluation and assessment if they meet one Staying Healthy Assessment (SHA) of the criteria listed below: PPGs/MSOs and PCPs are encouraged to make referrals to local health departments, mental health programs • Have a developmental delay in either cognitive, and regional centers. communication, social or emotional, adaptive, or physical and motor development including vision and hearing
14 Child Health and Disability Prevention (CHDP)
Out-of-Plan Case Management and Coordination of Care for Linked and Carved out Services Managed care plans maintain procedures to identify individuals, who may need or who are receiving services from out of plan providers and/or programs. These procedures are established in order to ensure coordinated service delivery and efficient and effective joint case management.
Medical Record Documentation Managed care plans require physician offices to maintain a certain level of medical record documentation. The managed care plan will assess records using the DHCS Medical Record Review Guidelines during the Facility Site Review process.
15 Behavioral Health
For non-specialty mental health services the services The Managed care plan may offer licensed behavioral listed below are provided to our members: health staff dedicated to supporting you with the services listed below: • Individual, and group mental health evaluation and treatment (psychotherapy) • Resolve behavioral health service access issues • Psychological testing when clinically indicated to evaluate a mental health condition • Ensure appropriate clinical transfer in behavioral health system of care • Outpatient services for the purposes of monitoring medication and treatment • Assist with service system coordination • Outpatient laboratory, medications, supplies and • Facilitate Care Coordination between Care supplements Management and SCMG Case Managers for • Psychiatric consultation behavioral health services. • For non-specialty mental health services, please contact: • Educate and train providers and the community
° Beacon Health Options • Support members with behavioral health grievances, ° Phone Line: 1-877-344-2850 appeals and advocacy
County Specialty Mental Health There are no changes to County Specialty Mental Health services provided by Los Angeles County Department of Mental Health (DMH) or Substance Use Disorder Treatment by the Department of Public Health (DPH). • For Specialty Mental Health services, please contact: ° L.A. County Department of Mental Health (DMH) ° Phone Line: 1-855-854-7771 • For Specialty Substance Use Disorder treatment, please contact: ° L.A. County Department of Public Health (DPH) ° Phone Line: 1-800-564-6600
16
Case Management
Your managed care plan has a Case Management department (also known as Care Management) with specially trained staff to help members with complex care needs or members at high risk for adverse outcomes. Examples of members with complex needs may include: • Serious acute or chronic health condition (trauma, new cancer diagnosis) • multiple uncontrolled health conditions • complicated social issues (no social support)
We will work with our members to develop an Individualized Care Plan (ICP) and provide you with updates to the plan after holding an Interdisciplinary Care Team (ICT) meeting with participants most appropriate to address individualized needs.
17
Managed Long-Term Services and Supports (MLTSS)
MLTSS is a wide range of services that provide support Managed care plan members receiving MLTSS often to seniors and individuals with disabilities so that they have complex needs. They may be diagnosed with can remain living safely at home. Services available to multiple chronic conditions (functional and members under MLTSS the managed care plan cognitive) or may lack social, educational, and include: economic support. The MLTSS department can help • In Home Supportive Services (IHSS): Provides in support your patient’s access to needed care by: home care for seniors and people with disabilities. Eligible members can hire anyone they wish to help • Determining if they are IHSS, CBAS, MSSP and them with their daily needs. This includes assistance LTC eligible with home chores, personal care assistance, basic • Coordinating and navigating IHSS, MSSP and medical needs, getting to provider appointments and CBAS assessment providing supervision for people with dementia or • Resolving IHSS, MSSP, CBAS and LTC related issues other mental impairments. and navigating the grievance and appeals process • Multipurpose Senior Services Program (MSSP): • Applying for IHSS and MSSP services Provides intensive care coordination services in • Coordinating requests for expedited assessments the home for seniors age 65 and older. An MSSP nurse and social worker team will provide eligible • Providing temporary services to fill in coordination of members with a full assessment of their health and care gaps social support needs. Additionally the MSSP team will • Following up with IHSS, MSSP, CBAS, and LTC identify, arrange and provide help with accessing services to ensure services are being provided resources, monitor the member’s wellbeing, and • Referring to local CBAS centers and MSSP sites purchase other needed services that may not be • Accessing community based organizations for available through the managed care plan or other non-plan services community based programs. • Community Based Adult Services (CBAS): Provides MLTSS Contact Information professional nursing services, physical, occupational For Managed Long Term Services and Supports questions and speech therapies, socialization, mental health please contact your managed care plan. services, therapeutic activities, social services, nutrition and nutritional counseling for people ages 18 and older. CBAS is a day program formerly known as adult day health care center.
• Long Term Care (LTC): Provides continuous skilled nursing care to eligible members with physical or mental conditions in a nursing home. The Medi-Cal LTC nursing facility benefit includes room and board and other medically necessary services.
18
Federal and State Statutes
Federal Statutes State Statutes The Centers for Medicare & Medicaid Services(CMS), The Department of Health Care Services (DHCS) was is part of the Department of Health and Human created and is directly governed by California statutes Services (DHHS). They administer Medicare, passed by the California Legislature. These statutes Medicaid, the Children’s Health Insurance Program grant DHCS the authority to establish programs and (CHIP) and parts of the Patient Protection and the adopt regulations. Affordable Care Act (ACA). The link below provides access to proposed and existing The link below provides access to proposed and existing statutes and regulations relevant to the DHCS. statutes and regulations relevant to CMS. http://www.dhcs.ca.gov/formsandpubs/laws/Pages/ https://www.cms.gov/Regulations-and-Guidance/ LawsandRegulations.aspx Regulations-and-Guidance.html
19
Timely Access to Care
Urgent Care In California, prior authorization prior authorization health care not required by health plan required by health plan consumers have 2 days 4 days Non-Urgent Care the right to an Doctor Appointment appointment PRIMARY CARE PHYSICIAN SPECIALTY CARE PHYSICIAN
10 business days 15 business days when needed. The law requires health plans licensed by Mental Health Appointment Appointment the DMHC to make primary care providers (non-physician1) (ancillary provider2) and hospitals available within specific geographic and time-elapsed standards. 10 business days 15 business days Health plans must ensure their network of 1 Examples of non-physician mental health providers include counseling professionals, substance providers, including doctors, can provide abuse professionals and qualified autism service providers. enrollees with an appointment within a 2 Examples of non-urgent appointment for ancillary services include lab work or diagnostic specific number of days or hours. testing, such as mammogram or MRI, and treatment of an illness or injury such as physical therapy.
Timely Access to Care Requirements
HOSPITAL 24/7
A
DISTANCE AVAILABILITY INTERPRETER Provide access to a primary care Your health plan should have Interpreter services must be coordinated provider or a hospital within 15 miles telephone services available with scheduled appointments for health care or 30 minutes from where on a 24/7 basis. services to ensure interpreter services are enrollees live or work. provided at the time of the appointment. Unable to get an Appointment Within the Timely Access Standard?
If you are not able to get an appointment within the timely access standard, you should first contact your health plan for assistance at the toll-free number listed on your health plan card. The DMHC Help Center is available at 1-888-466-2219 or www.HealthHelp.ca.gov to assist you if your health plan does not resolve the issue. The DMHC Help Center will work with you and your health plan to ensure you receive timely access to care.
If you believe you are experiencing a medical emergency, dial 9-1-1 or go to the nearest hospital. If your health issue is urgent, but not an emergency, and does not require prior approval or authorization from your health plan, you have the right to get care within 48 hours. The waiting time for an appointment may be extended if a qualified health care provider has determined and made record that a longer waiting time will not be harmful to the enrollee’s health.
20
Members Rights and Responsibilities CADMHC
Managed care plan Members have the right to the following: the formulation of their advanced directives. Written policies and procedures respecting advanced directives • Respectful and courteous treatment: Members have shall be developed in accordance. the right to be treated with respect, dignity and courtesy by their provider and staff. Members have the • Voice concerns: Members have the right to grieve right to be free from retaliation or force of any kind about the managed care plan and/or its affiliated when making decisions about their care. providers. They also have the right to receive care without fear of losing their benefits. Managed care • Privacy and confidentiality: Members have the right will help members with the grievance process. If to have their medical records kept confidential. plan members don’t agree with a decision, they have the Provider offices must implement and maintain right to appeal. Members have the right to disenroll procedures that protect against disclosure of from their health plan whenever they want. As a Medi- confidential patient information to unauthorized Cal member, they have the right to request a State Fair persons. Members also have the right to receive a copy Hearing, including information on the circumstances of and request corrections to their medical records. under which an expedited fair hearing is possible. Physicians must abide by California State minor consent laws. Members have the right to be counseled • Service outside of the managed care plan's provider on their rights to confidentiality and members consent network: Members have the right to receive is required prior to the release of confidential emergency or urgent services as well as family planning information, unless such consent is not required. and sexually transmitted disease services outside of their health plan’s network. Members also have access • Choice and involvement in their care: Members to Federally Qualified Health Centers and Indian have the right to receive information about their Health Services Facilities. health plan, services, and providers. Members have the right to choose their Primary Care Provider (PCP) • Service and information: Members have the right to from managed care plan's provider directory. request an interpreter at no charge and not use Members also have the right to obtain appointments a family member or a friend to translate for them. within access standards. Members have the right to Members have the right to access the Member talk with their provider about any care provided or Handbook and other information in another language recommended. Members have the right to discuss all or format, including; braille, large size print, and audio treatment options, and participate in making decisions format upon request. about their care. Members have the right to a second • Know their rights: Members have the right to receive opinion. Members have the right to speak candidly to information about their rights and responsibilities. their provider about appropriate or medically Members have the right to make recommendations about necessary treatment options for their condition. their rights and responsibilities. Members have the right Members have the right to deny treatment. Members to receive information on available treatment options and have the right to decide in advance how they want to alternatives, presented in a manner appropriate to the be cared for in case of a life-threatening illness or member’s condition and ability to understand. injury. Members also have the right to assist with
21
Members Rights and Responsibilities (continued)
As a member of a managed care plan members have the responsibility to:
• Act courteously and respectfully: Members are responsible for treating providers and staff with courtesy and respect. Members are responsible for being on time for their visits or calling your office at least 24 hours before the visit to cancel or reschedule. • Give up-to-date, accurate and complete information: Members are responsible for giving correct information and as much information as they can to all of their providers and managed care plan Members are responsible for getting regular check- ups and telling their provider about health problems before they become serious. • Members should follow their provider’s advice and take part in their care: Members are responsible for talking about their health care needs with their provider, developing and agreeing on goals, doing their best to understand their health problems following the treatment plans and instructions you both agree on.
• Use the Emergency Room only in an emergency: Members are responsible for using the emergency room in case of an emergency or as directed by their provider.
• Report wrong doing: Members are responsible for reporting health care fraud or wrong doing to the managed care plan Members can do this without giving their name by calling their managed care plan directly.
22
Cultural and Linguistic Services
Your managed care plan provides an array of cultural Interpreting Services and linguistic services and resources to assist you in Qualified interpreting services are essential to delivering effective patient-centered care. The following communicating effectively with limited English is a quick guide to help you and your staff understand proficient members. Your managed care plan's face- the state and federal regulatory requirements that guide to-face and telephonic interpreting services are cultural and linguistic services to ensure compliance. available to you and your staff at no charge. Interpreting services also include American Sign Language (ASL). Bilingual Staff Please call your managed care plan Effective communication though qualified interpreters directly for a list of provided services and contact improves quality of care, increases member satisfaction numbers. and minimizes the risk of liability and malpractice lawsuits. All managed care plans offer no cost qualified Key Things to Remember interpreting services to you and your members in an • Inform members of the availability of no-cost effort to discourage the use of bilingual staff as 24/7 interpreting services including ASL. interpreters. If a member of your staff is bilingual and • Document the member’s preferred language in the utilizes the second language to interact with members, it medical chart. is important they are qualified and proficient in English and the other language with proper training and • Discourage use of friends, family members and education. minors as interpreters. • Document member’s request/refusal of interpreting Please maintain the following documentation for your services in the medical chart after no-cost interpreting qualified bilingual staff: services are offered to them. • Certification for medical interpreters • Number of years of service employed as an interpreter (e.g. resume) • Certificate of completion interpreter training program • Bilingual skills self-assessment
Bilingual Language Skills Self-Assessment Tool The self-assessment tool is a resource to assist you in identifying language skills and resources existing in your office. It can be used to document bilingual skills of your staff before the professional assessment. The self- assessment tool is included in Section 1 of “What you need to know” in the Provider Toolkit. The assessment should be conducted annually for office staff and every three years for physicians.
23
Customer Service
The following are suggested best practices. The Determine if the member needs an interpreter information consists of useful reminders and tips for the visit providers and medical office staff can utilize to • Document the member’s preferred language in the enhance a positive customer service experience. member chart • Have an interpreter access plan. Use of interpreters Build rapport with the member with a medical background is strongly encouraged, • Address members by their last name if the member’s rather than family, minors or friends of the member preference of greeting is not clear • Assess your bilingual clinical staff for • Focus your attention on members when addressing them interpreter abilities • Learn basic words in your member’s primary language, like “hello” or “thank you” Give members the information they need • Have health education materials in languages that • Explain the different roles performed by office staff reflect your membership • Offer handouts such as immunization guidelines Make sure members know your role for adults and children, screening guidelines and • Take a few moments to prepare a handout that explains culturally relevant dietary guidelines for diabetes or office hours, how to contact the office when it is closed weight loss and how the provider coordinates specialty care • Have instructions professionally translated and Make sure members know what to do available in the common language(s) spoken by your • Review any follow-up procedures with the member member panel before they leave your office • It is not necessary to raise the volume of your voice if • Verify call back numbers, the locations for follow- the issue is language comprehension and not hearing up services such as labs, X-ray or screening tests and whether or not a follow-up appointment is necessary Keep members’ expectations realistic Develop pre-printed simple handouts of frequently • Inform members of delays or extended wait times used instructions and translate the handouts into the common language(s) spoken by your membership
Work to build members trust • Inform members of office procedures, such as when they can expect a call with lab results, how follow-up appointments are scheduled and routine wait times
24 Customer Service (continued)
Styles of Speech Body Language People vary greatly in the length of time between • Follow the member’s lead on physical distance comments and responses. The speed of their speech and and contact their willingness to interrupt may vary. • Stay sensitive to those who do not • Tolerate gaps between questions and answers; feel comfortable impatience can be seen as a sign of disrespect • Gestures can have different meanings • Listen to the volume and speed of the member’s • Be conservative in your own use of gestures and speech as well as the content. Modify your own body language speech to more closely match that of the member to • Do not interpret member’s feelings or level of pain make them more comfortable solely from facial expressions • Rapid exchanges and even interruptions are a part of some conversational styles Gently Guide Member Conversation • Do not be offended if a member interrupts you English language predisposes us to a direct communication style however, other languages and • Stay aware of your interruption patterns, especially if cultures differ. the member is older than you are • Non English speaking members or individuals from diverse cultural backgrounds may be less likely to Eye Contact ask questions The way people interpret various types of eye contact is tied to cultural background. Facilitate member-centered communication • Look people directly in the eyes to demonstrate • Avoid questions that can be answered with “yes” or “no” communication engagement • Steer the member back to the topic by asking a question • For other cultures, direct eye contact is considered that clearly demonstrates that you are listening rude or disrespectful. Never force a member to make eye contact with you. • Some members can tell you more about their health through story telling than by answering direct questions • If a member seems uncomfortable with direct eye contact, try sitting next to them instead of across from them
Thank you for taking this training. Please make sure to sign and attest that you have read and understood this information and provide a copy to ECHO MSO. If you would like more information, please refer to the managed care plan's Provider Manual. If you have additional questions, please contact SCMG or ECHO MSO.
25 General Compliance Training Why Do I Need Training?
Every year billions of dollars are improperly spent because of Fraud, Waste, and Abuse (FWA). It affects everyone – including you. This training helps you detect, correct, and prevent FWA. You are part of the solution. Compliance is everyone’s responsibility. As an individual who provides health or administrative services for Medicare enrollees, your every action potentially affects Medicare enrollees, the Medicare Program, or the Medicare Trust Fund.
General Compliance training must occur within 90 days of initial hire and at least annually thereafter. Course Content: This course consists of General Compliance program training and a post review assessment. Anyone who provides health or administrative services to Medicare or Medicaid enrollees must satisfy General Compliance and FWA training requirements. Reviewing this course will satisfy the CMS General Compliance training requirements.
Course Objectives: When you complete this course, you should be able to correctly: • Recognize how a compliance program operates; and • Recognize how compliance program violations should be reported.
Compliance Program Requirement: The Centers for Medicare & Medicaid Services (CMS) requires Sponsors to implement and maintain an effective compliance program for its Medicare Parts C and D plans. An effective compliance program should:
• Articulate and demonstrate an organization’s commitment to legal and ethical conduct; • Provide guidance on how to handle compliance questions and concerns; and • Provide guidance on how to identify and report compliance violations. What Is an Effective Compliance Program?
An effective compliance program fosters a culture of compliance within an organization and, at a minimum:
• Prevents, detects, and corrects non-compliance; • Is fully implemented and is tailored to an organization’s unique operations and circumstances; •s Ha adequate resources; • Promotes the organization’s Standards of Conduct; and • Establishes clear lines of communication for reporting non- compliance.
For more information, refer to: •2 4C ode of Federal Regulations (CFR) Section 422.503(b)(4)(vi) on the Internet; •2 4 CFR Section 423.504(b)(4)(vi) on the Internet; •M“ edicare Managed Care Manual,” Chapter 21 on the CMS website; and •M“ edicare Prescription Drug Benefit Manual,” Chapter 9 on the CMS website.
An effective compliance program is essential to prevent, detect, and correct Medicare non-compliance as well as Fraud, Waste, and Abuse (FWA). It must, at a minimum, include the seven core compliance program requirements.
HYPERLINK URL LINKED TEXT/IMAGE https://www.gpo.gov/fdsys/pkg/CFR-2014-title42-vol3/pdf/CFR-2014-title42-vol3- 42 Code of Federal Regulations (CFR Section 422.503(b)(4)(vi) sec422-503.pdf https://www.gpo.gov/fdsys/pkg/CFR-2014-title42-vol3/pdf/CFR-2014-title42-vol3- 42 CFR Section 423.504(b)(4)(vi) sec423-504.pdf https://www.cms.gov/Regulations-and- Medicare Managed Care Manual, Chapter 21 Guidance/Guidance/Manuals/Downloads/mc86c21.pdf https://www.cms.gov/Medicare/Prescription-Drug- Medicare Prescription Drug Benefit Manual, Chapter 9 Coverage/PrescriptionDrugCovContra/Downloads/Chapter9.pdf Seven Core Compliance Program Requirements CMS requires that an effective compliance program must include seven core requirements:
1. Written Policies, Procedures, and Standards of Conduct: These articulate the Sponsor’s commitment to comply with all applicable Federal and State standards and describe compliance expectations according to the Standards of Conduct. 2. Compliance Officer, Compliance Committee, and High-Level Oversight: The Sponsor must designate a compliance officer and a compliance committee that will be accountable and responsible for the activities and status of the compliance program, including issues identified, investigated, and resolved by the compliance program. The Sponsor’s senior management and governing body must be engaged and exercise reasonable oversight of the Sponsor’s compliance program. 3. Effective Training and Education: This covers the elements of the compliance plan as well as prevention, detection, and reporting of FWA. This training and education should be tailored to the different responsibilities and job functions of employees. 4. Effective Lines of Communication: Effective lines of communication must be accessible to all, ensure confidentiality, and provide methods for anonymous and good-faith reporting of compliance issues at Sponsor and First-Tier, Downstream, or Related Entity (FDR) levels. 5. Well-Publicized Disciplinary Standards: Sponsor must enforce standards through well-publicized disciplinary guidelines. 6. Effective System for Routine Monitoring, Auditing, and Identifying Compliance Risks: Conduct routine monitoring and auditing of Sponsor’s and FDR’s operations to evaluate compliance with CMS requirements as well as the overall effectiveness of the compliance program. NOTE: Sponsors must ensure that FDRs performing delegated administrative or health care service functions concerning the Sponsor’s Medicare Parts C and D program comply with Medicare Program requirements. 7. Procedures and System for Prompt Response to Compliance Issues The Sponsor must use effective measures to respond promptly to non-compliance and undertake appropriate corrective action. Ethics–Do the Right Thing!
As part of the Medicare and Medicaid Programs, you must conduct yourself in an ethical and legal manner. It’s about doing the right thing! • Act fairly and honestly; • Adhere to high ethical standards in all you do; • Comply with all applicable laws, regulations, and CMS requirements; and • Report suspected violations.
How Do You Know What Is Expected of You?
Beyond following the general ethical guidelines on the previous page, how do you know what is expected of you in a specific situation? Standards of Conduct (or Code of Conduct) state compliance expectations and the principles and values by which an organization operates. Contents will vary as Standards of Conduct should be tailored to each individual organization’s culture and business operations. If you are not aware of your organization’s standards of conduct, ask your management where they can be located.
Everyone has a responsibility to report violations of Standards of Conduct and suspected non-compliance. An organization’s Standards of Conduct and Policies and Procedures should identify this obligation and tell you how to report suspected non- compliance. What Is Non-Compliance? Non-compliance is conduct that does not conform to the law, federal health care program requirements, or an organization’s ethical and business policies. CMS has identified the following high risk areas: • Agent/broker misrepresentation; • Appeals and grievance review (for example, coverage and organization determinations); • Beneficiary notices; • Conflicts of interest; •Claims processing; • Credentialing and provider networks; • Documentation and Timeliness requirements; • Ethics; • FDR oversight and monitoring; • Health Insurance Portability and Accountability Act (HIPAA); • Marketing and enrollment; • Pharmacy, formulary, and benefit administration; and • Quality of care Know the Consequences of Non-Compliance Failure to follow Medicare or Medicaid Program requirements and CMS guidance can lead to serious consequences including: •Contract termination; • Criminal penalties; • Exclusion from participation in all Federal health care programs; or • Civil monetary penalties
Additionally, your organization must have disciplinary standards for non-compliant behavior. Those who engage in non-compliant behavior may be subject to any of the following: • Mandatory training or re-training; • Disciplinary action; or • Termination NON-COMPLIANCE AFFECTS EVERYBODY! Without programs to prevent, detect, and correct non-compliance, we all risk: • Harm to beneficiaries, such as: • Delayed services • Denial of benefits • Difficulty in using providers of choice • Other hurdles to care
Less money for everyone, due to: • High insurance copayments • Higher premiums • Lower benefits for individuals and employers •Lower Star ratings • Lower profits
Don’t Hesitate to Report Non-Compliance There can be no retaliation against you for reporting suspected non-compliance in good faith. Each sponsor must offer reporting methods that are: • Anonymous • Confidential; and • Non-retaliatory How to Report Potential Non-Compliance - Employees of a Sponsor • Call the Medicare or Medicaid Compliance Officer; • Make a report through your organization’s website; or • Call the Compliance Hotline First-Tier, Downstream, or Related Entity (FDR) Employees • Talk to a Manager or Supervisor; • Call your Ethics/Compliance Help Line; or • Report to the Sponsor
Beneficiaries • Call the Sponsor’s Compliance Hotline or Customer Service; • Make a report through the Sponsor’s website; or • Call 1-800-Medicare What Happens After Non-Compliance Is Detected? After non-compliance is detected, it must be investigated immediately and promptly corrected. However, internal monitoring should continue to ensure: • There is no recurrence of the same non-compliance; • Ongoing compliance with CMS requirements; • Efficient and effective internal controls; and • Enrollees are protected. What Are Internal Monitoring and Audits? • Internal monitoring activities are regular reviews that confirm ongoing compliance and ensure that corrective actions are undertaken and effective. • Internal auditing is a formal review of compliance with a particular set of standards (for example, policies and procedures, laws, and regulations) used as base measures. Lesson Summary:
Organizations must create and maintain compliance programs that, at a minimum, meet the seven core requirements. An effective compliance program fosters a culture of compliance.
To help ensure compliance, behave ethically and follow your organization’s Standards of Conduct. Watch for common instances of non-compliance, and report suspected non-compliance.
Know the consequences of non-compliance, and help correct any non-compliance with a corrective action plan that includes ongoing monitoring and auditing.
Compliance is Everyone’s Responsibility!
Prevent: Operate within your organization’s ethical expectations to prevent non-compliance.
Detect & Report: If you detect potential non-compliance, report it!
Correct: Correct non-compliance to protect beneficiaries and save money!
Monitor: Regular reviews to confirm ongoing compliance and ensure corrective action is undertaken.
Audit: Formal review of compliance with a particular set of standards. Lesson Review: Now that you have completed the Compliance Program Training review, let’s do a quick knowledge check.
Knowledge Check #1:
You discover an unattended email address or fax machine in your office that receives beneficiary appeals requests. You suspect that no one is processing the appeals. What should you do?
Select the correct answer. ○ A. Contact law enforcement ○ B. Nothing ○ C. Contact your compliance department (via compliance hotline or other mechanism) ○ D. Wait to confirm someone is processing the appeals before taking further action ○ E. Contact your supervisor
Answer: C
Knowledge Check #2:
A sales agent, employed by the Sponsor’s First-Tier or Downstream entity, submitted an application for processing and requested two things: 1) to back-date the enrollment date by one month, and 2) to waive all monthly premiums for the beneficiary. What should you do?
Select the correct answer. ○ A. Refuse to change the date or waive the premiums, but decide not to mention the request to a supervisor or the compliance department ○ B. Make the requested changes because the sales agent determines the beneficiary’s start date and monthly premiums ○ C. Tell the sales agent you will take care of it, but then process the application properly (without the requested revisions) – you will not file a report because you don’t want the sales agent to retaliate against you ○ D. Process the application properly (without the requested revisions) – inform your supervisor and the compliance officer about the sales agent’s request ○ E. Contact law enforcement and the Centers for Medicare & Medicaid Services (CMS) to report the sales agent’s behavior
Answer: D Knowledge Check #3:
You work for a Sponsor. Last month, while reviewing a monthly report from the Centers for Medicare & Medicaid Services (CMS), you identified multiple enrollees for which the Sponsor is being paid, who are not enrolled in the plan. You spoke to your supervisor who said not to worry about it. This month, you have identified the same enrollees on the report again. What should you do?
Select the correct answer. ○ A. Decide not to worry about it as your supervisor instructed – you notified him last month and now it’s his responsibility ○ B. Although you have seen notices about the Sponsor’s non-retaliation policy, you are still nervous about reporting – to be safe, you submit a report through your compliance department’s anonymous tip line so you cannot be identified ○ C. Wait until the next month to see if the same enrollees appear on the report again, figuring it may take a few months for CMS to reconcile its records – if they are, then you will say something to your supervisor again ○ D. Contact law enforcement and CMS to report the discrepancy ○ E. Ask your supervisor about the discrepancy again
Answer: B
Knowledge Check #4:
You are performing a regular inventory of the controlled substances in the pharmacy. You discover a minor inventory discrepancy. What should you do?
Select the correct answer. ○ A. Call local law enforcement ○ B. Perform another review ○ C. Contact your compliance department (via compliance hotline or other mechanism) ○ D. Discuss your concerns with your supervisor ○ E. Follow your pharmacy’s procedures
Answer: E Additional Resources
For more information on laws governing the Medicare or Medicaid program and Medicare or Medicaid noncompliance or for additional healthcare compliance resources please see:
• Title XVIII of the Social Security Act • Medicare Regulations governing Parts C and D (42 C.F.R. §§ 422 and 423) • Civil False Claims Act (31 U.S.C. §§ 3729-3733) • Criminal False Claims Statute (18 U.S.C. §§ 287,1001) • Anti-Kickback Statute (42 U.S.C. § 1320a-7b(b)) • Stark Statute (Physician Self-Referral Law) (42 U.S.C. § 1395nn) • Exclusion entities instruction (42 U.S.C. § 1395w-27(g)(1)(G)) • The Health Insurance Portability and Accountability Act of 1996 (HIPAA) (Public Law 104-191) (45 CFR Part 160 and Part 164, Subparts A and E) • OIG Compliance Program Guidance for the Healthcare Industry: http://oig.hhs.gov/compliance/compliance-guidance/index.asp
Resources Resource Website Compliance Education Materials: Compliance 101 https://oig.hhs.gov/compliance/101 Health Care Fraud Prevention and Enforcement https://oig.hhs.gov/compliance/provider-compliance- Action Team Provider Compliance Training training OIG’s Provider Self-Disclosure Protocol https://oig.hhs.gov/compliance/self-disclosure- info/files/Provider-Self-Disclosure-Protocol.pdf Part C and Part D Compliance and Audits - Overview https://www.cms.gov/medicare/compliance-and- audits/part-c-and-part-d-compliance-and-audits Physician Self-Referral https://www.cms.gov/Medicare/Fraud-and- Abuse/PhysicianSelfReferral A Roadmap for New Physicians: Avoiding Medicare https://oig.hhs.gov/compliance/physician-education Fraud and Abuse Safe Harbor Regulations https://oig.hhs.gov/compliance/safe-harbor-regulations Medicare Learning Network® (MLN) – Your free Medicare education and information resource! The MLN is home for education, information, and resources for the health care professional community. The MLN provides access to the CMS Program information you need, when you need it, so you can focus more on providing care to your patients. Serving as the umbrella for a variety of CMS education and communication activities, the MLN offers: 1. MLN Educational Products, including MLN Matters® Articles; 2. WBT Courses (many offer Continuing Education credits); 3. MLN Connects® National Provider Calls; 4. MLN Connects® Provider Association Partnerships; 5. MLN Connects® Provider eNews; and 6. Provider Electronic Mailing Lists. The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS).
HYPERLINK URL LINKED TEXT/IMAGE https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN Educational Products MLN/MLNProducts https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN Matters® Articles MLN/MLNMattersArticles https://learner.mlnlms.com WBT Courses https://www.cms.gov/Outreach-and-Education/Outreach/NPC MLN Connects® National Provider Calls https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN Connects® Provider Association Partnerships MLN/MLN-Partnership https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg MLN Connects® Provider eNews Fraud, Waste, & Abuse Training Why Do I Need Training?
Every year billions of dollars are improperly spent because of Fraud, Waste, and Abuse (FWA). It affects everyone – including you. This training helps you detect, correct, and prevent FWA. You are part of the solution. Combating FWA is everyone’s responsibility! As an individual who provides health or administrative services for Medicare or Medicaid enrollees, every action you take potentially affects Medicare/Medicaid enrollees, the Medicare/ Medicaid Program, or the Medicare Trust Fund.
General Compliance training must occur within 90 days of initial hire and at least annually thereafter. What Are My Responsibilities?
You are a vital part of the effort to prevent, detect, and report Medicare non-compliance as well as possible fraud, waste, and abuse.
First you are required to comply with all applicable statutory, regulatory, and other Program requirements, including adopting and implementing an effective compliance program.
Second you have a duty to the Medicare and Medicaid Programs to report any violations of laws that you may be aware of.
Third you have a duty to follow your organization’s Code of Conduct that articulates your and your organizations commitment to standards of conduct and ethical rules of behavior. Course Content: This course consists of two lessons:
1. What is FWA? 2. Your Role in the Fight Against FWA
Anyone who provides health or administrative services to Medicare or Medicaid enrollees must satisfy general compliance and FWA training requirements. Completing this course will satisfy the FWA training requirements.
Course Objectives: When you complete this course, you should be able to correctly:
• Recognize FWA in the Medicare Program; • Identify the major laws and regulations pertaining to FWA; • Recognize potential consequences and penalties associated with violations; • Identify methods of preventing FWA; • Identify how to report FWA; and • Recognize how to correct FWA FWA DEFINITIONS
Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program, or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program. In other words, fraud is intentionally submitting false information to the Government or a Government contractor to get money or a benefit.
The Health Care Fraud Statute makes it a criminal offense to knowingly and willfully execute a scheme to defraud a health care benefit program. Health care fraud is punishable by imprisonment for up to 10 years. It is also subject to criminal fines of up to $250,000.
Waste includes overusing services, or other practices that, directly or indirectly, result in unnecessary costs to the Medicare Program. Waste is generally not considered to be caused by criminally negligent actions but rather by the misuse of resources.
Abuse includes actions that may, directly or indirectly, result in unnecessary costs to the Medicare Program. Abuse involves payment for items or services when there is not legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment.
For the definitions of fraud, waste, and abuse, refer to Chapter 21, Section 20 of the “Medicare Managed Care Manual” and Chapter 9 of the “Prescription Drug Benefit Manual” on the Centers for Medicare & Medicaid Services (CMS) website.
HYPERLINK URL LINKED TEXT/IMAGE https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/mc86c21.pdf Medicare Managed Care Manual https://www.cms.gov/Medicare/Prescription-Drug- Prescription Drug Benefit Manual Coverage/PrescriptionDrugCovContra/Downloads/Chapter9.pdf Examples of FWA
Examples of actions that may constitute Medicare/Medicaid fraud include: • Knowingly billing for services not furnished or supplies not provided, including billing Medicare/ Medicaid for appointments that the patient failed to keep; • Billing for non-existent prescriptions; and • Knowingly altering claim forms, medical records, or receipts to receive a higher payment.
Examples of actions that may constitute Medicare/Medicaid waste include: • Conducting excessive office visits or writing excessive prescriptions; • Prescribing more medications than necessary for the treatment of a specific condition; and • Ordering excessive laboratory tests.
Examples of actions that may constitute Medicare/Medicaid abuse include: • Billing for unnecessary medical services; • Billing for brand name drugs when generics are dispensed; • Charging excessively for services or supplies; and • Misusing codes on a claim, such as upcoding or unbundling codes.
Differences among Fraud, Waste, and Abuse There are differences among fraud, waste, and abuse. One of the primary differences is intent and knowledge. Fraud requires intent to obtain payment and the knowledge that the actions are wrong. Waste and Abuse may involve obtaining an improper payment or creating an unnecessary cost to the Program, but does not require the same intent and knowledge. Understanding FWA
To detect FWA, you need to know the law. The following pages provide high-level information about the following fraud, waste, and abuse laws:
• Civil False Claims Act,
• Health Care Fraud Statute, and
• Criminal Fraud;
• Anti-Kickback Statute;
• Stark Statute (Physician Self-Referral Law);
• Exclusion; and
• Health Insurance Portability and Accountability Act (HIPAA).
For details about the specific laws, such as safe harbor provisions, consult the applicable statute and regulations. Civil False Claims Act (FCA)
The civil provisions of the FCA make a person liable to pay damages to the Government if he or she knowingly: • Conspires to violate the FCA; • Carries out other acts to obtain property from the Government by misrepresentation; • Knowingly conceals or knowingly and improperly avoids or decreases an obligation to pay the Government; • Makes or uses a false record or statement supporting a false claim; or • Presents a false claim for payment or approval.
For more information, refer to 31 United States Code (U.S.C.) Sections 3729-3733 on the Internet.
EXAMPLE: A Medicare Part C plan in Florida hired an outside company to review medical records to find additional diagnosis codes that could be submitted to increase risk capitation payments from the Centers for Medicare and Medicaid Services (CMS). The Plan was informed by the outside company that certain diagnosis codes previously submitted to Medicare were undocumented or unsupported. The Plan failed to report the unsupported diagnosis codes to Medicare and agreed to pay 22.6 million to settle FCA allegations.
HYPERLINK URL LINKED TEXT/IMAGE https://www.gpo.gov/fdsys/pkg/USCODE-2015-title31/pdf/USCODE-2015-title31- 31 U.S.C. Sections 3729-3733 subtitleIII-chap37-subchapIII.pdf Civil False Claims Act (FCA) (continued)
Whistleblowers
A whistleblower is a person who exposes information or activity that is deemed illegal, dishonest, or violates professional or clinical standards.
Protected: Persons who report false claims or being legal actions to recover money paid on false claims are protected from retaliation.
Rewarded: Persons who bring a successful whistleblower lawsuit receive at least 15 percent but not more than 30 percent of the money collected.
Civil False Claims Act (FCA) Damages and Penalties:
Any person who knowingly submits false claims to the Government is liable for three times the Government’s damages caused by the violator plus a penalty. Health Care Fraud Statute The Health Care Fraud Statute states that “Whoever knowingly and willfully executes, or attempts to execute, a scheme to …defraud any health care benefit program … shall be fined … or imprisoned not more than 10 years, or both.”
Conviction under the statute does not require proof that the violator had knowledge of the law or specific intent to violate the law. For more information, refer to 18 U.S.C. Section 1346 on the Internet.
EXAMPLES:
A Pennsylvania pharmacist:
• Submitted claims to a Medicare Part D plan for non-existent prescriptions and for drugs not dispensed; • Plead guilty to health care fraud; and • Received a 15 month prison sentence and was ordered to pay more than $166,000 in restitution to the plan.
The owners of a Florida Durable Medical Equipment (DME) companies:
• Submitted false claims of approximately $4 million to Medicare for products that were not authorized and not provided; • Were convicted of making false claims, conspiracy, health care fraud, and wire fraud; • Were sentenced to 54 months in prison; and • Were ordered to pay more than $1.9 million in restitution.
HYPERLINK URL LINKED TEXT/IMAGE https://www.gpo.gov/fdsys/pkg/USCODE-2015-title18/pdf/USCODE-2015-title18-partI- 18 U.S.C. Section 1346 chap63-sec1346.pdf Criminal Health Care Fraud
Persons who knowingly make a false claim may be subject to:
• Criminal fines up to $250,000; •isonImpr ment for up to 20 years; or • Both.
If the violations resulted in death, the individual may be imprisoned for any term of years or for life. For more information, refer to 18 U.S.C. Section 1347 on the Internet.
HYPERLINK URL LINKED TEXT/IMAGE https://www.gpo.gov/fdsys/pkg/USCODE-2015-title18/pdf/USCODE-2015-title18- 18 U.S.C. Section 1347 partI-chap63-sec1347.pdf Anti-Kickback Statute The Anti-Kickback Statute prohibits knowingly and willfully soliciting, receiving, offering, or paying remuneration (including any kickback, bribe, or rebate) for referrals for services that are paid, in whole or in part, under a Federal health care program (including the Medicare Program).
Anti-Kickback Statute Damages and Penalties
Violations are punishable by:
•e Aof fin up to $25,000; • Imprisonment for up to 5 years; or • Both. For more information, refer to the Secocial urity Act (theAct), Section 1128B(b) on the Internet.
For more information, refer to 42 U.S.C. Section 1320a-7b(b) on the Internet.
EXAMPLE A radiologist who owned and served as medical director of a diagnostic testing center in New Jersey: • Obtained nearly $2 million in payments from Medicare and Medicaid for MRIs, CAT scans, ultrasounds, and other resulting tests; • Paid doctors for referring patients; • Pleaded guilty to violating the Anti-Kickback Statute; and • Was sentenced to 46 months in prison. The radiologist was among 17 people, including 15 physicians, who have been convicted in connection with this scheme.
HYPERLINK URL LINKED TEXT/IMAGE https://www.gpo.gov/fdsys/pkg/USCODE-2015-title42/pdf/USCODE-2015-title42- 42 U.S.C. Section 1320a-7b(b) chap7-subchapXI-partA-sec1320a-7b.pdf https://www.ssa.gov/OP_Home/ssact/title11/1128B.htm Social Security Act (the Act), Section 1128B(b) Stark Statute (Physician Self-Referral Law) The Stark Statute prohibits a physician from making referrals for certain designated health services to an entity when the physician (or a member of his or her family) has:
• An ownership/investment interest; or • A compensation arrangement (exceptions apply). For more information, refer to 42 U.S.C. Section 1395nn on the Internet. Stark Statute (Physician Self-Referral Law) Damages a nd Penalties: Medicare claims tainted by an arrangement that does not comply with the Stark Statute are not payable. A penalty of around $23,800 may be imposed for each service provided. There may also be around a $159,000 fine for entering into an unlawful arrangement or scheme.
For more information, visit the Physician Self-Referral webpage on the CMS website and refer to the Act, Section 1877 on the Internet.
EXAMPLE A physician paid the Government $203,000 to settle allegations that he violated the physician self- referral prohibition in the Stark Statute for routinely referring Medicare patients to an oxygen supply company he owned.
HYPERLINK URL LINKED TEXT/IMAGE https://www.gpo.gov/fdsys/pkg/USCODE-2015-title42/pdf/USCODE-2015-title42- 42 U.S.C. Section 1395nn chap7-subchapXVIII-partE-sec1395nn.pdf https://www.cms.gov/Medicare/Fraud-and-Abuse/PhysicianSelfReferral Physician Self-Referral webpage https://www.ssa.gov/OP_Home/ssact/title18/1877.htm the Act, Section 1877 Civil Monetary Penalties (CMP) Law
The Office of Inspector General (OIG) may impose civil penalties for a number of reasons, including: • Arranging for services or items from an excluded individual or entity; • Providing services or items while excluded; • Failing to grant OIG timely access to records; • Knowing of an overpayment and failing to report and return it; • Making false claims; or • Paying to influence referrals
For more information, refer to 42 U.S.C. 1320a-7a and the Act, Section 1128A(a) on the Internet.
CMP Damages and Penalties:
The penalties can be around $15,000 to $70,000 depending on the specific violation. Violators are also subject to three times the amount:
• Claimed for each service or item; or • Of remuneration offered, paid, solicited, or received.
EXAMPLE
A California pharmacy and its owner agreed to pay over $1.3 million to settle allegations they submitted claims to Medicare Part D for brand name prescription drugs that the pharmacy could not have dispensed based on inventory records.
HYPERLINK URL LINKED TEXT/IMAGE https://www.gpo.gov/fdsys/pkg/USCODE-2015-title42/pdf/USCODE-2015-title42- 42 U.S.C. 1320a-7a chap7-subchapXI-partA-sec1320a-7a.pdf http://www.ssa.gov/OP_Home/ssact/title11/1128A.htm the Act, Section 1128A(a)
Exclusion No Federal health care program payment may be made for any item or service furnished, ordered, or prescribed by an individual or entity excluded by the OIG. The OIG has authority to exclude individuals and entities from federally funded health care programs and maintains the List of Excluded Individuals and Entities (LEIE). You can access the LEIE on the Internet.
The United States General Services Administration (GSA) administers the Excluded Parties List System (EPLS), which contains debarment actions taken by various Federal agencies, including the OIG. You may access the EPLS on the System for Award Management website.
If looking for excluded individuals or entities, make sure to check both the LEIE and the EPLS since the lists are not the same. For more information, refer to 42 U.S.C. Section 1320a-7 and 42 Code of Federal Regulations Section 1001.1901 on the Internet.
EXAMPLE A pharmaceutical company pleaded guilty to two felony counts of criminal fraud related to failure to file required reports with the Food and Drug Administration concerning oversized morphine sulfate tablets. The executive of the pharmaceutical firm was excluded based on the company guilty plea. At the time the executive was excluded, he had not been convicted himself, but there was evidence he was involved in misconduct leading to the company’s conviction.
HYPERLINK URL LINKED TEXT/IMAGE https://exclusions.oig.hhs.gov LEIE https://www.sam.gov/portal/SAM/#1 EPLS https://www.gpo.gov/fdsys/pkg/USCODE-2015-title42/pdf/USCODE-2015-title42- 42 U.S.C. Section 1320a-7 chap7-subchapXI-partA-sec1320a-7.pdf https://www.gpo.gov/fdsys/pkg/CFR-2015-title42-vol5/pdf/CFR-2015-title42-vol5- 42 Code of Federal Regulations Section 1001.1901 sec1001-1901.pdf Health Insurance Portability and Accountability Act (HIPAA) HIPAA created greater access to health care insurance, protection of privacy of health care data, and promoted standardization and efficiency in the health care industry.
HIPAA safeguards help prevent unauthorized access to protected health information. As an individual with access to protected health care information, you must comply with HIPAA.
For more information, visit the HIPAA webpage on the Internet. Damages and Penalties:
Violations may result in Civil Monetary Penalties. In some cases, criminal penalties may apply.
EXAMPLE A former hospital employee pleaded guilty to criminal HIPAA charges after obtaining protected health information with the intent to use it for personal gain. He was sentenced to 12 months
and 1 day in prison.
HYPERLINK URL LINKED TEXT/IMAGE https://www.hhs.gov/hipaa HIPAA webpage Lesson Summary: There are differences among FWA. One of the primary differences is intent and knowledge. Fraud requires that the person have intent to obtain payment and the knowledge that their actions are wrong. Waste and abuse may involve obtaining an improper payment but do not require the same intent and knowledge.
Laws and regulations exist that prohibit FWA. Penalties for violating these laws may include:
• Civil Monetary Penalties; • Civil prosecution; • Criminal conviction/fines; • Exclusion from participation in all Federal health care programs; •isonImpr ment; or • Loss of provider license. Lesson Review:
Knowledge Check #1: Which of the following requires intent to obtain payment and the knowledge that the actions are wrong? Select the correct answer. ○ A. Fraud ○ B. Abuse ○ C. Waste Answer: A
Knowledge Check #2: Which of the following is NOT potentially a penalty for violation of a law or regulation prohibiting Fraud, Waste, and Abuse (FWA)? Select the correct answer. ○ A. Civil Monetary Penalties ○ B. Deportation ○ C. Exclusion from participation in all Federal health care programs Answer: B Your Role in the Fight Against FWA Introduction and Learning Objectives
This lesson explains the role you can play in fighting against Fraud, Waste, and Abuse (FWA), including your responsibilities for preventing, reporting, and correcting FWA. It should take about 10 minutes to complete. Upon completing the lesson, you should be able to correctly:
• Identify methods of preventing FWA; • Identify how to report FWA; and • Recognize how to correct FWA. What Are My Responsibilities?
You play a vital part in preventing, detecting, and reporting potential FWA, as well as Medicare non-compliance.
First you must comply with all applicable statutory, regulatory, and other Medicare Part or Part D requirements, including adopting and using an effective compliance program.
Second you have a duty to the Medicare Program to report any compliance concerns, and suspected or actual violations that you may be aware of.
Third you have a duty to follow your organization’s Code of Conduct that articulates your and your organization’s commitment to standards of conduct and ethical rules of behavior.
How Do You Prevent FWA? • Look for suspicious activity; • Conduct yourself in an ethical manner; • Ensure accurate and timely data/billing; • Ensure you coordinate with other payers; • Keep up to date with FWA policies and procedures, standards of conduct, laws, regulations, and the CMS guidance; and • Verify all information provided to you.
Stay Informed About Policies and Procedures
Familiarize yourself with your entity’s policies and procedures. Every Sponsor and First-Tier, Downstream, and Related Entity (FDR) must have policies and procedures that address FWA. These procedures should help you detect, prevent, report, and correct FWA.
Standards of Conduct should describe the Sponsor’s expectations that:
• All employees conduct themselves in an ethical manner; • Appropriate mechanisms are in place for anyone to report non-compliance and potential FWA; and; • Reported issues will be addressed and corrected.
Standards of Conduct communicate to employees and FDR’s that compliance is everyone’s responsibility from the top of the organization to the bottom.
Report FWA
Everyone must report suspected instances of FWA. Your Sponsor’s Code of Conduct should clearly state this obligation. Sponsors may not retaliate against you for making a good faith effort in reporting.
Do not be concerned about whether it is fraud, waste, or abuse. Just report any concerns to your compliance department or your Sponsor’s compliance department. Your Sponsor’s compliance department area will investigate and make the proper determination. Often, Sponsors have a Special Investigations Unit (SIU) dedicated to investigating FWA. They may also maintain an FWA Hotline.
When in doubt, call your Compliance Department or the FWA Hotline.
Reporting FWA Outside of Your Organization: If warranted, Sponsors and FDRs must report potentially fraudulent conduct to Government authorities, such as the Office of Inspector General (OIG), the Department of Justice (DOJ), or the Centers for Medicare and Medicaid Services (CMS). Individuals or entities who wish to voluntarily disclose self-discovered potential fraud to OIG may do so under the Self-Disclosure Protocol (SDP). Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government- directed investigation and civil or administrative litigation.
Details to Include When Reporting FWA: When reporting suspected FWA, you should include:
•ntCo act information for the source of the information, suspects, and witnesses; • Details of the alleged FWA; • Identification of the specific Medicare rules allegedly violated; and •e Th suspect’s history of compliance, education, training, and communication with your organization or other entities. WHERE TO REPORT FWA
To report suspected fraud, waste and abuse call or contact any of the following:
FHCP’s Ethics & Concerns Help Line @ (386) 615-4080 or;
FHCP’s Member Services Department @ 1– 877–615-4022
HHS Office of Inspector General:
• Phone: 1-800-HHS-TIPS (1-800-447-8477) or TTY 1-800-377-4950 • Fax: 1-800-223-8164 • Email: [email protected] • Online: https://forms.oig.hhs.gov/hotlineoperations/index.aspx
For Medicare Parts C and D: • National Benefit Integrity Medicare Drug Integrity Contractor (NBI MEDIC) at 1-877-7SafeRx (1-877-772-3379)
For all other Federal health care programs: • CMS Hotline at 1-800-MEDICARE (1-800-633-4227) or TTY 1-877-486-2048 • HHS and U.S. Department of Justice (DOJ): https://www.stopmedicarefraud.gov FWA Correction:
Once fraud, waste, or abuse has been detected, it must be promptly corrected. Correcting the problem saves the Government money and ensures you are in compliance with CMS requirements.
Develop a plan to correct the issue. Consult your organization’s compliance officer to find out the process for the corrective action plan development. The actual plan is going to vary, depending on the specific circumstances. In general:
•s De ign the corrective action to correct the underlying problem that results in FWA program violations and to prevent future non-compliance; • Tailor the corrective action to address the particular FWA, problem, or deficiency identified. Include timeframes for specific actions; • Document corrective actions addressing non-compliance or FWA committed by a Sponsor’s employee or FDR’s employee and include consequences for failure to satisfactorily complete the corrective action; and • Once started, continuously monitor corrective actions to ensure they are effective.
Corrective Action Examples
Corrective actions may include:
• Adopting new prepayment edits or document review requirements; • Conducting mandated training; • Providing educational materials; • Revising policies or procedures; • Sending warning letters; • Taking disciplinary action, such as suspension of marketing, enrollment, or payment; or • Terminating an employee or provider. Indicators of Potential FWA Now that you know about your role in preventing, reporting, and correcting FWA, let’s review some key indicators to help you recognize the signs of someone committing FWA.
The following pages present issues that may be potential FWA. Each page provides questions to ask yourself about different areas, depending on your role as an employee of a Sponsor, pharmacy, or other entity involved in the delivery of Medicare Parts C and D benefits to enrollees. Key Indicators: Potential Beneficiary Issues • Does the prescription, medical record, or laboratory test look altered or possibly forged? • Does the beneficiary’s medical history support the services requested? • Have you filled numerous identical prescriptions for this beneficiary, possibly from different doctors? •e Isper thson receiving the medical service the actual beneficiary (identity theft)? •e prIs esth cription appropriate based on the beneficiary’s other prescriptions?
Key Indicators: Potential Provider Issues • Are the provider’s prescriptions appropriate for the member’s health condition (medically necessary)? • Does the provider bill the Sponsor for services not provided? • Does the provider write prescriptions for diverse drugs or primarily for controlled substances? •e proviIs th der performing medically unnecessary services for the member? •e proviIs th der prescribing a higher quantity than medically necessary for the condition? •e proviIs th der’s diag nosis for the member supported in the medical record? Key Indicators: Potential Pharmacy Issues
• Are drugs being diverted (drugs meant for nursing homes, hospice, and other entities being sent elsewhere)? • Are the dispensed drugs expired, fake, diluted, or illegal? • Are generic drugs provided when the prescription requires that brand drugs be dispensed? • Are PBMs being billed for prescriptions that are not filled or picked up? • Are proper provisions made if the entire prescription cannot be filled (no additional dispensing fees for split prescriptions)? • Do you see prescriptions being altered (changing quantities or Dispense as Written)?
Key Indicators: Potential Wholesaler Issues
• Is the wholesaler distributing fake, diluted, expired, or illegally imported drugs? • Is the wholesaler diverting drugs meant for nursing homes, hospices, and Acquired Immune Deficiency Syndrome (AIDS) clinics and then marking up the prices and sending to other smaller wholesalers or pharmacies?
Key Indicators: Potential Manufacturer Issues
• Does the manufacturer promote off-label drug usage? • Does the manufacturer provide samples, knowing that the samples will be billed to a Federal health care program?
Key Indicators: Potential Sponsor Issues
• Does the Sponsor encourage/support inappropriate risk adjustment submissions? • Does the Sponsor lead the beneficiary to believe that the cost of benefits is one price, only for the beneficiary to find out that the actual cost is higher? • Does the Sponsor use unlicensed agents? Lesson Summary:
• As a person who provides health or administrative services to healthcare enrollees, you play a vital role in preventing FWA. Conduct yourself ethically, stay informed of your organization’s policies and procedures, and keep an eye out for key indicators of potential FWA.
• Report potential FWA. Every Sponsor must have a mechanism for reporting potential FWA. Each Sponsor must be able to accept anonymous reports and cannot retaliate against you for reporting.
• Promptly correct identified FWA with an effective corrective action plan. Lesson Review: You have completed the Fraud, Waste, and Abuse training review, let’s do a quick knowledge check.
Knowledge Check #1: A person comes to your pharmacy to drop off a prescription for a beneficiary who is a “regular” customer. The prescription is for a controlled substance with a quantity of 160. This beneficiary normally receives a quantity of 60, not 160. You review the prescription and have concerns about possible forgery. What is your next step? Select the correct answer. ○ A. Fill the prescription for 160 ○ B. Fill the prescription for 60 ○ C. Call the prescriber to verify the quantity ○ D. Call the Sponsor’s compliance department ○ E. Call law enforcement
Answer: C
Knowledge Check #2: Your job is to submit a risk diagnosis to the Centers for Medicare & Medicaid Services (CMS) for the purpose of payment. As part of this job you verify, through a certain process, that the data is accurate. Your immediate supervisor tells you to ignore the Sponsor’s process and to adjust/add risk diagnosis codes for certain individuals. What should you do? Select the correct answer. ○ A. Do what your immediate supervisor asked you to do and adjust/add risk diagnosis codes ○ B. Report the incident to the compliance department (via compliance hotline or other mechanism) ○ C. Discuss your concerns with your immediate supervisor ○ D. Call law enforcement
Answer: B Knowledge Check #3: You are in charge of payment of claims submitted by providers. You notice a certain diagnostic provider (“Doe Diagnostics”) requested a substantial payment for a large number of members. Many of these claims are for a certain procedure. You review the same type of procedure for other diagnostic providers and realize that Doe Diagnostics’ claims far exceed any other provider that you reviewed. What should you do? Select the correct answer. ○ A. Call Doe Diagnostics and request additional information for the claims ○ B. Consult with your immediate supervisor for next steps or contact the compliance department (via compliance hotline, Special Investigations Unit (SIU), or other mechanism) ○ C. Reject the claims ○ D. Pay the claims
Answer B
Knowledge Check #4: You are performing a regular inventory of the controlled substances in the pharmacy. You discover a minor inventory discrepancy. What should you do? Select the correct answer. ○ A. Call local law enforcement ○ B. Perform another review ○ C. Contact your compliance department (via compliance hotline or other mechanism) ○ D. Discuss your concerns with your supervisor ○ E. Follow your pharmacy’s procedures
Answer: E Resources:
The MLN is home for education, information, and resources for the health care professional community. The MLN provides access to the Centers for Medicare & Medicaid Services (CMS) Program information you need, when you need it, so you can focus more on providing care to your patients. Serving as the umbrella for a variety of CMS education and communication activities, the MLN offers: 1. MLN Educational Products, including MLN Matters® Articles; 2. Web-Based Training (WBT) Courses (many offer Continuing Education credits); 3. MLN Connects® National Provider Calls; 4. MLN Connects® Provider Association Partnerships; 5. MLN Connects® Provider eNews; and 6. Provider electronic mailing lists.
The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS).
ACRONYM TITLE TEXT CMS Centers for Medicare & Medicaid Services MLN Medicare Learning Network® HYPERLINK URL LINKED TEXT/IMAGE https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN Educational Products MLN/MLNProducts https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN Matters® Articles MLN/MLNMattersArticles https://learner.mlnlms.com WBT Courses https://www.cms.gov/Outreach-and-Education/Outreach/NPC MLN Connects® National Provider Calls https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLN- MLN Connects® Provider Association Partnerships Partnership Applicable Laws for Reference:
Law Available At Anti-Kickback Statute https://www.gpo.gov/fdsys/pkg/USCODE-2015- 42 U.S.C. Section 1320a-7b(b) title42/pdf/USCODE-2015-title42-chap7-subchapXI-partA- sec1320a-7b.pdf Civil False Claims Act https://www.gpo.gov/fdsys/pkg/USCODE-2015- 31 U.S.C. Sections 3729–3733 title31/pdf/USCODE-2015-title31-subtitleIII-chap37- subchapIII.pdf Civil Monetary Penalties Law https://www.gpo.gov/fdsys/pkg/USCODE-2015- 42 U.S.C. Section 1320a-7a title42/pdf/USCODE-2015-title42-chap7-subchapXI-partA- sec1320a-7a.pdf Criminal False Claims Act https://www.gpo.gov/fdsys/pkg/USCODE-2015- 18 U.S.C. Section 287 title18/pdf/USCODE-2015-title18-partI-chap15-sec287.pdf Exclusion https://www.gpo.gov/fdsys/pkg/USCODE-2015- 42 U.S.C. Section 1320a-7 title42/pdf/USCODE-2015-title42-chap7-subchapXI-partA- sec1320a-7.pdf Criminal Health Care Fraud https://www.gpo.gov/fdsys/pkg/USCODE-2015- Statute title18/pdf/USCODE-2015-title18-partI-chap63-sec1347.pdf 18 U.S.C. Section 1347 Physician Self-Referral Law https://www.gpo.gov/fdsys/pkg/USCODE-2015- 42 U.S.C. Section 1395nn title42/pdf/USCODE-2015-title42-chap7-subchapXVIII-partE- sec1395nn.pdf
ECHO PROVIDER MANUAL TABLE OF CONTENTS
A. Manual Overview B. ECHO Overview C. ECHO Mission Statement D. Manual Updates 1. Policy and Procedures 2. Summary of Effected Changes 3. ECHO Code of Business Conduct of Ethics 4. 2017 General Compliance and Fraud, Waste, and Abuse (FWA) Training 5. Distribution Letter 6. Acknowledgment of Receipt (AOR)
E. ORGANIZATIONAL STRUCTURE
A. ECHO Organization Chart B. Quality Management Committee C. Peer Review Subcommittee D. Credentialing Subcommittee E. Utilization Management (UM) Subcommittee
2. CREDENTIALING AND RECREDENTIALING
A. ECHO Practitioner Guidelines 1. B. Practitioner Credentialing Requirements 2. D. Hospital Privileges 3. E. Health Care Delivery Organization Providers 4. F. Credentialing Appeals process Attachments
3. FACILITY SITE REVIEW
A. Facility Site Review and Medical Records Review Survey Requirements and Monitoring B. Physical Accessibility Review Survey (PARS)
4. MEDICAL RECORDS REQUIREMENTS
A. PCP and IPA Medical Records Requirements
1
B. Information Disclosure and Confidentiality of Medical Records C. Informed Consent D. Advance Health Care Directive
5. ACCESS STANDARDS
A. Access Standards B. Missed Appointments C. Access to Care for people with Disabilities (1) Members who are Deaf or Hard- of- Hearing D. Access to Sensitive Services E. Open Access to Obstetrical or Gynecological Services F. Cultural and Linguistic Services (1) Foreign Languages Capabilities (2) Spanish Language Competency Audits (3) Non-Discrimination Attachment
6. UTILIZATION MANAGEMENT
A. Utilization Management Monitoring B. Review Procedures 1. PCP referral tracking log 2. Standing Referral/ Extended Access to Specialty Care C. Second Opinions D. Emergency Services E. Pre- Service Referral Authorization Process F. Expedited Initial Organization Determination (EIOD) G. Acute Admission and Concurrent Review
7. COORDINATION OF CARE A. Care Management Requirements (1) Transition of Care (TOC) (2) Management of care
8. QUALITY MANAGEMENT
A. Quality Studies Medical Records Access B. Corrective Action Plan (CAP) Requirements C. Quality Management (QM) Reporting Requirements D. IPA Quality Management Program Structure Requirements E. Quality Management (QM) Program Overview for Members, Providers and Practitioners
2
9. PROVIDER NETWORK
A. IPA Medical Director Standards B. Leave of Absence C. ECHO Terminations of PCP’s and provider changes
10. CLAIMS PROCESSING
A. Sorting and Batching Claims B. Corrective Claim Determination C. Timely payment of non-contracted provider clean claims D. Claim denials
11. COMPLIANCE
A. Monitoring of First Tier Downstream and Related Entities B. IPA Performance Evaluation C. HIPPA Protected Health Information (PHI) D. Health Care Professional Advice to Members Attachments
3
INTRODUCTION
A. Manual Overview
The Elite Care Health Organization (ECHO) Provider Policy and Procedure Manual is designed to help ECHO’S Contracted Entities (Providers) understand hoe ECHO works and understand the rules and regulations ECHO must comply with, as governed by the California Department of Health Care Services (DHCS), California Department of Managed Health Care (DMHC), and The centers for Medicare and Medicaid Services (CMS). The provision of this manual must be adhered to by all ECHO’S Providers.
This Manual is intended to incorporate the statutory, regulatory and contractual requirements imposed by DHCS, DMHC, CMS and other agencies such as medical professional licensing boards. It is not intended to replace or exclude any statutory, regulatory or contractual requirements not stated herein.
In addition to the Provider Policy and Procedure Manual, a Federal link to the Benefit manual is included in the annual mailing to ECHO’S Contracted Entities. The Federal Benefit Manual is offered as a guideline to determine benefit eligibility and is not intended to be constructed as or to serve as a standard of medical care, or as a contractual agreement for payment.
The Delegate or Provider has the responsibility of ensuring the appropriate people in there organization review and understand the information contained in this Manual. Additionally, periodic updates are sent to keep the Manual current and our Providers informed of any policy changes.
ECHO holds training sessions for its providers to assist in learning ECHO policies and procedures as outlined in this Manual.
B. ECHO OVERVIEW
Elite Care Health Organization (ECHO) is a not for profit public entity that is a Health Maintenance Organization (HMO) beneficiaries residing in Riverside and San Bernardino Counties.
ECHO is a Knox-Keene licensed Health Plan and is regulated by the California Department of Managed Health Care (DMHC), the California Department of Health Services (DHSC), and the federal government’s Centers for Medicare and Medicaid Services (CMS). 4
C. MISSION STATMENT
Through operational excellence and passion, we relentlessly deliver the services and technology solutions necessary to empower, inspire and support our healthcare partners in their pursuit of exceptional patient care.
Vision:
To achieve nationwide growth as the premier management services organization (MSO) through competence leading quality, serving IPAs, Medical Groups, hospitals and value based entities.
Values:
Passionate about service quality and integrity with determination to embrace innovative physician and patient value systems.
Elite Care Health Organization, Inc. (ECHO) is a management services organization (MSO) that provides consulting and administrative services to independent physician associations (IPAs), medical groups and other risk-bearing organizations that contract with HMO plans for risk services. Partnership with Elite Care Health Organization empowers physicians to maintain their collective independence and fulfill their vision while enabling them to focus on their patients. Our delivery systems support IPA physicians and medical groups desiring to serve the medical needs of HMO Members in their communities.
D. Manual Updates
The Elite Care Health Organization (ECHO) Provider Policy and Procedure Manual (Provider Manual) is reviewed and updated in its entirety at least once a year. ECHO maintains and issues Manuals on CD that are distributed externally to contracting entities in accordance with Contractual and regulatory requirements.
The provider Manual annual update includes the following: A. Policy and Procedures Manual B. Summary of Effected Changes C. ECHO Code of Business Conduct and Ethics D. General Compliance and Fraud, Waste and Abuse (FWA) HIPPA Privacy and Security Training E. Distribution Letter F. Acknowledgement of Receipt (AOR)
5
Quality Management (QM) Committee
ROLE:
1. The QM Committee directs the continuous monitoring of all aspects of health care of being administered to ECHO Members, with oversight by the ECHO Chief Medical Officer and/or Medical Director. All Committee findings and recommendations for policy decisions are reported through the Chief Medical Officer to the ECHO Governing Board on an annual basis, or sooner if indicated. 2. Objectives of the QM Committee include: review, oversight and evaluation of delegated and non- delegated Quality Management (QM) activities, including the accessibility of health care services and actual care rendered; ensuring continuity and coordination of care; oversight of delegated activities such as Utilization Management, Quality Management, Grievance & Appeals; Credentialing/Re- Credentialing activities; facility and medical record compliance with established standards; Member Satisfaction; quality and safety of services; safety of clinical care and adequacy of treatment, Peer review, and utilization data are used identify and track problems, and implement corrective actions. The QM Committee monitors member interaction at all levels, representing the entire range of care, from the Member’s initial enrollment to final outcomes. 3. The QM Committee is responsible for annual review, update, and approval of the QM program description including QM policies, procedures and activities, providing direction for development of the annual Work Plan and Calendar and making recommendations for improvements to the ECHO Governing Board as needed. Ancillary Subcommittees are instituted to assist with study development as needed. The QM Committee receives updates from Peer Review, Credentialing, Utilization Management, Behavioral Health, Compliance, Quality Improvement, Delegation Oversight, and Pharmacy and Therapeutics Subcommittees at least quarterly or more frequently as indicated. The QM Committee reviews subcommittee activity reports and is responsible for periodic assessment and redirection of subcommittee activities and recommendations, with subsequent reporting to the ECHO Governing Board through the Chief Medical Officer as needed. 4. ECHO may delegate Quality Management and Improvement activities to those entities with current NCQA accreditation. The ECHO QM Committee provides oversight of these elected activities.
FUNCTION:
1. The following elements define the function of the QM Committee in monitoring and oversight for care administered to Members: a. Seek methods to increase the quality of health care for the served populations b. Design and direct QM Program objectives, goals, and strategies; c. Recommend policy decisions; d. Review, analyze, and evaluate results of QM activities at least annually and revise as necessary e. Identify and prioritize quality issues, institute needed actions and ensure follow-up f. Develop and assign responsibility for achieving goals; g. Monitor quality improvement h. Monitor clinical safety i. Provide oversight and direction for Subcommittees and related programs and activities; j. Oversee the identification of trends and patterns of care; 7
k. Monitor grievances and appeals for quality issues l. Develop and monitor Corrective Action Plan (CAP) performance. m. Report progress and key issues to the ECHO Governing Board, as needed n. Assess the direction of health education resources; o. Ensure incorporation of findings based on Member and Provider input/issues into ECHO policies and procedures; p. Review behavioral health care reports from quality issues; q. Review and approve clinical practice and preventive health guidelines; and r. Review the Program descriptions of contracted IPA’s and other delegate entities on an annual basis.
STRUCTURE:
1. The QM Committee is composed of IPA Medical Directors and other practitioners who are representatives for their physicians serve on Subcommittees that report to the QM committee. Additional representatives may include optometrists, public health representatives, pharmacist’s representatives, specialists, and ECHO staff. 2. Ancillary subcommittees are instituted to assist with study development as needed.
MEMBERSHIP:
1. Membership is comprised of the ECHO Chief Medical Officer or appointed Medical Director as Chairperson, ECHO Associate Medical Director as Chairperson, ECHO Associate Medical Directors, participating IPA Medical Directors, appointed representatives from the Public Health Departments of Riverside County and San Bernardino County, participating pharmacists, participating optometrists and a behavioral health practitioner. a. Prospective appointed physician and pharmacist Members of the Committee are subject to verification of license, and malpractice history prior to participating on the Committee. b. Prospective physician and pharmacist Members not providing requested information to perform verification in a timely manner, or who do not meet ECHO’s requirements upon verification in a timely manner, or who do not meet ECHO’s requirements upon verification may not participate on the Committee. 2. ECHO staff participating on the QM Committee consists of the following: Chief Officers, Directors, QM management, and other ECHO staff as necessary 3. ECHO staff participating on the QM committee have been selected to allow input and technical expertise related to Member and Provider experience, encounter data and to provide links back to other ECHO departments 4. The Medical Management Supervisor acts as secretary to the Committee 5. Regulatory agency representatives may attend QM Committee meetings according to contractual arrangements. 6. The ECHO Chief Medical Officer or designee selects Medial Directors, Physicians, Pharmacists, and Optometrists for committee Membership from the ECHO Provider Network
TERMS of SERVICE:
8
1. ECHO staff attend as permanent Members of the QM Committee. The full term for a QM Committee physician, pharmacist or optometrist Member is two (2) years, with additional terms as recommended by the entire Committee. Public Health Department representatives serve for two (2) years and are selected by each Health Department, with approval by the ECHO Chief Medical Officer. The determination of whether any practitioner Member may serve additional terms is at the sole discretion of the Chief Medical Officer or designee.
VOTING RIGHTS:
1. Voting rights are restricted to the Chairperson, ECHO Medical Directors and appointed Committee Members. ECHO staff, with the exception of the Chief Medical Officer, or designee and Medical Directors, do not have voting privileges.
QUORUM:
1. Voting cannot occur unless there is a quorum of voting Members present. For decision purposes, a quorum can be composed of one of the following: a. The Chairperson or ECHO Medical Director and two (2) appointed Committee Members. 2. An optometrist must be present for all vision related issues and a behavioral health Practitioner for any behavioral health issues 3. Non-physician Committee Members may not vote on medical issues.
MEETINGS:
1. The QM Committee meets at least quarterly, with additional meetings as necessary. Issues requiring immediate assistance that arise prior to the next scheduled WM Committee meetings are reviewed by the Chief Medical Officer and/or ECHO Medical Directors and reported back to the QM Committee when applicable.
MINUTES:
1. ECHO has a standardized format and process for documentation of meetings, attendees, and action items for the QM Committee and related Subcommittees. Detailed minutes are recorded at each meeting, with review by the Chairperson. Minutes include recommendations, actions and activities addressed in committee meetings. Minutes are dated signed, and reflect responsible persons for follow-up actions. Minutes are stored in a confidential and secure place with access only by authorized staff. The committee approves minutes at the next scheduled meeting. REPORTS:
1. QM Committee findings and recommendations are reported through the Chief Medical Officer to the ECHO Governing Board as needed or as requested. Information in the QM Summary reports sent to the ECHO Governing Board may include: Overview of Delegation Oversight Activities, Quality Management (QM) Reports, Review of Quality Management Annual Evaluation, Quality Management Program Description, and Quality Managements Work Plan. The Quality Management Work Plan includes yearly comprehensive plan of studies to be performed including studies that adequately address the health care and demographics pertinent to ECHO Members.
9
CONFIDENTIALITY:
1. All Members of the QM Committee, participating ECHO staff and guests are required to sign the Committee attendance record at each meeting which includes a statement of confidentiality and conflict of interest disclosure form, signed annually.
RECUSAL POLICY:
1. If a Member has an interest that may affect or be perceived to affect the Member’s independence of judgement, the Member must recuse himself/herself from the voting process. The recusal includes but is not limited to refraining from deliberation or debate, making recommendations, volunteering advise, and/or participating in the decision- making process in any way. 2. The Chairperson will review the criteria that Committee Members should use to determine whether to recuse themselves from the voting process at the beginning of each meeting and ask whether any Member need to recuse themselves.
AFFIRMATION STATEMENT:
1. The QM Committee attendance record signed by all QM Committee Members, ECHO participating staff and guests includes an affirmation statement acknowledging that utilization decisions made by the Committee for ECHO Members are based solely on medical necessity. ECHO does not compensate or offer financial incentives to practitioners or individuals for denials of coverage or service. The affirmation statement also addresses conflict of interest and confidentiality issues.
10
PEER REVIEW SUBCOMMITTEE
ROLE:
1. The Peer Review Subcommittee performs peer review for ECHO. This Subcommittee is responsible for reviewing Member, Practitioner or Provider grievances and/or appeals, Practitioner related quality issues including Facility Site and Medical Record Reviews, sanctioning, and other peer review matters as directed by the ECHO Chief Medical Officer. 2. The Subcommittee performs oversight of the credentialing activities of IPAs who have been delegated credentialing responsibilities and Providers directly credentialed by ECHO, including retrospective Practitioner quality reviews referred by the Grievance and Appeal Trend Review Committee, ECHO’s Chief Medical Officer for Practitioner or Provider appeals for adverse credentialing decisions. 3. The subcommittee monitors the ECHO Credentialing and Re-Credentialing Program and the grievance and appeals processes with recommendations for modification as necessary. 4. The responsibility of monitoring for Practitioner compliance and development of action plans regarding clinical quality issues, Practitioner quality of care concerns, and Practitioner grievances to address problem areas is appointed by the ECHO QM Committee to the Peer Review Subcommittee.
FUNCTION:
1. The following elements define the functions of the Peer Review Subcommittee in monitoring peer review matters: a. Serve as the committee for clinical quality review of Practitioners b. Evaluate, assess, and make decisions regarding Practitioner or Member grievances and clinical quality of care exception cases referred by the Grievance and Appeal Trend Review Committee, Chief Medical Officer, or ECHO Medical Director, as well as Practitioner or IPA credentialing or re-credentialing issues, sanctioning and develop or recommend action plans as required. c. Retrospectively review Practitioners with potential or suspected quality issues referred by the ECHO Medical Director that have been credentialed and approved for participation in ECHO’s network by IPA’s who have been delegated credentialing and re-credentialing activities and Providers directly credentialed by ECHO. d. Review Practitioners referred by the Grievance Trend Review Committee, Chief Medical officer, due to grievance and/or compliant trend review, other quality indicators, sanctions or other information related to Practitioners’ quality of care or qualifications; e. Review all Practitioner or Provider appeals related to clinical issues or adverse credentialing/re-credentialing decisions; f. Review, analyze and recommend any changes to the ECHO Credentialing and re- credentialing Program policies and procedures on an annual basis or as deemed necessary; and g. Monitor the delegated credentialing and re-credentialing process, facility review and outcomes for Practitioners and IPAs.
11
STRUCTURE:
1. The Peer Review Subcommittee is structured to provide oversight of quality of care concerns, delegated credentialing activities and the overall credentialing program to ensure compliance with the ECHO requirements. Practitioners with medically related grievances that cannot be resolved at the Provider level may address problems to the Subcommittee. Activities of the Subcommittee including minutes and appropriate reports are reported back to the QM Committee on a quarterly basis or more frequently for issues of a more serious nature. Providers that are suspended from Medi-Cal or are identified as a sanctioned Provider on the HHS-Office of Inspector General (OIG) report or are on the Medicare Opt-Out Report for Northern and Southern California, are reported to Compliance Committee. 2. The Peer Review Subcommittee meets at least quarterly, with additional meetings as necessary.
MEMBERSHIP:
1. Membership is comprised of the ECHO Chief Medical Officer and at least four (4) IPA Medical Directors or designated physician’s representative of network Practitioners. An Optometrist, Behavioral Health Provider and any other specialty not represented by Subcommittee Members serve on an ad hoc basis for related issues. a. Prospective appointed physician Members of the Subcommittee are subject to verification of license. Drug Enforcement Agency (DEA) and malpractice history prior to participating on the Subcommittee. b. Prospective physician Members not providing requested information to perform verification in a timely manner or who do not meet ECHO’s requirements upon verification may not participate on the Subcommittee. 2. ECHO staff participating on the Subcommittee consists of the Director of Network Management, Medical Management Supervisor, Credentialing Supervisor. 3. TERMS of SERVICE:
1. ECHO staff attends as permanent Members of the Peer Review Subcommittee. The full term for a Peer Review Subcommittee voting Member is two (2) years, with replacements selected from the ECHO network. The determination of whether any physician Subcommittee Member may serve additional terms is at the sole discretion of the ECHO Medical Director, with approval by the Subcommittee. The initial term(s) of Subcommittee Members are staggered to ensure consistent Subcommittee operation. VOTING RIGHTS:
1. All physician Subcommittee Members have voting rights. In case of a tic, the Credentialing Chairperson will have a vote. ECHO non-physician staff Members do not have voting privileges.
QUORUM:
1. Voting cannot occur unless there is a quorum of voting Members present. For decision purposes, a quorum can be comprised of one of the following:
12
a. The Chairperson, ECHO Chief Medical Officer, and three (3) appointed Subcommittee Members or; b. The Chairperson or ECHO Chief Medical Officer and two (2) appointed Subcommittee Members. 2. All specialists including optometry and behavioral health are available on an ad hoc basis for issues related to those fields. MINUTES:
1. The Medical Management Supervisor records in depth minutes at each meeting with review and approval by the Credentialing Supervisor and the ECHO Chief Medical Officer. Minutes include all activities addressed in Subcommittee meetings, including credentialing appeals and Practitioner improvement plans, grievances and resolutions, and reportable deficiencies with actions takes including status/completion of action plans. Minutes are dated, signed, and reflect responsible person for follow-up actions. Minutes are stored in a confidential secure location with access restricted to authorized staff only. CONFIDENTIALITY and AFFIRMATION STATEMENT:
1. All Members of the Peer Review Subcommittee, participating ECHO staff, and guests are required to sign the Subcommittee attendance record at each meeting, including a statement of confidentiality and a conflict of interest disclosure form, signed annually. It includes an affirmation statement acknowledging that utilization decisions are based solely on medical necessity and a statement that credentialing and re-credentialing decisions are not based solely on an applicant’s race, ethic/national identity, gender, age, sexual orientation or patient in which the Practitioner specialized. ECHO does not compensate or offer financial incentives to Practitioners or individuals for denials of coverage or service.
13
CREDENTIALING SUBCOMMITTEE
ROLE:
1. The Credentialing Subcommittee is responsible for reviewing individual Practitioners who are directly contracting with ECHO for denial or approval of Practitioner’s participation in the ECHO network. 2. The ECHO Quality Management Committee appoints the responsibility for reviewing and approving or denying individual Practitioner’s participation in the ECHO network, as applicable, to the Credentialing Subcommittee. FUNCTIONS:
1. The following elements define the function of the Credentialing Subcommittee in reviewing individual Practitioners for participation in the ECHO network: a. Review Practitioner qualifications including adverse findings, as applicable, and approve or deny participation in ECHO’s network for those Practitioners directly contracted with ECHO. b. Approve Practitioner’s continued participation in ECHO’s network every thirty-six (36) months in conjunction with re-credentialing. c. Ensure that the decision to credential and re-credential a Practitioner’s continued participation in ECHO’s network is conducted in a nondiscriminatory manner by not basing the decision on an applicant’s race, ethnic/national identity, gender, age, sexual orientation or the types of procedures (e.g. abortions) or patients (e.g. Medicaid) in which the Practitioner specializes. This does not preclude the organization from including in its network Practitioners who meet certain demographic or specialty needs. For example, to meet cultural needs of Members. d. Ensure that notification to approve or deny a Practitioner’s application occurs within sixty (6) days of the credentialing decision. e. Review, analyze, and recommend any changes to the ECHO Credentialing and re-credentialing Program policies and procedures on an annual basis or as deemed necessary. STRUCTURE:
1. The Credentialing Subcommittee is structured to provide review of Practitioners applying for participation with ECHO and to ensure compliance with ECHO requirements. Activities of the Subcommittee are reported to the QM Committee on a monthly basis or more frequently for issues of a more serious nature. MEMBERSHIP:
1. Membership is composed of an ECHO Medical Director or designee as Chairperson, Chief Medical Officer, at least four (4) multidisciplinary participating PCPs or specialty physician representative of network Practitioners. Any other specialty not represented by Subcommittee Membership including vision and behavioral health Practitioner serves on ad hoc basis for related issues. a. Prospective appointed physician Members of the Subcommittee are subject to verification of license, Drug Enforcement Agency (DEA) and malpractice history prior to participating on the Subcommittee.
14
b. Prospective physician Members not providing requested information to perform verification in a timely manner, or who do not meet ECHO’s requirements upon verification may not participate on the Subcommittee. 2. ECHO staff participating on the Subcommittee consists of the Director of Network Operations, Medical Management Supervisor, Credentialing Supervisor and other ECHO staff as necessary. 3. The Credentialing Supervisor acts as secretary to the Credentialing Subcommittee. TERMS OF SERVICE:
1. ECHO staff attends as permanent Members of the Credentialing Subcommittee. The full term for practicing primary care and specialist Subcommittee voting Members is two (2) years, with replacements selected from network Practitioners. The determination of whether any Practitioner Member may serve additional terms is at the sole discretion of the Chief Medical Officer and Medical Director, with approval of the Subcommittee, the initial term(s) of Subcommittee Members are staggered to ensure consistent Subcommittee operations. VOTING RIGHTS:
1. Voting rights are restricted to the Chairperson, the Chief Medical Officer and appointed Subcommittee Members (physician only). ECHO non-physician staff does not have voting privileges. QUORUM:
1. Voting cannot occur unless there is a quorum of voting Members present. For decision purposes a quorum can be composed of one of the following: a. The Chairperson, Chief Medical Officer, ECHO Medical Director, and three appointed Subcommittee Members; or b. The Chairperson, or Chief Medical Officer and two (2) appointed Subcommittee Members. MEETINGS:
1. The Credentialing Subcommittee meets monthly with additionally meetings as needed. MINUTES:
1. In depth minutes are recorded at each meeting by the Credentialing Supervisor and reviewed with ECHO Medical Director or designee. Minutes include all activities addressed in Subcommittee meetings, including credentialing and re-credentialing decisions, and other business related to credentialing and re-credentialing of Practitioners including thoughtful discussion and consideration of all Practitioners being credentialed and recredentialed before a credentialing decision is determined. Minutes are dated, signed, and reflect the responsible person to follow-up actions. Credentialing Subcommittee minutes are stored in a confidential and secure location with access only to authorized staff. REPORTS:
1. Updated of activities including minutes and appropriate reports are submitted to the QM Committee on a monthly basis, or more frequently as needed. CONFIDENTIALITY AND AFFIRMATION STATEMENT:
15
1. All Members of the Credentialing Subcommittee, participating ECHO staff, and guests are required to sign the Subcommittee attendance record at each meeting, including a statement of confidentiality and a conflict of interest disclosure form signed annually. It includes an affirmation statement acknowledging that utilization decisions are based solely on an applicant’s race, ethnic/national identity, gender, age, sexual orientation or patient in which the Practitioner specializes. ECHO does not compensate or offer financial incentives to Practitioners or individuals for denials of coverage or service.
16
UTILIZATION MANAGEMENT (UM) SUBCOMIITTEE
ROLE:
1. The UM Subcommittee directs the continuous monitoring of all aspects of UM and Care Management (CM), including the development of appropriate standards administered to Members, with oversight by the ECHO Chief Medical Officer and/or Medical Director. All Subcommittee findings and recommendations for policy decisions are reported to the Quality Management (QM) Committee through the Chief Medical Officer and/or Medical Director on a quarterly basis, or sooner if indicated. FUNCTION:
1. The function of the UM Subcommittee is to: a. Annually review and approve the UM and QM Program Description and applicable Work Plans. b. Annually review the UM and QM policies, procedures, and criteria utilized in the evaluation of appropriate clinical and behavioral health care services, coordination and continuity of care, and for DM interventions; c. Develop special studies based on data obtained from UM reports to review areas of concern and to identify utilization and/or quality problems that affect outcomes of care; d. Retrospectively evaluate potential over and underutilization issues through review of the UM data reports against thresholds including; bed-day utilization, physician referral patterns, Member and practitioner satisfaction surveys, readmission reports, length of stay, and referral treatment authorizations. Action plans in areas not meeting thresholds are developed including standards, timelines, interventions and evaluations. e. Regularly audits the process for monitoring consistency of application of criteria within the UM Department f. Require a regular audit process for monitoring QM and UM activities. g. Ensure that UM decision-making is based only on the appropriateness of care and services; h. Evaluate Member surveys for satisfaction with the UM process annually and report results to the QM Committee; i. Evaluate the effectiveness of the UM Program using data on Member and practitioner satisfaction; j. Identify potential quality issues related to UM or QM with subsequent reporting to the QM Committee; k. Assist in review of new technologies and new applications of existing technologies that are not primarily medication related proposed for inclusion as an ECHO benefit. l. Review literature and set standards for non-preventive / preventive clinical care guidelines with subsequent recommendation to the QM committee. m. Ensure that training and education on ECHO UM policies and procedures are available to UM staff, IPAs, or contract Practitioners and Providers. n. Facilitate UM education for Providers; o. Monitor CM, BH, and DM activities; and
17
p. Provide information to Contracts Administration regarding the local delivery system and new contract needs
STRUCTURE:
1. The UM Subcommittee provides oversight for the UM and QM Programs and is composed of IPA Medical Directors, ECHO Medical Directors, and Associate Medical Directors, or designees who are representatives for their practicing physicians. Additional representatives the Medical Management Supervisor and ECHO staff. . A Behavioral Health Practitioner is present for assistance with behavioral health issues and the behavioral health aspects of the UM program. These practitioners represent the appropriate level of knowledge to adequately assess and adopt healthcare standards. MEMBERSHIP:
1. Appointed Subcommittee Membership is comprised of the ECHO Chief Medical Officer, Medical Director or designee as Chairperson, Medical Directors, Associate Medical Directors or designated physician representatives of network practitioners. A Behavioral Health Practitioner is present for assistance with behavioral health issues and the behavioral health aspects of the UM Program. These practitioners represent the appropriate level of knowledge to adequately assess and adopt healthcare standards 2. ECHO staff participating on the UM Subcommittee include the following: Director of Health Administration, Clinical Director of UM, Operations Director of UM, UM Managers, Director of UM, Senior Director of Care Management, Senior Director of Healthcare Informatics, Senior Director of Pharmaceutical Services, Behavioral Health Medical Director, Director of Health Education, Clinical Pharmacist, QM Manager, Delegation Oversight Nurse, Director of Grievance and Appeals, and Care Management Manager. Additional staff attends on an ad hoc basis. 3. The Medical Management Supervisor acts as secretary to the Subcommittee 4. Prospective appointed licensed professional (optometrists, physicians, etc.) Members of the Subcommittee are subject to verification of license and malpractice history prior to participating on the Subcommittee 5. Prospective licensed professional Members not providing requested information to perform verification in a timely manner, or who do not meet ECHO’s requirements upon verification may not participate on the subcommittee. TERMS of SERVICE:
1. ECHO staff attends as permanent Members of the UM Subcommittee, the full term of service for non-ECHO physician Members is for two (2) years, with replacements selected from network physicians. Terms are staggered to ensure consistent Subcommittee operation. Members may be re-appointed to serve additional terms at the discretion of the ECHO Medical Director with approval by the Subcommittee. VOTING RIGHTS:
1. Voting rights are restricted to the Medical Director or designee as Chairperson and appointed physician Members. With the exception of the ECHO Chief Medical Officer and Medical Director, Medical Directors and Associate Medical Directors, ECHO staff Members do not have voting privileges. 18
QUORUM:
1. Voting cannot occur unless there is a quorum of voting Members present. For decision purposes, a quorum, can be composed of the following: a. The Medical Director or designee as Chairperson or the ECHO Chief Medical Officer, Medical Director and two (2) appointed Subcommittee Members. 2. An optometrist must be present for all vision related issues and the BH Medical Director or designee must be present for behavioral health related issues. MEETINGS:
1. The UM Subcommittee meets at least quarterly. Issues that arise prior to scheduled UM Subcommittee meetings that need immediate attention are reviewed by the Medical Director and reported back to the UM Subcommittee when applicable. 2. Interim issues requiring Subcommittee approval may be approved by an ad hoc teleconference meeting called by the Chair. MINUTES:
1. In-depth minutes are recorded at each meeting by a Utilization Management Administrative Assistance or Medical Services Coordinator, with review by the Medical Director. Minutes include Subcommittee activities addressed in Subcommittee meetings. Minutes are dated, signed, and reflect responsible person for follow-up actions. Minutes are stored in a confidential and secure place with access only by authorized staff. The UM Subcommittee approves minutes at the next scheduled meeting. REPORTS:
1. Updates of activities including minutes and appropriate reports and submitted to the QM committee on a quarterly basis, or more frequently as needed. CONFIDENTIALITY:
1. At each meeting, all UM Subcommittee Members, participating ECHO staff, and guests are required to sign the Subcommittee attendance record, including a statement of confidentiality and conflict of interest disclosure form. 2. All UM Subcommittee Members are held to honoring the privacy and security of Protected Health Information (PHI) AFFIRMATION STATEMENT:
1. At each meeting, each Subcommittee Member must sign an affirmation statement that UM decisions are based on appropriateness of care and service and their understanding that ECHO does not compensate or offer incentives to practitioners or individuals for denials. The affirmation statement also addressed conflict of interest and confidentiality issues. 2. ECHO abides by the California Health and Safety Code, Section 1371.8 that includes the following statement: “A health care service plan that authorizes a specific type of treatment by a Provider shall not rescind or modify this authorization after the provider renders the health care service in good faith and pursuant to the authorization. This section shall not be construed to expand or alter the benefits available to the enrollee or subscriber under a plan.”
19
20
CREDENTIALING AND RECREDENTIALING
APPLIES TO: This policy applies to Elite Care Health Organization Contracted (ECHO) Providers.
POLICY: A. IPAs are expected to use these guidelines for recommended education and/or training for PCPs and specialists, patient age ranges for practitioners, hospital arrangements, and recommendations for review of malpractice or other adverse history when making credentialing and recredentialing decisions. B. ECHO follows these same guidelines for practitioners directly credentialed by ECHO. C. ECHO and IPAs adhere to all procedural and reporting requirements under state and federal laws and regulations regarding the credentialing and recredentialing process, including the confidentiality of practitioner information obtained during the credentialing process. PROCEDURES:
A. Effective May 1, 2018, ECHO Credentialing guidelines require Providers to meet the internship and residency requirements to be a Pediatric, Internal Medicine or Family Practice, or Preventive Medicine Provider in order to be credentialed as a Primary Care Provider in ECHO’s network. Practitioners who have not completed internship and residency requirements will be credentialed as General Practice specialty. General Practice specialty is not a specialty recognized by the ABMS or the AOA. General Practice Practitioners will be credentialed in accordance with ECHO policy, by submitting the following documentation: 1. General Practice (All ages or 14 and above only) submitted prior to May 1, 2018, must meet the following criteria as indicated:
a. Facility Site Review (FSR)/Medical Record Review (MRR) Guidelines. PCP’s must pass all requirements for the FSR/MRR. Providers at a site without an active participating PCP must still have an FSR/MRR completed and passed to be considered a Non-Par Provider in the network. No PCPs or Non-Par Providers will be able to provide services at sites without completing an FSR/MRR. b. Education and Training Guidelines 1. Completion of one (1) year rotating internship or PGY-1 Family Practice;
c. Malpractice Insurance Coverage. Must have current and adequate malpractice insurance coverage that meets the following criterion: 1. Minimum $1 million per claim/$3 million per aggregate 2. Coverage for the specialty the Provider is being credentialed and contracted for 3. Coverage for all locations the Provider will be treating ECHO patients
21
B. ECHO and its Contracted IPAs must use the following guidelines when credentialing or recredentialing practitioners for participation in ECHO’s network.
1. PCPs – physicians being reviewed for credentialing as a PCP must meet the following criteria as indicated; a. Facility Site Review (FSR)/Medical Record Review (MRR) Guidelines. PCP’s must pass all requirements for the FSR/MRR MED_QM 6A. Providers at a site without an active participating PCP must still have an FSR/MRR completed and passed to be considered a Non-Par Provider in the network. No PCPs or Non-Par Providers will be able to provide services at sites without completing an FSR/MRR. b. Education and Training Guidelines 1. Family Practice (all Ages or 14 and above only) Must meet the education requirements set forth by the ABMS or AOA: Board certified Family Practice; Three (3) years training in family Practice; or One (1) year rotating internship plus two (2) years residency (PGY-2, 3) in Family Practice. 2. Internal Medicine (14 and above, 18 and above, or 21 and above) Must meet the education requirements set forth by the ABMS or AOA: Board certified in Internal Medicine; or Three (3) years training in Internal Medicine. 3 Preventive Medicine (18 and above or 21 and above) Must meet the education requirements set forth by the ABMS or AOA: Board certified in Preventive Medicine; or Completion of training requirements set by the ABMS or AOA for Preventive Medicine, to include, evidence of nine
(9) months direct patient care experience (completed during or after residency). The nine (9) months direct patient care is in addition to a twelve (12) month internship.
4. Family Practice Must have privileges at an ECHO network hospital and meet the following criterion: Board certified in Family Practice or three (3) years in training in Family Practice; Provide a written agreement (CPPA Addendum A) for an available back up Provider is required. The Provider must be credentialed, contracted and hold admitting privileges to the ECHO hospital linked with the Family Practice Provider; and c. Malpractice Insurance Coverage. Must have current and adequate malpractice insurance coverage that meets the following criterion: 1. Minimum $1 million per claim/$3 million per aggregate. 2. Coverage for the specialty the provider is being credentialed and contracted for. 3. Coverage for all locations the provider will be treating ECHO patients. 2. Practitioners outside of scope - occasionally Practitioners may practice outside of scope with approval from the by the ECHO Chief Medical Officer. Further review may be completed by the Peer Review Subcommittee who will either approve or deny. The Provider must submit the
22
documents referenced in this policy under Provider Privilege Adjustment, in addition to the following requirements: a. Education and Training Requirements 1. Internal Medicine Providers with expanded age range to all ages, will be processed with a secondary specialty of General Practice, if they provide the following information: Provide documentation of primary care practice in the United States for the past five (5) years which includes a mix of pediatric and adult patients. (See Attachment, “ECHO Addendum E” in Section 5); 2. Pediatric Providers with expanded age range to all ages, will be processed with a secondary specialty of General Practice, if they provide the following information: Provide documentation of primary care practice in the United States for the past five (5) years which includes a mix of pediatric and adult patients. (See Attachment, “ECHO Addendum E” in Section 5); b. Malpractice Insurance Coverage. Must have current and adequate malpractice insurance coverage that meets the following criterion: Minimum $1 million per claim/$3 million per aggregate. Coverage for the specialty the Provider is being credentialed and contracted for. Coverage for all locations the Provider will be treating ECHO patients. 3. Specialists – physicians being reviewed for credentialing as a Specialist must meet the following criteria: a. Education and Training 1. Board Certified in the specialty and subspecialty, if applicable. 2. If the practitioner is not board certified in the subspecialty in which he/she is applying, there must be evidence of verification of residency and training in the subspecialty (e.g. Fellowship in Cardiology, Rheumatology, Pediatric Endocrinology, etc.), as relevant to the credentialed specialty. 3. Specialties not recognized by either board are subject to Chief Medical Officer Review. Further review may be completed by the Peer Review Subcommittee who will either approve or deny. b. Hospital Admitting Privileges 1. Specialists must have full hospital admitting privileges or provide a written agreement (CPPA Addendum A) for an available back up Provider is required. The Provider must be credentialed, contracted and hold admitting privileges to the ECHO hospital linked with the Specialists Provider; and c. Malpractice Insurance Coverage. Must have current and adequate malpractice insurance coverage that meets the following criterion: 2. Minimum $1 million per claim/$3 million per aggregate. 3. Coverage for the specialty the Provider is being credentialed and contracted for. 4. Coverage for all locations the Provider will be treating ECHO patients. C. Patient Age Ranges
23
1. Patient age ranges for PCPs and non-physician practitioners must be specifically delineated as part of the IPA credentialing process. 2. Guidelines for age ranges for PCPs are: a. Pediatrics - ages 0-18 or 0-21. b. Family Practice - all ages, or 14 and above only. c. Internal Medicine - ages 14 and above, 18 and above, or 21 and above. d. Preventive Medicine – ages 18 and above or 21 and above. e. OB/GYN - ages 14 and above, restricted to females. f. General Practice – ages 14 and above or all ages ranges if evidence of pediatric training, experience and/or CME is present. 3. Guidelines for age ranges for non-physician practitioners which include Nurse Practitioners (NPs), Physician Assistants (PAs), Certified Nurse Midwives (CNMs), Physical Therapists (PT), Occupational Therapists (OT), Speech/Language Therapists (S/LT), Dieticians and Nutritionists are as applicable to the training and certification of the non-physician practitioner. 4. Patient age ranges for specialty physicians are specific to the specialty involved, training, and education of the physician. D. Provider Privilege Adjustment 1. Providers are required to submit a detailed explanation when requesting a change in practice parameters such as an expansion or education in Member age range specialty care privileges. 2. ECHO or the IPA will consider all relevant information including practice site demographics, Provider training, experience and practice capacity issues before granting any such change. 3. At a minimum, Provider submissions must include: a. A written explanation specifically outlining the material basis for the requested change; b. Documentation of any relevant training (e.g., Continuing Medical Education, post graduate/residency training, etc.); c. Practical experience relating to the request (e.g., years in clinical practice, direct care experience with the relevant membership, etc.); and d. All limitations or expansions of age ranges will be reviewed and approved by ECHO Medical Director or Chief Medical Officer. Further review may be completed by the Peer Review Subcommittee who will either approve or deny.
E. Adverse History Guidelines. ECHO and its Delegated IPAs must carefully review all practitioners with evidence of adverse history, including malpractice history, adverse licensing, privileges, sanctions or other negative actions. These discussions must be documented in the Credentialing Subcommittee, Peer Review Subcommittee or Quality Management meeting minutes while making a credentialing decision. The discussions include, but are not limited to the following: 1. Licensure Actions. Practitioners who have any adverse history and/or events with the Medical Board of California, Osteopathic Medical Board of California, Board of Podiatric Medicine, Board of Behavioral Sciences, Board of Psychology, California 24
Board of Chiropractic Examiners, Dental Board of California, California Board of Occupational Therapy, California Board of Optometry, Physical Therapy Board of California, Physician Assistant Committee, California Board of Registered Nursing, Speech-Language Pathology and Audiology Board, or nay appropriate licensing board, must be fully discusses and reviewed by the Credentialing Subcommittee or Peer Review Subcommittee. The reason for the adverse history and/or events must be considered during the credentialing decision making process. 2. Medical History. For practitioners with a history of malpractice suits or decisions, the following criteria warrants full ECHO Medical Director review of the history and should be applied in making credentialing and recredentialing decisions: a. Number of claims - any claims within the prior seven (7) years. b. Results of cases - any settlements within the prior seven (7) years. c. Trends in cases - practitioners with multiple malpractice claims in a similar area (e.g., missed diagnosis, negative surgical outcomes, etc.). d. Higher than average grievance rate or trend in grievances. 1) Provider has a greater than or equal to 2x ECHO overall grievance rate. 2) Provider has greater than or equal to 3 Level 1 grievances in the past twelve (12) months. 3) Provider has greater than or equal to 3 Level 2 grievances in past twelve (12) months. 4) Provider has 1 or more Level 3 or 4 grievances in past three (3) years. 3. Providers Excluded/ Sanctioned by Medicare or Medicaid (OIG). ECHO prohibits employment or contracting with practitioners (or entities that employ or contract with such practitioners) that are excluded/sanctioned from participation (practitioners found on OIG report). Providers identified on the OIG report, will not be credentialed or contracted, and terminated from our network if they are existing Providers. 4. Medicare Opt-Out Providers who are identified on the Medicare Opt-Out will not be contracted for Medicare line of business. 5. Loss of Clinical Privileges. Negative privilege actions or other negative actions against Providers (felony convictions, etc.) must be fully discussed and reviewed by the Credentialing Subcommittee. F. Practitioners can appeal adverse decisions by the ECHO Peer Review Subcommittee as delineated in ECHO’s Peer Review Process and Level I Review and Level II Appeal.
ECHO PRACTITIONER GUIDELINES
APPLIES TO:
25
This policy applies to all ECHO Providers.
POLICY:
A. ECHO provides all credentialing and recredentialing functions for Contracted IPAs.
B. IPAs are required to credential all of their contracted practitioners defined as PCPs, specialists, non-physician practitioners, and physician admitters, . At a minimum, this includes all Physicians (MDs), Osteopaths (DOs), Podiatrists (DPMs), Nurse Practitioners (NPs), Physician Assistants (PAs), Certified Nurse Midwives (CNMs), Physical Therapists (PT), Occupational Therapists (OT), Speech/Language Therapists (S/LT), Audiologists (AUD), Dieticians and Nutritionists (R.D.), Chiropractors (D.C.) who are contracted to treat Members and who fall within the IPA’s scope of authority and action. ECHO is required to credential all psychiatrists, psychologists, master level clinical nurses, Licensed Clinical Social Workers (LCSW), and Marriage, Family & Child Counselors (MFCC), and other behavioral health professionals licensed to provide behavioral health services in the state of California. ECHO requires IPAs to contract and credential Oral Surgeons (DDS or DMD) who provide medical services only (if applicable). ECHO does not require IPAs to credential practitioners that are hospital based and do not see Members on a referral basis. C. Verification of information submitted through one of the following means: 1. Verbal Verification - Requires a dated, signed document naming the person at the primary source who verified the information, his/her title, the date and time of verification and include what was verified verbally. 2. Automated Verification - Requires there be a mechanism to identify the name of the entity verifying the information, the date of the verification, the source, and the report date, if applicable.
3. Written Verification - Requires a letter or documented review of cumulative reports. The IPA must use the latest cumulative report, as well as periodic updates released by the primary source. The date on which the report was queried and the volume used must be noted. 4. Using the Internet for Primary Source Verification (PSV): PSV on documents that are printed/processed from an internet site (e.g. Breeze, NPDB, etc), the data source date (as of date, release date) must be queried within the timeframe. The date of the query must be verified prior to the Credentialing Decision. If there is no data source date, the verifier must document the review date on the verification or the checklist. Verification must be from an NCQA approved and appropriate state-licensing agency. 5. PSV Documentation Methodology. The organization may use an electronic signature or unique electronic identifier of staff to document verifications (to replace the dating and initialing of each verification) if it can demonstrate that the electronic signature or unique identifier can only be entered by the signatory. The system must identify the individual verifying the information and the date of verification
26
D. ECHO is required to verify the accreditation status, license, certification and standing with regulatory bodies of all subcontracted organizational Providers (as applicable), in compliance with the most current NCQA standards. Subcontracted organizational Providers include but are not limited to hospitals, home health agencies, laboratories, skilled nursing facilities, and freestanding surgical centers, including family planning facilities and alternative birth centers. Subcontracted mental health and substance abuse Providers include inpatient, residential, and ambulatory settings are carved out. E. IPAs must obtain approval of practitioners seeking participation with IPA from the ECHO Credentialing Committee and IPA Medical Director before submitting credentialed Primary Care Practitioners (PCPs) to health plans for review and assignment of Members. IPA credentialed and approved practitioners must meet ECHO practitioner guidelines for education, age limits and other criteria. F. IPAs must maintain a full credentialing file and perform all necessary credentialing activities per the most current ECHO, NCQA, State and Federal regulatory guidelines. Process to document IPA’s receipt and review of all documentation via date stamp and initials on the following: 1. Application; 2. Attestation; 3. Queries; 4. Copies of Licensures and Certificates; and 5. Any document containing practitioner signature. G. IPAs must submit specific credentialing information to ECHO for all PCPs and for all other practitioner as listed above. H. All PCPs must pass a required initial facility review performed by ECHO prior to receiving ECHO enrollment and treating Members. ECHO has ninety (90) days from the submission of all required credentialing information to complete the facility site review. I. ECHO is responsible for recredentialing contracted PCPs, non-physician practitioners, specialists, and admitting physicians as defined above every thirty-six (36) months from their last credentialing decision date. J. ECHO and IPAs are required to adhere to all procedural and reporting requirements under state and federal laws and regulations regarding the credentialing process, including the confidentiality of practitioner information obtained during the credentialing process.
PROCEDURES:
Credentialing Policies
A. The Credentialing Guidelines and Program specifies: 1. The types of practitioners it credentials and recredentials. At minimum, the IPA’s are required to credential and recredential Providers that fall under the following scope, Providers who are contracted, and treat the IPA Members and fall within the IPA’s scope of authority and action, which include but are not limited to:
27
a. Doctors of Medicine (M.D.) b. Doctors of Osteopathic Medicine (D.O.) c. Doctors of Podiatric Medicine (D.P.M.) d. Doctor of Dental Surgery (D.D.S.) or Doctor of Dental Medicine (D.M.D.), who provide medical services only e. Occupational Therapists (O.T.’s) f. Physical Therapy (P.T.) g. Physician Assistants (P.A.) or Physician Assistants Certified (P.A.-C) h. Certified Nurse Midwives (C.N.M.) i. Nurse Practitioners (N.P.) j. Speech Pathologists (S.P.) k. Audiologists (Au.) l. Registered Dieticians (R.D.) and Nutritionists 2. ECHO is required to credential all Behavioral Health Providers which include a. Psychiatrists (M.D.’s) b. Licensed Marriage and Family Therapists (L.M.F.T.) c. Licensed Clinical Social Workers (L.C.S.W.) d. Psychologists (Ph.D., Psy.D.)
3. ECHO does not require covering practitioners and locum tenens that do not have an independent relationship with ECHO or an IPA to be credentialed. ECHO does not require IPAs to credential practitioners that are hospital based and do not see Members on a referral basis. The policy and procedures must describe the verification sources and timeframes used to verify credentialing information of each of the following criterion: a. State License to Practice (Verification Time Limit (VTL): one hundred-eighty (180) calendar days prior to Credentialing decision date. Must be valid, current, and unencumbered at the time of committee and remain valid and current throughout the practitioner’s participation with ECHO). Failure to maintain a valid and current license at all times, will result in an administrative termination of the practitioner. All practitioners must be licensed by the State of California by the appropriate state licensing agency. The following license verifications must be obtained by the licensing board or their designated licensing and enforcement systems. The following licensures may be verified through BreEZe Online services online or directly with the licensing board via phone or mail: 1) Medical Board of California (M.D.) 2) Osteopathic Medical Board of California (D.O.) 28
3) Board of Podiatric Medicine (D.P.M.) 4) Board of Behavioral Sciences (L.M.F.T., L.C.S.W., M.F.C.C) 5) Board of Psychology (Ph.D., Psy.D.) 6) Dental Board of California (D.D.S., D.M.D.) 7) California Board of Occupational Therapy (O.T.) 8) California State Board of Optometry (O.D.) 9) Physical Therapy Board of California (P.T.) 10) Physician Assistant Committee (P.A., P.A.-C) 11) California Board of Registered Nursing (C.N.M., N.P.)
4. The following license verifications must be verified by the licensing board via online, mail or phone: a. California Board of Chiropractic Examiners (D.C.) b. Speech-Language Pathology & Audiology Board (S.P., Au) c. Acupuncture Board (L.Ac.) 1) DEA Certificate. 2) DEA Certificate or Controlled Dangerous Substance (CDS) certificate, as applicable. (VTL: one hundred-eighty (180) calendar days prior to Credentialing decision date. Must be valid and current at the time of committee and remain valid and current throughout the practitioner’s participation with ECHO). Failure to maintain an active DEA, may result in an administrative termination of the practitioner.
All practitioners who are qualified to write prescriptions, except non-prescribing practitioners, must have a valid and current DEA certificate. Verification may be in the form of a photocopy of the current DEA certificate or a query of the National Technical Information Service (NTIS) database .The copy of the practitioner’s certificate or query must be initialed and date stamped to show receipt prior to the credentialing decision.
ECHO may credential a practitioner whose DEA certificate is pending or pending a DEA with a California address, if the delegate has a documented process for allowing a practitioner with a valid DEA certificate to write all prescriptions requiring a DEA number for the prescribing practitioner until the practitioner has a valid DEA certificate.
If a practitioner does not have a DEA or CDS certificate, the delegate must have a documented process to require an explanation why the practitioner does not prescribe medications and to provide arrangements for the practitioner’s patients who need prescriptions requiring DEA certification.
Education and Training VTL: Prior to the Credentialing Decision) All practitioners must have completed appropriate education and training for practice in the U.S. or a residency program recognized by NCQA, in the designated specialty or subspecialty they request to be credentialed and contracted. The delegate
29
verifies the highest of the following three levels of education and training obtained by the practitioner, as appropriate.
If the practitioner is not board certified in the specialty or sub- specialty in which he/she is applying, there must be evidence of verification of residency and training in the sub-specialty (e.g. Fellowships in Cardiology, Rheumatology, Pediatric Endocrinology etc.), as relevant to the credentialed specialty. ECHO may use any of the following to verify education and training:
The primary source from the Medical School or through a clearinghouse The state licensing agency or specialty board if the state agency and specialty board, respectively, perform primary source verification. The organization obtains, at least annually, written confirmation of this fact, uses a printed, dated screenshot of the state licensing agency’s or specialty board’s website displaying the statement that it performs primary source verification of practitioner education and training information or provides evidence of a state statute requiring licensing to obtain verification of education and training directly from the institution. Sealed transcripts if the organization provides evidence that it inspected the contents of the envelope and confirmed that practitioner completed (graduated from) the appropriate training program. 3) Below are acceptable sources for physicians (M.D., D.O.) to verify Graduation from Medical School: AMA Physician Masterfile. American Osteopathic Association (AOA) Official Osteopathic Physician Profile Report or AOA Physician Master File. Educational Commission for Foreign Medical Graduates ECFMG) for international medical graduates licensed after 1986.
5. For Physicians (M.D., D.O.) ABMS or its Member boards, or an official ABMS Display Agency, where a dated certificate of primary-source authenticity has been provided. AMA Physician Master File. AOA Official Osteopathic Physician Profile Report or AOA Physician Master File. Boards in the United States that are not Members of the ABMS or AOA if the organization documents within its policies and procedures which specialties it accepts and obtains annual written confirmation from the boards that the boards performs primary source verification of completion of education and training. For other health care professionals o Registry that performs primary source verification of board that the registry performs primary source verification of board certification status. For Podiatrists (D.P.M.) o American Board of Foot and Ankle Surgery (formerly The American Board of Podiatric Surgery).
30
The American Board of Podiatric Medicine. o American Board of Multiple Specialties in Podiatry For Nurse Practitioners (N.P.) o American Association of Nurse Practitioners (AANP) o American Nurses Credentialing Center (ANCC) o National Certification Corporation for the Obstetrics, Gynecology and Neonatal Nursing Specialties (NCC) o Pediatric Nursing Certification Board (PNCB) o American Association of Critical-Care Nurses (AACN) For Physician Assistants (P.A.-C) o National Commission of Certification of P.A.’s (NCCPA) For Certified Nurse Midwives (C.N.M.) o American Midwifery Certification Board (AMCB) For Psychologists (Ph.D., Psy.D. o American Boar of Professional Psychology (ABPP)
6. Work History (VTL: one hundred-eighty (180) calendar days prior to Credentialing decision date)
Must obtain a minimum of the most recent five (5) years of work history as a health professional through the application, Curriculum Vitae (CV) or work history summary/attachment, providing it has adequate information.
Work history review must be documented on the application, CV, or checklist that includes the signature or initials of staff who reviewed work history and the date of review.
Documentation of work history must meet the following:
Must include the beginning and ending month and year for each work experience. The month and year do not need to be provided if the practitioner has had continuous employment at the same site for five (5) years or more. The year to year documentation at that site meets the intent. If the practitioner completed education and went to straight into practice, this will be counted as continuous work history. If the practitioner has practiced fewer than five (5) years from the date of credentialing. The work history starts at the time of initial licensure. The delegate must review for any gaps in work history. If a work history gap of six (6) months to one (1) year is identified, the delegate must obtain an explanation from the practitioner. Verification may be obtained verbally or in writing or in writing for gaps of six (6) months to one (1) year. Any gap in work history that exceeds one (1) year must be clarified in writing from the practitioner. The explanation of the gap needs to be sufficient to ascertain that the gap did not occur as a result of adverse and/or reportable situations, occurrences or activities. B. Malpractice Claim History
VTL:one hundred-eighty (180) calendar days prior to Credentialing decision date)
31
The delegate must obtain confirmation of the past five (5) years of malpractice settlements through one of the following sources:
Malpractice Insurance Carrier National Practitioner Data Bank Query Evidence of Continuous Query (formerly Proactive Disclosure Services (PDS). Continuous Query must be reviewed within one hundred-eighty (180) calendar days of the initial credentialing decision. Evidence must be documented in the file or on checklist. A minimum the five (5) years claim history must be reviewed for initial credentialing and all claim history activities after the previous credentialing decision date, will be reviewed for recredentialing. The five (5) year period may include residency and fellowship years. The delegate is not required to obtain confirmation from the carrier for practitioners who had a hospital insurance policy during a residency and fellowship.
C. Current Malpractice Insurance Coverage
(VTL: Must be evidence that the practitioner has current and adequate malpractice coverage prior to the Credentialing Committee date and remain valid and current throughout the practitioner’s participation with ECHO). Failure to maintain
current malpractice coverage for the specialty the Provider is being credentialed for and for all locations the practitioner will be treating IPAs patients, will result in an administrative termination of the practitioner.
All practitioners must have current and adequate malpractice insurance coverage that is current and meets ECHO’s standard of
$1 million/$3 million as well as the IPAs standards. The malpractice coverage must include coverage for the specialty the Provider is being credentialed for and for all locations the practitioner will be treating IPAs patients. Professional Liability Insurance coverage and amounts of coverage must be verified with the insurance carrier or through the practitioner via a copy of the policy and the signed attestation completed by the practitioner. The copy of the practitioner’s certificate must be initialed and date stamped to show receipt prior to the credentialing decision and to show it was effective at the time of the credentialing decision. If the specialty coverage and/or the locations are not identified on the malpractice insurance certificate, the coverage must be verified with the insurance carrier and documented in the practitioners file.
1. Hospital Admitting Privileges
(VTL: one hundred-eighty (180) calendar days prior to Credentialing decision)
All practitioners must have admitting privileges or appropriate admitter arrangements at a contracted Hospital, as necessary. Practitioners (in the appropriate specialties) must have a formal inpatient coverage
32
arrangement. If the practitioner does not have clinical privileges, a written statement delineating the inpatient coverage arrangement must be provided to IPA/ECHO. Specialties such as Dermatology, Podiatry, or Ophthalmology may not have hospital privileges, documentation must be note in the file as to the reason for not having privileges (e.g. A note stating that they do not admit as they only see patients in an outpatient setting is sufficient).
State Sanctions and Restrictions on Licensure and Limitation on Scope of Practice (VTL: one hundred-eighty (180) calendar days prior to Credentialing decision
Verification sources for sanctions or limitations on licensure include:
Chiropractors: State Board of Chiropractic Examiners CIN- BAD, NPDB . Oral Surgeons: State Board of Dental Examiners, or State Medical Board, NPDB. Physicians: Appropriate state board agencies, FSMB, NPDB Podiatrists: State Board of Podiatric Examiners, Federation of Podiatric Medical Boards, NPDB. Non-physician Healthcare Professionals: State licensure or certification board, appropriate state agency, NPDB.
Continuous Query (formerly Proactive Disclosure Service (PDS))
Evidence of current enrollment must be provided Report must be reviewed within one hundred eighty (180) calendar days of the initial credentialing decision Evidence of review must be documented in the file or on checklist
Medicare/Medicaid Sanctions
(VTL: one hundred-eighty (180) calendar days prior to Credentialing decision) Verification Sources for Medicare/Medicaid Sanctions: NPDB FSMB FEHB Program Department Record, published by the Office of Personnel Management, OIG List of Excluded Individuals and Entities (maintained by OIG) Medicare Exclusions Database State Medicaid Agency or intermediary and the Medicare intermediary Continuous Query (formerly Proactive Disclosure Service (PDS)) Evidence of current enrollment must be provided. Report must be reviewed within one hundred-eighty (180) calendar days of the initial credentialing decision. Evidence of review must be documented in the file or on checklist. For CMS only: OIG must be the verification source. Date of query and staff initials ust be evident on a checklist or the OIG page must be in the file
1) National Provider Identifier (NPI) Practitioners are required to maintain an individual NPI number, which must be verified through 33
CMS. The NPI number must be active while in the network and the Provider details must be kept current at all times, (i.e. Primary Practice Address must be registered to an address within California) Providers that have a group NPI number may submit that information to ECHO, in addition to the mandatory individual NPI number. 2) Facility Site Reviews All PCPs must pass an ECHO facility review at the time of initial credentialing. 2. The policy and procedures define the criteria required to reach a credentialing decision and are designed to assess the practitioner’s ability to deliver care, which may include but are not limited to:
a. A current and valid, unencumbered license to practice medicine in his/her state of practice. b. Appropriate malpractice claim history. c. Must not have engaged in any unprofessional conduct of unacceptable business practices. d. Absence of sanctions or restrictions on licensure. e. Current and valid DEA to practice in CA. f. Absence of use of illegal drugs. g. Absence of criminal history.
At minimum, the Credentialing Committee must receive and review the credentials of practitioners who do not meet the delegate’s established criteria. Policy must identify what is considered acceptable to be determined as a clean file, if the delegate utilizes a clean file process.
3. ECHO’s Policies and Procedures describe the process used to determine and approve clean files. They Medical Director or equally qualified practitioner is the individual with the authority to determine that a file is “clean” and to sign off on it as complete, clean and approved.
INITIAL CREDENTIALING
A. ECHO verifies that the following are within the prescribed time limits, for all credentialing applications: 1. A valid license to practice. 2. A valid DEA or CDS certificate, if applicable. 3. Education and Training.
34
4. Board Certification Status, if applicable. 5. Work History. 6. A history of professional liability claims that resulted in the settlement or judgment paid on behalf of the practitioner. 7. State sanctions, restrictions on licensure or limitations on scope of practice. 8. Medicare and Medicaid Sanctions. 9. Applications for credentialing include the following: a. Reasons for inability to perform the essential functions of the position; b. Lack of present illegal drug use; c. History of loss of license and felony convictions; d. History of loss or limitation of privileges or disciplinary actions; e. Current Malpractice Insurance coverage; and f. Current and signed attestation confirming the correctness and completeness of the application. 10. Hospital Admitting Privileges, if applicable. 11. Monitoring Physicians Who Have Opted Out: a. Initial Credentialing is only for those practitioners who are initiating a contract with the organization; and b. Practitioner Termination: If an organization terminates a practitioner and later wishes to reinstate, the organization must initially credential if there is a break in service for more than thirty (30) days.
RECREDENTIALING VERIFICATION
A. ECHO verifies that the following are within the prescribed time limits, for all credentialing and recredentialing applications:
1. A valid license to practice. 2. A valid DEA or CDS certificate, if applicable.
3. Board Certification Status, if applicable. 4. A history of professional liability claims that resulted in the settlement or judgment paid on behalf of the practitioner. 5. State sanctions, restrictions on licensure or limitations on scope of practice. 6. Medicare and Medicaid Sanctions. 7. Applications for credentialing include the following: a. Reasons for inability to perform the essential functions of the position;
35
b. Lack of present illegal drug use; c. History of loss of license and felony convictions; d. History of loss or limitation of privileges or disciplinary actions; e. Current Malpractice Insurance coverage; and f. Current and signed attestation confirming the correctness and completeness of the application. 8. Hospital Admitting Privileges, if applicable. 9. Monitoring Physicians Who Have Opted Out. 10. Review of Performance Information. B. ECHO includes information from quality improvement activities and Member complaints in the recredentialing decision-making process, to include but not limited to: 1. Quality activities (e.g. adverse events and data from quality improvement activities. Performance information may also include additional information such as: utilization management data, enrollee satisfaction surveys, other activities of the organizations). 2. Grievance/complaints: a. Late Recredentialing: Per NCQA, a practitioner cannot be initially credentialed if their recredentialing is past due. The exception is: If a practitioner is on active military assignment, maternity/medical leave or sabbatical. If the practitioner is on active military assignment, maternity/medical leave or sabbatical, recredentialing must be completed within sixty (60) calendar days of when practice is resumed.
b. Recredentialing: The delegate must formally recredential its practitioners within thirty-six (36) months through information verified from primary source verifications. Failure to meet the thirty-six (36) month time frame will result in the administrative termination of the practitioner. ONGOING MONITORING
A. ECHO requires IPAs to submit specific information on practitioner status to facilitate continuous monitoring of the IPA’s credentialing processes. ECHO monitors appropriate interventions by: 1. Collecting and reviewing Medicare and Medicaid Sanctions.
a. Reviewing the information within thirty (30) calendar days of its release. b. Following a consistent process for ongoing monitoring. c. Subscription to the sanctions alert service. 2. Collecting and reviewing sanctions or limitations on licensure.
36
a. ECHO is responsible for reviewing the information within thirty (30) calendar days for those boards that release on a set schedule. Any board that releases on a routine schedule (monthly/quarterly); this is considered a set schedule. b. Subscription to the sanction alert service. c. In areas where reporting entities do not publish sanction information on a set schedule, the delegate must query this information at least every six (6) months. d. If the reporting entity does not release sanction information reports, the delegate is required to conduct individual queries for any affected practitioner twelve to eighteen (12-18) months after the last credentialing cycle. 3. Collecting and reviewing complaints a. ECHO must investigate practitioner specific complaints from Members upon their receipt. b. ECHO must evaluate the practitioner’s history of issues, if applicable, at least every six (6) months. c. The IPA is responsible for notifying ECHO of any findings and the actions decided by the Credentialing Committee, to include (When the decision was made, IPA’s plan of action, frequency of monitoring (if applicable), and if any follows ups are scheduled). 4. Collecting and reviewing information from identified adverse events a. ECHO must monitor practitioner adverse events at least every six (6) months. b. ECHO may limit monitoring of adverse events to primary care physicians and high-volume behavioral healthcare Providers.
NOTIFICATION TO AUTHORITIES AND PRACTITIONER APPEAL RIGHTS
A. ECHO has policies and procedures that specify the following: 1. The range of actions available to the organization that may be taken to improve the practitioner performance before termination (i.e. Profiling, Corrective Actions, Monitoring, Medical Record Audit, etc). 2. Reporting to Authorities. Policies have clear procedures that describe what specific incidents are reportable to include, suspensions, terminations, restrictions, and revocations; how and when reporting to authorities occurs and to whom the incidents are reported, which should include, but not limited to: a. Appropriate Licensing Board; b. National Practitioner Data Banks; and c. Health Plans. 37
3. ECHO gives practitioners the right to appeal with the following steps of the appeal process: a. Provide written notification when a professional review action has been brought against the practitioner, reasons for the action and a summary of the appeal rights and process. b. Allow practitioners to request a hearing and the specific time period for submitting the request. c. Allow at least thirty (30) calendar days after the notification for practitioners to request a hearing.
d. Allowing practitioner to be represented by an attorney or another person of their choice.
1) A practitioner has the right to an attorney. 2) Policy cannot state that it is at the discretion of the chairperson for attorney representation. 3) Policy must state that the IPA cannot have an attorney, if the practitioner does not have attorney representation.
e. Appoint a hearing officer or a panel of individuals to review the appeal.
f. Provide written notification of the appeal decision that contains the specific reasons for the decision. E. Upon receipt of credentialing files, ECHO will begin the credentialing process. F. Once all credentialing information is received, ECHO schedules a facility site review, for all PCP practitioners. ECHO completes within 90 days of credentialing approval. G. If a practitioner is changing from one IPA to another, the new IPA must submit a complete credentialing profile within sixty (60) days of the effective date of the change. Failure to meet this timeframe will result in “freezing” the Provider to auto-assignment of Members. H. If a practitioner’s profile for initial or recredentialing is incomplete and/or missing supporting documentation, the profile is returned to the IPA via email explaining that the process is terminated for the practitioner until a new completed packet is received from the provider. I. ECHO completes a practitioner quality review within 90 days of credentialing approval.
FACILITY SITE REVIEW
APPLIES TO: This policy applies to all new PCPs. Initial site audits are conducted on patient care sites of new providers.
38
The same procedures for an initial site visit will be followed when a provider relocates, opens a new site, or based on needs identified by the QIC.
1. A site visit may be initiated at the direction of the Medical Director or the Quality Improvement Committee based on a complaint about an office. Member complaints regarding credentialed practitioners received via customer service, grievance and appeals, provider relations or other mechanisms of communication will be reported to QIC for review and consideration of onsite evaluation audits. 2. Follow up would be the same as documented in the procedure below and completed within two weeks from the date the complaint is received by ECHO/IPA/Medical Group. POLICY:
1. A systematic mechanism is utilized for assessing the setting in which primary care is provided to IPA/Medical Group Members. A structured review of the site and its practices is conducted to ensure compliance with the IPA/Medical Group standards for safety, cleanliness, confidentiality, timely access and enrollee satisfaction. Results of an Onsite facility evaluation will be included as part of the initial credentialing process. For Practitioners with multiple practice locations, each facility where IPA/Medical Group Members are treated will be assessed. Results of the Onsite facility evaluation will be part of on-going monitoring of practitioners’ facilities in response to member complaints. PROCEDURE:
1. The appropriate staff member will schedule audits in a timely manner and fax or mail the applicable audit tool to the office prior to the actual audit. See the Onsite Evaluation Tool Policy. 2. Components of the ECHO/IPA/Medical Group approved facility evaluation tool used in the assessment process include but are not limited to: a. Facility accessibility and appearance b. Facility waiting and examining room space c. Facility safety d. Medical Records keeping practices e. Appointment Availability f. Access/ Availability of proper equipment g. Medication storage/practices h. Radiology safety (where applicable) i. Laboratory Procedures 3. Practitioners must meet the minimum threshold score of 90% to be in compliance. Results are sent to the individual practitioners within 30 days of the audit. At the discretion of the reviewer, some deficiencies may be addressed during the on-site visit. Mandatory Follow up Visits will be initiated if any of the following events, indicators or deficiencies is found: a. Inadequate or non-compliant infection control practices or emergency protocols b. The provider or office manager requests a follow up visit c. Other deficiencies have been identified which by their nature require that resolution/correction be verified via a re-audit. d. At the recommendation of the Medical Director and/or the QI Committee 4. Practitioners whose scores fall below the minimum threshold of 90% must submit a corrective action plan to the QI Supervisor within 30 days of the site visit, addressing how deficiencies are to be corrected. If the practitioner does not appear to correct the issues, the QI Supervisor will
39
follow-up with written and/or telephonic communications to ensure compliance within the next 30 days. The QI Supervisor may also schedule a re-audit during this time. If a practitioner does not correct the deficiencies within the required time period, he/she will be referred to the Credentials/QI Committee for further action. 5. To compute the overall compliance score, divide the number of yes answers by the total number of yes + no responses and multiply by 100 to get the percentage score, i.e. TOTAL: YES x 100 = Percentage of Compliance TOTAL YES + TOTAL NO 6. Final audit results are tracked and trended. Upon the recommendation of the Credentialing/QI Committee, selected areas of non-compliance compiled from aggregate data computations may be identified for education intervention to the IPA/Medical Group physicians. If a Provider participates in more than one ECHO/IPA/Medical Group Service Area, the individual audit results will appear in each applicable ECHO/IPA/Medical Group Service Area report. 7. Office Site audit statistics are included in the Quality Improvement report that is submitted on quarterly basis to the QO Committee, the IPA/Medical Group Board of Directors.
MEDICAL RECORDS REQUIREMENTS A. PCP and IPA MEDICAL RECORD REQUIREMENTS
APPLIES TO:
A. This Policy applies to all ECHO IPA Clients.
POLICY:
A. ECHO is responsible for establishing medical record standards in the ECHO provider Policy and Procedures Manual and promulgating these to Providers and Primary Care Physicians (PCP’s). B. All Providers and practitioner offices must maintain policies and procedures consistent With state and federal laws and regulations for maintenance of Member medical records. 40
C. IPA’s are responsible for monitoring contracted practitioners for compliance with Medical records standards. D. ECHO Performs PCP Facility Site Review and Medical Record Review Surveys prior to site Participation. E. A Medical Record Review is performed at the time of the Facility Site Review if medical Records are available: otherwise, Medical Record Review is performed within ninety to One hundred eighty (90-180) days of the provider’s effective date with ECHO.
PROCEDURES:
IPA Responsibilities:
A. IPA’s are responsible for monitoring contracted Providers for compliance with all applicable ECHO related to medical records. 1. IPA medical record policies and procedures must be consistent with ECHO requirements. 2. IPA’S must ensure that contracted Providers have copies of medical record policies and Procedures available at the practice site. 3. IPA’s must assess medical record documentation and maintenance during the initial Credentialing site review. 4. IPA’s must implement Corrective Action Plans (CAP) for medical record deficiencies.
ECHO Medical Records Standards
A. Individual Medical Records - An individual medical record is created for each Member treated by an ECHO Provider or a practitioner. The medical record is designed to maintain a Member’s documented medical information of the care provided, as well as all ancillary services/diagnostic tests ordered by a Provider or a practitioner and all referred diagnostic and therapeutic services in a consistent, logical, and uniform manner. The same medical record may be used by other treating Providers or practitioners within the same group in order to provide conformity and coordination of Member care. This unique medical record must be updated by the Provider, practitioner or office staff with each Member visit or contact. Detailed behavioral health and substance abuse records may be filed separately to maintain confidentiality. B. Member Identification – Members should be linked to their individual medical records through an assigned unique identifier for filing purposes and to distinguish that record from any other Member record. Each page, test result, letter, and item of correspondence regarding that individual Member must contain the unique identifier, and Member (patient) name as a means of Member identification.
C. Audit Score- Medical Record Review Score results are as follows, on accordance with Department of Health Care Services (DHCS) requirements: Medical Record Review Survey: Total points will vary based on the type of charts Reviewed, i.e., Ped’s vs. Audit vs. OB, and the overall number of charts. The following Compliance level categories will apply: 1. Exempted Pass 90% and above with all individual section scores at 80 % or 2. Conditional Pass 80-89% or 90% and above with one or more individual Section score below 80%. 3. Fail Below 80%.
41
Full points are given if the scored element meets the applicable criteria. Partial points are not given for any scored element that is considered only “partially” met. Zero (0) points are given if an element does not meet criteria.
D. Member Demographics – Each medical record must contain a section for Member identification that includes name, age, employer, occupation, work and home telephone numbers, address, insurance information, marital status and emergency contact person information. E. Responsible Party – Physicians designate individuals responsible for record maintenance. Responsible parties must follow established protocols for the daily collection, research, retrieval, securing, maintaining, and transporting of medical records within the physician setting. F. Legal Document – The medical record is a legal document and all contents must be maintained in a confidential manner. G. Medical Record Maintenance – The Member medical record must be maintained in a current and detailed organized manner that reflects effective care of the Member and also facilitates quality review. H. Protection and Confidentiality – Physicians must limit medical records access to authorized practitioners and associated staff. Records must be maintained in a protective and confidential manner and are not readily accessible to unauthorized persons or visible to the general public. Practitioners and Providers must maintain policies and procedures to ensure appropriate record processing to prevent breach of protection or confidentiality or the unauthorized release of Member information to any internal or external person. Practitioners and Providers must educate staff regarding confidentiality and records maintenance policies and procedures and ensure that confidentiality statements are signed. I. Storage, Filing and Availability – Physicians must maintain an organized recordkeeping system to make the individual medical records available for each Member visit or contact including: collection, processing, maintenance, storage, retrieval, identification, and distribution. Records must be stored in a secured location either in the Physician’s office or in a central file area that is inaccessible to unauthorized persons. Physicians must maintain procedures to assign the unique identifier to each individual record and ensure that the appropriate record is pulled for each Member. Filing of records must be done in a consistent manner either alphabetically or by Member identifier number. Physicians must have written procedures for the disposition of medical records including designation of a person or persons responsible for record maintenance. In addition, procedures must outline the methodology for pulling requested records, methodology for tracking, the amount of notification time required, and system of distribution and collection. Physicians must have provisions for obtaining medical records on an emergency basis. Medical records are to be kept in a clean, secure environment and in good condition. J. Record Retention – Physicians must retain medical records pertaining to Members for a period of ten (10) years from the end of the fiscal year in which ECHO’s contract expires or is terminated. Pediatric medical records must be maintained for a minimum of ten (10) years or until the Member’s 19th birthday, but in no event for less than ten (10) years. All medical records, medical charts and prescription files, and other documentation pertaining to medical and non-medical services rendered to Members are subject to this requirement. K. Informed Consent for Treatment – Providers and Practitioners must obtain appropriate written consent for treatment prior to actual procedure performance including the human sterilization consent procedures required by Title 22, C CR, Section 51305.1 through 51305.6. Consent forms must
42
be completely filled out to include risk, benefits and alternative treatments, signed in ink, and retained in the Member’s medical records. If someone other than the Member signs the consent, the legal relationship should be noted on the consent form. Provider/practitioner staff must witness, sign, and date consent forms. Practitioners must not require a Member, as a condition of receiving health care services, to sign a consent that would permit the disclosure of medical information. Refer to Policy 7C, informed Consent”, for more information. L. Release of Information – Medical records contain confidential information that is not to be released to another party without the expressed written consent of the Member or legal representative. Providers must maintain procedures for obtaining written consent prior to release of copied records. The consent should be filed in the Member’s medical record and include: the purpose for the request, the information being requested, name of receiving or requesting party, the date when copies were released, a list of the copied portion of the medical record and the length of time the information is kept (for behavioral health services only). Member medical records must be made available to authorized reviewers per applicable state laws and regulations. Section 123110 of the Health & Safety Code states that any adult patient, or any minor patient who by law can consent to medical treatment is entitled to inspect patient records upon written request within five (5) working days after receipt of the written request. M embers are also entitled to copies of all or any portion of his or her records upon written request. Physicians must provide Members with copies within fifteen (15) days of the receipt of a written request. Physicians receiving medical records request from other Medical Providers must submit the medical records within fifteen (15) days of receiving the written request to avoid any delay in the Member’s care. Refer to Policy 7B, “Information Disclosure and Confidentiality of Medical Records,” for more information. The State has determined that a managed Medi-Cal Member can never be charged for any covered services, as outlined in Policy 18L, “Providers Charging Members.” As it is customary for physicians not to charge, ECHO encourages our practitioners to offer this as a complimentary service to other physicians. When absolutely necessary to charge another physician, the law allows only $0.25 per page and to limit a total charge to $20. M. Legibility and Maintenance - Providers must establish a uniform format to organize medical records and maintain all medical records in a consistent and comprehensive manner. Medical record entries are to be legible, made in a timely manner, dated, and signed by the appropriate Provider/practitioner or staff. Records may be maintained in hard copy format or electronically as long as they are easily accessible, have sufficient backup to prevent loss of information and have a unique electronic identifier for the author. The medical record must be legible to someone other than the author. N. Exam Information- Each medical record entry must contain all pertinent information related to the Member contact including all: complaints; symptoms, examinations results, medical impressions, Treatments, member condition, test results, and proposed follow- up. A subjective complaints, Objective finding, assessment, and plan (SOAP) format may be used to satisfy this requirement. O. Medical Record Contents- Physicians must maintain a complete and comprehensive medical record for each member. The record must include all Provider services rendered including all examinations, Member contacts, health maintenance or preventative services, laboratory and radiology test results or reports, procedures, ancillary services, off-site treatments, Emergency Room records, and hospital admission and discharge information. Correspondence regarding the Member’s medical condition, such as consultation records, specialist reports, and referrals, must also be included in the Member record. Pathology and laboratory/radiology reports must be included in the record with a special notation for all abnormal findings. Each page, insert, test, and lab entry must identify by Member
43
name and/or Member identifier. The medical record must include Member identification, biographical data, emergency contact information, and informed consents. P. Documentation standards- The ECHO documentation standards and goals for medical record maintenance are as follows: 1. Each page in the record contains the Member’s name and/or identification number. 2. Medication allergies and adverse reactions are noted in a consistent, prominent place. Otherwise, no known allergies or history of adverse reactions is noted. 3. Past medical history for Members seen more than three times is documented. This documentation includes serious accidents, operations and childhood illnesses. For children and adolescents (20.99 years and younger), past medical history relates to prenatal care, birth, operations and childhood illnesses. 4. The use of cigarettes, alcohol and history of substance abuse noted for Members age 12 and older (substance abuse history is queried for Members seen three (3) or more times) 5. Problem lists are maintained for Members with significant illnesses and/or conditions that are monitored. A chief complaint and diagnosis or probable diagnosis is included. 6. The history and physical examination records must include appropriate subjective and objective information pertinent to the Member’s presenting complaints. 7. Documentation of exams is appropriate for the medical condition. 8. All medications prescribed include the name, dosage, frequency, and route unless medication only comes in oral form. 9. Medications given on-site list name, dosage, and route as well as the site given, manufacturer’s name and lot number and whether the Member had a reaction to the medication. 10. Laboratory and other studies are ordered and documented, as appropriate. 11. All treatments, procedures, and tests, with results, are documented. 12. Working diagnoses are consistent with findings. 13. Treatment plans are consistent with diagnoses. 14. Notes have a notation, when indicated, regarding needed follow-up care, calls or visits. The specific time of return is noted in weeks, months, or as needed. 15. Unresolved problems from previous office visits are addressed in subsequent visits 16. Member education, recommendations and instructions given are included. 17. Pediatric Members’ (age 20.99 and under) records have a completed immunization record or notation of immunizations up to date. 18. An immunization history has been noted for adults 19. There is no evidence that the Member is placed at inappropriate risk by a diagnosis or therapeutic procedure. 20. Preventive screening and services are offered and documented in accordance with ECHO standards. 21. Referrals for specialty care or testing are noted, when appropriate. 22. Consultant notes are present, as applicable 23. Consultation, lab and imaging reports filed in the chart are initialed by the Provider or Practitioner who ordered them to signify they have been reviewed. Review and signature by professionals other than the ordering Provider or practitioner do not meet this requirement. If the reports are presented electronically or by some other method, there is also representation
44
of review by the ordering Provider or practitioner. Consultation, abnormal lab and imaging study results have an explicit notation in the record of follow-up plans. 24. For ages 18 years and older, as well as Emancipated Minors, documentation of Advance Directives discussion is present. Q. Completeness of the Medical Record – The medical record must be checked to assure that all ordered procedure and referral notes are returned and filed in the chart within three (3) working days of the visit, procedure, or receipt of the report/progress notes from any outside Provider or practitioner into the physician office. The Provider/practitioner must review and initial all test results and consultations and document follow-up treatment for abnormal lab results. R. Laboratory and Radiology Results – Providers must maintain procedures for filing laboratory and radiology results in the member’s medical record. STAT tests are to be performed and reported within twenty-four (24) hours. Physicians must have procedures for review of test results, notations of normal and abnormal results in the medical record, and documentation of instructions for follow-up. Providers must have guidelines identifying which staff member is authorized to notify Members of test results. tests performed by the provider or practitioner must have results documented in the medical record. S. Language Preference- Each medical record must include designation of primary languages and documentation of request or refusal of language interpretation services. Provider/practitioner documentation must be in English. T. Physician, Practitioners and Staff Entries and Signatures – Each entry including chief complaint and vital signs or member contact, including telephone conversation/advice noted in a member’s medical record must be dated and signed by the Provider/Practitioner and/or staff, if applicable, including the title of the person making the chart entry. This includes all therapies, procedures, and medications administered to a member. When documentation errors occur, the person that makes the error must correct the error in the following manner: 1. A single line is drawn through the error; 2. The corrected information is written as a separate entry and includes the following a. Date of the entry; b. Signature (or initials); and c. Title 3. There are to be no unexplained cross-outs, erased entries or use of correction fluid Both the original entry and corrected entry are to be clearly preserved. One Method used for correcting documentation errors is the S.L.I.D.E. Rule; Single Line, Initial, Date and Error. U. Follow-Up Care Documentation – Specific follow-up care instructions and a definite time for return visit or other follow-up care is appropriately documented in the Member’s medical record. The time period for return visit or other follow-up care is definitively stated in number of days, weeks, months or PRN. V. Advance Directives – Adult medical records that contain information regarding execution of advance directives such as a living will or Durable Power of Attorney for Health Care, for Members 18 years or older, as well as Emancipated Minors, must be prominently noted. Refer to Policy 7D, “Durable Power of Attorney for Healthcare,” for more information W. Preventive Health Screening and Individual Health Education Behavioral Assessment – Providers must have a system to notify Members of the need for an initial health assessment within one hundred twenty (120) days of enrollment to assess current medical conditions, institute any necessary 45
treatments, and outline preventive health care programs and within sixty (60) days of enrollment for Members under the age of 18 months. This offers the Member and Provider/practitioner an opportunity to discuss medical concerns and establish a baseline for future care. The initial preventive health screening includes a comprehensive history and physical exam, documentation of an Individual Health Education Behavioral Assessment (IHEBA) and any referrals to health education services. Specific notations must be made concerning use of cigarettes, alcohol, and substance abuse for Members age 12 or older. Included with the notation should be health education or counseling regarding such use. X. Follow-up Care for Referrals, Emergency Treatment, Hospitalization, Home Health Care, Skilled Nursing Facility (SNF) or Surgical Treatment Rendered at Surgical Center – The medical record must reflect continuity of care for any treatment, emergency or otherwise, rendered in a hospital, emergency room, urgent care, home health, SNF, or surgical center setting. Documentation must include the provisions for follow-up or continued treatment. Providers and practitioners must document referrals to specialists or waiver programs, treatments rendered or recommendations made and follow-up care to be instituted.
Monitoring: A. Audit Scope - The Medical Record Review Survey process is focused on Primary Care Providers. B. Audit Frequency - ECHO conducts a Medical Record Review Survey for Providers at the time of the Initial Facility Site Review Survey, when records are available or within ninety (90) days of the Provider effective date after the initial review. An additional extension of ninety (90) calendar days may be allowed only if the new Provider does not have sufficient Member assignment to complete a review of ten (10) medical records. If there are still fewer than ten (10) assigned Members at the end of six (6) months, a medical record review is completed on the total number of records available or on a sample chart and the scoring adjusted according to the number of records received. The Medical Record Review Survey evaluates compliance with ECHO Policies and Procedures and is conducted every three (3) years. C. Medical Record Information – The information in the medical record is evaluated and performance improvement actions required as necessary to ensure that the documentation is current, detailed, and organized and that it shows sound professional practice and appropriate preventive health education and referral. D. Medical Records Systems – Medical record systems for Providers are evaluated for adequacy and appropriateness by ECHO during the Site Review Surveys. The Medical Record Review Survey is utilized to gather information necessary to evaluate Provider and organization-wide compliance with ECHO approved medical record standards. E. Maintenance of Medical Record Policy - Each contracted Provider is responsible for maintaining medical record policies and procedures in compliance with ECHO, regulatory, and NCQA requirements.
ACCESS STANDARDS
APPLIES TO:
46
A. This policy applies to all ECHO Contracted Providers.
POLICY:
A. All applicable practitioners including Primary Care Physicians (PCPs), PCP/OBs, and Specialists must meet the access standards delineated below to participate in the ECHO network. B. ECHO monitors practitioner access to care through ECHO and IPA performed access studies, review of grievances and other methods. C. In accordance with Title VI of the Civil Rights Act and Title 42, Code of Federal Regulations, Section 442.110, all Members must receive access to all covered services without restriction based on race, ethnicity, national origin, religion, sex, age, mental or physical disability or medical condition, sexual orientation, claims experience, medical history, evidence of insurability (including conditions arising out of acts of domestic violence), disability, genetic information, or source of payment D. ECHO requires IPAs to provide covered services to all Members assigned to them at an appropriate facility without imposing restrictions as listed in C above. E. All IPAs are required to provide or ensure that twenty-four (24)-hour, seven (7) days a week access to medical care for Members is available, including after business hours telephone access to a PCP or a triage system utilizing specific licensed personnel. 1. For medical triage, licensed and trained screening or triage personnel include, Nurse Practitioners (NP) or Physician Assistants (PA). Physician backup must be available.
PROCEDURES:
A. Access Standards for Clinical Services - The following information delineates the access standards for availability of services to Members including primary care, specialty care, after hours emergency services, waiting times for appointments, and proximity of specialists and Hospitals to primary care.
2. Appointment Standards (see next page)
47
Primary Care Physician Type of Visit Timeframe Emergency Immediate disposition of Member to appropriate care setting Urgent Visit Forty-eight (48) hours
Urgent Visit, requiring authorization Ninety-six (96) hours
Non-Urgent, acute illness visit Three (3) business days, or as directed by physician Routine Non-Urgent Visit Within ten (10) business days of request
Well Child Visit Two (2) weeks Routine Physical Thirty (30) days
Initial Preventative Physical Exam Thirty (30) days within six (6) months of enrollment Routine Pelvic, Pap and breast exam Thirty (30) days
Follow up exam As directed by physician
Specialist Emergency Immediate disposition of Member to appropriate care setting Urgent Visit Forty-Eight (48) hours
Urgent Prenatal Visit Forty-Eight (48) hours
Urgent Visit, requiring authorization Ninety-six (96) hours Non-urgent, acute illness visit Three (3) business day, or as directed by physician Non-urgent, with a non-Physician Behavioral Within ten (10) business days of request Health Provider Non-Urgent ancillary services (for diagnosis Within fifteen (15) business days of request and treatment) Initial Prenatal Visit One (1) week
Routine Prenatal Care Two (2) weeks or as directed by physician
Routine Pelvic, Pap, and breast exam Thirty (30) days
Non-urgent appointments with specialist Within fifteen (15) business days of request physician Follow up exam As directed by physician
48
2. Preventive care services and periodic follow up care, including but not limited to, standing referrals to specialists for chronic conditions, periodic office visits to monitor and treat pregnancy and other conditions, lab and radiological monitoring for recurrence of disease, may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating licensed Health Care Provider acting within the scope of his or her practice. 3. Practitioner Office Waiting Time - For primary or specialist care, the waiting time for a scheduled appointment must be no longer than sixty (60) minutes. Waiting times for Members that are advised to “walk-in” to be seen must be no longer than four (4) hours 4. The applicable waiting time for a particular appointment may be extended if the referring or treating licensed Health Care Provider, or the health professional providing triage or screening services, as applicable, acting within the scope of his or her practice and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the enrollee 5. Proximity of Specialists, Hospitals, and other Providers to Sources of Primary Care - ECHO network specialists, pharmacies, Hospitals, and other Providers must be located within fifteen (15) miles or thirty (30) minutes travel time from assigned Members residence, as applicable, based on geographic regions. These proximity standards must be met whether using private car, public bus, hospital van, dial-a-ride, or Metrolink train transportation. 6. Proximity of PCPs to Members – ECHO network PCPs must be located within ten (10) miles or thirty (30) minutes travel time from assigned Members’ residence, as applicable, based on geographic regions. This proximity standard must be met whether using private car, public bus, hospital, van, dial-a-ride, or Metrolink Transportation. 7. Minimum Hours On-Site - The PCP must be on site and available for Member care a minimum of sixteen (16) hours per week, ” 8. Telephone Answer Time - All telephone calls to a PCP or Specialist must be answered within six (6) rings. Initial answer by an automatic answering system is acceptable if it has an option to directly access a live person 9. Telephone Hold Time – A Member must not be kept on hold for more than ten (10) minutes. If a Member is placed on hold, an employee should let the Member know the reason for the delay and offer the Member the choice to either wait or have his/her call returned within the timeframe specified in this policy. 10. Telephone Access Standards - When a Member leaves a message with the office of a PCP or specialist, requesting a return call, an employee of the office must attempt to return the Member’s call within the following timeframes and log that attempt: a. Within three (3) working days for a non-urgent matter (e.g. refills for medications that have not run out; requests for paperwork or medical records; requests for appointments for non-acute conditions b. No later than the same day for an urgent (non-emergency) matter (e.g. refills of critical medications which have run out; acute illness or acute complaint not already dealt with at the Provider’s office). c. A minimum of three (3) attempts must be made to return the Member’s call. It is understood that the same staff member or physician with whom the Member wishes to speak with, may or may not be the 49
party available to return the Member’s call. It is also understood that the staff member returning the call may or may not be able to definitively address the Member’s issue during that call. However, it will be expected that the staff member returning the Member’s call be prepared to do at least one of the following during that return phone call: 1) Determine the urgency of the Member’s request, solicit more information from the Member if needed, and act accordingly; 2) Reassure the Member if appropriate; 3) Agree to pass a message to the Member’s physician or to another relevant staff member if appropriate; and/or 4) Provide the Member with a timeline or expectation of when the request can be definitively addressed. d. This time requirement and policy for attempting to return Member phone calls three (3) business days for non-urgent, same day for urgent non-emergency, with a minimum of three (3) attempts is understood to be a minimal guideline; i.e this policy is not meant to over-ride more rigorous internal office policy, if one is already in place. e. Members who reach voice mail must receive detailed instructions on how to proceed. 11. Telephone Answer Time: All telephone calls to a PCP or Specialist Office must be answered within six (6) rings. Initial answer by an automatic answering system or individual’s voicemail is acceptable if it has an option to directly access live person. a. Telephone Hold Time – A Member must not be kept on hold for more than five (5) minutes. If a Member is placed on hold, an employee should let the Member know the reason for the delay and offer the Member the choice to either wait or have his/her call returned within the timeframe specified in this policy. 12. All PCP offices must have an active and working fax machine twenty-four (24) hours per day, seven (7) days per week.
B. EMERGENCY SERVICES – ECHO network physicians and Hospitals must provide access to appropriate triage personnel and emergency services twenty-four (24) hours a day, seven (7) days a week. 1. ECHO evaluates inappropriate use of Emergency Room services, issues regarding Member access to health care, and under- or over-utilization of services through assessment of encounter data, special studies, claims information, and medical record audits with oversight of the Quality Management (QM) Committee.
C. EMERGENCY MEDICAL CONDITION - This is a medical condition which is manifested by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
1. Placing the health of the individual (or in the case of a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; or 2. Serious impairment to bodily function; or 3. Serious dysfunction of any bodily organ or part.
50
D. URGENT CARE SERVICES - These are health care services needed to diagnose and/or treat medical conditions that are of sufficient severity that care is needed within forty-eight (48) hours, but are not emergency medical conditions. E. URGENT VISIT – These are referrals to health care professionals who have advance education and training in a specific area but are not emergency medical conditions. Visits requires prior authorization within ninety-six (96) hours. F. FOLLOW UP OF ED OR URGENT CARE VISITS – ECHO is responsible for informing PCPs of Members that receive an ED or Urgent Care visit when notified, including information regarding needed follow- up, if any. PCPs are responsible for obtaining any necessary medical records from such a visit, and arranging any needed follow-up care. G. ROUTINE NON-URGENT VISIT – These are health care services needed to diagnose and/or treat medical conditions that do not need urgent care or non-emergent attention. These visits are used for routine check-ups and can be scheduled within ten (10) business days of request H. NON-URGENT, ACUTE ILLNESS VISIT - These are health care services needed to diagnose and/or treat medical conditions that are of sufficient severity to be addressed within three (3) days, however, they do not warrant an urgent care visit I. PHYSICAL EXAM – This is a routine preventive exam occurring every, one to three (1-3) years. These visits must be scheduled within thirty (30) days. J. WELL-CHILD VISIT - These are periodic health care services needed to provide preventive health services for Members under the age of 21 years. These visits must be scheduled within two (2) weeks K. WALK – IN CLINIC VISITS - If an ECHO Member is informed by the PCP or the PCP’s office staff that they may “walk-in” on a particular day for routine, non-urgent or non-urgent acute visits, the ECHO Member must be seen at that office on the same day in which the Member was advised to come in, and must not have a wait time in excess of four (4) hours L. URGENT PRENATAL - These are health care services needed to diagnose and/or treat actual or perceived prenatal conditions that are of sufficient severity that care is needed within forty-eight (48) hours, but are not emergency medical conditions. M. INITIAL PRENATAL - These are health care services needed to determine potential risk factors and the care plan for a woman during the period of pregnancy. This exam must take place within one (1) week of confirmation of pregnancy. N. ROUTINE PRENATAL CARE - These are routine medical visits throughout the period of pregnancy. These visits consist of periodic exams and monitoring for the determination of the condition of both the fetus and the mother. These visits should be scheduled within two (2) weeks or as directed by the physician in order to detect any untoward changes in the condition of the fetus or mother so that necessary treatment may be initiated. O. NON – URGENT SPECIALIST APPOINTMENT - These are referrals to a health care professional who has advanced education and training in a specific area. The appointment to the specialist is to be scheduled within fifteen (15) business days of request unless otherwise indicated by the referring physician. P. MEDICAL TRIAGE SCREENING AND ADVICE DURING BUSINESS HOURS - All PCP sites must have licensed staff available for telephone or on-site triage for Members during normal business hours. Triage and screening waiting time must not exceed thirty (30) minutes. Waiting time may be extended if the trained, licensed staff has determined and documented that a longer waiting time will not have a detrimental impact on the health of the Member and has informed the Member when the triage and screening will be completed. Approved licensed triage personnel include RNs, NPs, or PAs. ECHO has 51
not developed specific triage protocols; it is expected that all licensed triage personnel use appropriate medical judgment in determining the disposition of the patient (e.g., treat at office, refer to Urgent Care, Emergency Department, or call 911). There must be sufficient information on how to proceed for Members who reach voice mail. Q. MISSED APPOINTMENTS - ECHO network practitioners must maintain procedures to identify and follow-up on missed appointments, including staff training. Missed and/or rescheduled appointments must be scheduled appropriate to the health care and continuity of care and needs of the Member. R. HOSPITAL STANDARDS - All contracted Hospitals must provide timely access for ECHO Members accessing Emergency Departments, being admitted for an inpatient stay, or utilizing hospital based diagnostic or treatment services. Hospital based clinics must meet all the primary care and specialty access standards delineated above. S. PROVIDER SHORTAGE - If timely appointments within the time or distance standards required are not available, then the IPA shall refer Member to or assist in locating available and accessible contracted Provider to obtain the necessary health care services in a timely manner appropriate for the Member’s needs
SPECIAL ACCESS STANDARDS
A. The following information outlines the standards for special access needs for Members including sensitive services and access for the disabled and hearing impaired, as well as behavioral health, and special programs: 1. Sensitive Services for Minors and Adults - Providers and practitioners must have procedures to ensure that minors and adults have access to sensitive and confidential services minors and adolescents have the right of access to treatment and/or referral for sensitive services without parental consent. Sensitive services include: access to family planning, STI, and HIV testing and counseling services from qualified family planning Providers or the Local Health Department (LHD). Sensitive services for minors include sexual assault, drug or alcohol abuse, pregnancy, family planning, sexually transmitted diseases, and behavioral health care. 2. Access for People with Disabilities - All ECHO facilities and practitioners are required to maintain access in accordance with the requirements of Title III of the Americans with Disabilities Act of 1990. Each PCP’s office is assessed to identify if barriers to Member care exist during the site reviews. Areas audited include but are not limited to: designated parking spaces, wheelchair access, restroom and drinking fountain access for wheelchair users, handrails near toilets, appropriately placed telephones, and appropriate signage. If a practitioner’s office or building is not accessible to Members with disabilities, an alternative access to care must be provided. 3. Access and Interpretation Services for People with Hearing Impairments and/or Limited English Proficiency - All ECHO network Providers and practitioners, including network pharmacy and vision practitioners, must provide services to limited English proficient Members in the Member’s primary language. For face-to-face interpretation services, including sign language, practitioners must provide interpreters, as needed, for Members appointments. 4. Interpretation Services - All Providers must provide services to limited English proficient Members in the Member’s primary language.
52
a. These linguistic capabilities must be available to Members twenty-four (24) hours a day, seven (7) days a week. b. During the process of adding a physician to ECHO’s network, all physicians are asked to indicate their foreign language abilities. Assignment of Members to PCPs able to communicate in the Member’s preferred spoken language is done whenever possible. c. Providers may use face-to-face interpreters or telephonic interpretation services to meet the requirement of providing linguistic services to Members. d. Providers are encouraged to have bilingual practitioners and staff. e. f. 5. Access Standards for Behavioral Health Services – The following information delineates the access standards for availability of services to ECHO Members for Behavioral Health care and after-hours emergency services. a. Appointment Standards:
b. After hours Access for Behavioral Health Care” 1. All Behavioral Health Providers are required to have an automated answering system twenty-four (24) hours a day, seven (7) days a week, to direct Members to call 911 or to go to the nearest Emergency Room for any life threatening medical or psychiatric emergencies.
Behavioral Health Type of Visit Timeframe Life- threatening emergency Immediate disposition of Member to appropriate care setting Non life-threatening emergency Six (6) hours
Urgent behavioral health needs Within forty-eight (48) hours
Urgent behavioral health visit, requiring Within forty-eight (48) hours authorization Initial routine (non-urgent) visit with a Within ten (10) business days of request Behavioral Health Care Provider Follow-up routine (non-urgent) Within ten (10) business days of request
MONITORING
A. ECHO will annually assess the access standards of Primary Care Physicians, high volume Specialists, Behavioral Health, and Ancillary Providers using the Department of Managed Health Care (DMHC) Provider Appointment Availability Survey Methodology. This methodology includes the use of the DMHC Provider Appointment Availability Survey for Primary Care Physicians, Specialty Care Physicians and Non-Physician Mental Health Providers. The DMHC’s Provider Appointment Availability Survey Methodology with a modification. For Primary Care Physicians, the Plan will not perform a sampling of the Providers. Instead, the Plan will survey all active Primary Care Physicians. ECHO will follow the 53
sampling methodology as outlined by the DMHC for Specialty Care and Ancillary Care Providers. ECHO will separately report a rate of compliance for each of the time elapsed standards for each IPA located in each county of ECHO’s service area annually using the DMHC Provider Appointment Availability Survey Methodology and the DMHC Provider Appointment Availability Survey tools for Primary Care Physicians, Non-Physician Behavioral Health Providers, Specialty and Ancillary Care Providers (See Attachments, “DMHC Provider Appointment Availability Survey Methodology” and “DMHC Appointment Availability Survey Tools in Section 9). ECHO may utilize a 3rd party survey vendor to implement all or part of the DMHC Provider appointment Availability Survey methodology.
CORRECTIVE ACTION PLAN
A. ECHO reviews results of each audit or study and identifies deficiencies as noted in ECHO policies and procedures B. ECHO requests CAPs to be submitted addressing deficiencies according to established policy or as otherwise directed by ECHO. The CAP must be submitted to ECHO within thirty (30) calendar days of written notification by ECHO of the audit results. C. ECHO will provide advance written notice to contracted Providers affected by a CAP, including a description of the identified deficiencies, the rationale for the corrective action, and the name and telephone number of the person authorized to respond to Provider concerns regarding the plan’s corrective action D. Failure to submit CAPs may result in one of the following activities, depending on the seriousness of the deficiency: 1. Delegate is frozen to new Member enrollment 2. Request for cure under contract compliance 3. Requirement to subcontract out the deficient activities within MSO or Delegate; 4. De-delegation of specified functions; 5. Contract non-renewal; or 6. Contract termination Delegates can appeal the results of any oversight activity or specialized study or audit.
REFERENCES:
A. Civil Rights Act of 1964 § 7 B. 42 Code of Federal Regulations § 442.110 C. Title III of the Americans with Disabilities Act of 1990
54
Utilization Management
APPLIES TO: A. This policy applies to all ECHO clients
POLICY:
• Provide a system to ensure that medical services are delivered at the most appropriate level of care in a timely, effective, and efficient manner consistent with the delivery of quality of care • Track and trend ER Utilization, Bed Days, Behavioral Health Coordination, Pharmacy Services, Outpatient Services, HEDIS/P4P will be done • Follow written policies and procedures that reflect medical coverage rules, practice guidelines, and current standards of medical practice when processing requests for initial or continued authorization of services • Has in effect a mechanism to continuously monitor both underutilization, over utilization of services and inefficient coordination of medical resources. • Has in effect mechanisms to ensure consistent application of review criteria and compatible decisions • Has a clinical peer review decision to deny authorization on grounds of medical appropriateness; • Does not structure UM activities so that they provide inappropriate incentives for denial (e.g., no money paid for denial of medically necessary services), limitation, or discontinuation of authorized services. • Does not prohibit providers from advocating on behalf of members within the UM process. • Comply with national and local coverage decisions, general Medicare coverage guidelines, and written coverage decisions of local Medicare contractors. • Continually monitors, evaluates, and optimizes healthcare utilization resources by applying UM policies and procedures to review medical care and services. • Monitor both inpatient and outpatient care for possible quality of care deficiencies and to utilize referral indicator screening criteria. Document and submit to the Quality Improvement Committee (QIC) (If delegated; if not submit to health plans' QIC) all potential deficiencies. • Educate contracted practitioners on the policies and procedures of UM to ensure compliance with the policies, procedures, goals, and objectives of the UM Program. • Assure payors and other regulatory agency guidelines, standards and criteria are
55
adhered to, when applicable. • Comply with Federal laws and requirements, including the Civil Rights Act, ADA, Age Discrimination Act, and Federal Funds Laws. • Monitor utilization practice patterns of contracted practitioners to identify variations and continuously review the performance of health care personnel, the utilization of services and facilities and cost through Provider Network, Inter- rater Reliability audits, High Dollar monitoring, etc • Conduct medical review of all potential denials of services, including denials due to non- eligibility • Provide all medically necessary care within the contracted network of practitioners • Identify high-risk members and ensure appropriate care is delivered by accessing the most efficient resources through proactive planning and prevention and providing a treatment continuum. • Facilitate communication and develop positive relationships between members, practitioners, and health plans by preserving the patient-practitioner relationship and providing education related to appropriate utilization. • Implement procedures to prevent the re-occurrence of problematic utilization issues. UM department will work along with QM staff to resolve any issues that prevent quality service or care
PROCEDURE:
Elite Care Health Organization shall conduct the following activities to ensure accomplishment of the goals:
Assess Utilization Policies and Procedures against external requirements and standards. Expand existing Policies and Procedures as necessary to meet regulatory requirements. Create I revise policies and procedures as required and present for approval through appropriate committee structure at least annually. Develop a system to track, compile, evaluate, and compare utilization statistical information to benchmarks. Measure improvement opportunities. Develop corrective action plans as issues are identified. Develop and coordinate an internal system, which documents the interface for referring quality issues from UM to Quality Improvement. Develop and implement a system to track and monitor quality issues that are referred from UM to Quality Improvement. Analyze indicators, such as bed days and Length of Stay (LOS) for trends and comparisons with standards. Provide UM reports to practitioners Assess, evaluate, and share utilization data as a method of educating practitioners to promote growth and develop through monthly educational meetings. Develop a system of monitoring the referral turnaround time frames Develop and implement a system to link practitioner and member satisfaction survey results to the UM process.
56
Provide alternative suggestions of treatment to the physician when a service is denied based on the medical information submitted. Document current review on all hospitalized and skilled nursing patients to reflect the medical necessity of continued stay. Initiate discharge planning prior to, or on the day of, the hospital admission by identifying the individual needs of those members which will facilitate a timely discharge to a lower level of care with efficiency... Identify 'high risk' members and work with the network providers to ensure the delivery of appropriate care by using the most efficient resources. Integrate established Health Plan Care Management Programs into the existing Case Management Program as appropriate
CONFIDENTIALITY Due to the nature of routine UM operations, Elite Care Health Organization (ECHO) has implemented policies and procedures to protect and ensure the confidential treatment of personal and health information of members and privileged medical record information. Upon employment, all ECHO UM employees, including contracted professionals who have access to confidential or member information sign a written statement delineating responsibility for maintaining confidentiality. In addition, all UM staff, UMC members and new employees upon hire are required to sign a Confidentiality Attestation Statement on an annual basis.
Both the ECHO UM staff voice mail phone message line for utilization review information and the computer network system are controlled by a secured password system, accessible only by the individual employee.
The facsimile machines used for utilization review purposes are located within the department to assure monitoring of confidential medical record information by ECHO UM staff.
Any reference to patients will be made by Health Plan subscriber number, to insure confidentiality
Peer Review records and proceedings will be kept confidential according to Section 1157 of the California Evidence Code.
Elite Care Health Organization (ECHO)GOVERNING BODY
The Governing Body of ECHO is the Executive Committee.
• The ECHO Executive Committee has granted the UMC the authority to develop and monitor the UM Program. In addition, the Executive Committee has authorized the UMC to oversee the activities to manage the administration/application of clinical criteria and to communicate with
57
participating physicians as necessary. • The UMC reports to and submits a quarterly report of all activities to the ECHO Executive Committee. In addition, the UMC will make recommendations to the respective plan Quality Improvement Committee (QIC) on any/all issues concerning quality of care, physician practice compliance and over/under utilization. • Annual review and approval of the UM Program, • Annual review and approval of all UM Policies • Annual review the UM criteria & the procedures for applying them, & updates the criteria when appropriate. • Provide feedback and recommendations to the committees after reviewing summary reports. • Review and approve Annual Inter-rater Reviewer Reliability Studies to ensure consistency of application of criteria across the network. When deficiencies are noted, corrective action plans are put in to place with follow up at the next UMC. • Evaluate and assess implementation of UM activities through the Work Plan and Calendar of Activities.
Chief Medical Officer The ECHO Chief Medical Officer: • Reports to the Board of Directors and Chief Executive Officer • The Chief Medical Officer has an unrestricted license and is Board Certified in the State of California • Develops and implements the UM/QM/CM Programs. The program's effectiveness is enhanced under the governance of the Chief Medical Officer/Medical Director who functions in a full time capacity • Execution of the UM/QM/CM Program under the direction of the Chief Medical Officer
Medical Director The ECHO Medical Director is a senior level management member who is given the authority and responsibility for the overall operation of the UM program who chair UMC.
(S) he is the ECHO senior physician with a current license to practice without restriction in the State of California. A copy of the current un-restricted license is kept on file at all times.
The Medical Director or Designee is available 24- hours per day, 7- days per week to manage/support UM processes and services. (S)he has responsibility for the management and oversight of all clinical activities / decision making within the UM department and reports to the ECHO Executive Committee.
Responsibilities include: • Active involvement in the development and implementation of the UM Program • Oversight responsibility for all denials and clinical decision making for medical appropriateness 58
UM Committee Chairperson The ECHO UMC Chairperson's is the UM Medical Director. His/ her responsibilities include, but are not limited to, the following: • Chairing all committee meetings or designating a substitute in his/her absence. • Participates in the determination of the UMC schedule, oversees the documentation of UMC minutes and other documentation associated with the UMC. • Oversees the development and implementation of policies and procedures associated with the referral process. • Oversees the training and education of all primary care physicians regarding UM policies and procedures and regulatory requirements as well as the training and education of new UMC members. • Communicates to the ECHO Executive Committee any issues that impact the clinical operations of the UMC.
Physician Committee Members • Shall consist of at least three (3) Physician members • Physician members have 'voting' authority on the committee • Shall, at least annually develop, review, approve included, but not limited to the following: • UM Policies & Procedures • Clinical Review Criteria • UM Program Description • UM Work Plan • Other Primary Physicians
The contracted Primary Care Physician agrees to comply with the ECHO UM Program. Primary Care Physicians are notified of their responsibilities in the contractual service agreement that they sign to become a provider of ECHO.
UM Supervisor The UM Supervisor is a Registered Nurse or Licensed Vocational Nurse with an active un- restricted license to practice in the State of California.
The UM Supervisor has the authority and responsibility for management and oversight of the medical management processes.
Responsibilities include:
• Reports to the Chief Medical Officer. • Works with the Chief Medical Officer, Chief Executive Officer, Chief Operational Officer and Medical Directors daily. 59
• Prepares/attends Care Management meetings, Joint Operations meetings, Physician Meetings and Health Plan meetings. • Develops and administers the UM Policies and Procedures, ensures the application of approved Clinical Review Criteria. • Manages UM staff. • Manages staff performance to strategic and operational goals. • Ensure adherence to Local, State and Federal Laws and guidelines. • Participates in UMC Meetings. • Reads claims for appropriate authorization and process improvement. • Participates in departmental meetings as required/requested. • Oversight of compliance with Turnaround time, Denial letters, UM/QM Programs. • Responsible for health plan reporting 1. UM Coalition 2. UM Plan 3. Audits/Corrective Action 4. Monthly reporting 5. Compliance/QI UM Staff: Clinical and Non-Clinical
• Licensed staff members supervise all favorable review decisions • ECHO verifies the current licensure or certification of staff whose job description requires licensure or certification upon hire, and thereafter no less than every year. • Non-Clinical staff function in support of licensed staff • Non-Clinical staff maintain records, reports, and other duties as assigned in relation to duties within their work scope. • Non-Clinical staff are not involved in any decisions that require clinical judgement. Professional Licensure monitoring of licensed physicians and clinical staff:
• ECHO staff is required to notify the organization in a timely manner of an adverse change in licensure or certification status • A corrective action plan is put into place upon notification of an adverse change in licensure or certification status • Changes include but not limited to, changes in staff assignment to non-licensed jobs/function • All professional licensure and certification are verified before hire, and thereafter no later than scheduled expiration.
UM Committee (UMC) STRUCTURE
The UMC is composed of Board Certified physician members, who are considered "voting members" for all clinical and administrative items. The purpose of the committee is to continually monitor, evaluate, and optimize health care resource utilization. Staff positions and committee descriptions explain all associated needs and are accommodated by the UM Program's budget. Reporting relationships are clearly defined. Performance objectives are included in the staff evaluations. Interdepartmental coordination of managed care utilization 60
services is clearly delineated in the description of each department.
Functions/Responsibilities of the UMC:
• Develop, evaluate, and implement the UM Program. • Develop, evaluate, and implement clinical guidelines relating to quality of care. • Monitor over/under utilization of health care services. • Monitor appropriate levels of healthcare and timelines of the delivery of healthcare services. • Review all proposed UM clinical and operational policies and procedures for utilization by the clinical and non-clinical staff. • Review of Health Plan's determination of all clinical appeals. • Monitor all inpatient services.
Evaluate new and existing medical technology through Medical Technology assessment as determined by the Health Plans. Coordinate quality issues items with the Quality Improvement Department Committee (if delegated; not delegated refer to the Plan's QI Department) for recommendations and corrective plans of action Monitor compliance with prescription drug formulary through health plan reports to the UM Committee. Monitor effectiveness of the medical management process through member and practitioner satisfaction survey results. Oversee the implementation of and monitoring the Annual UM Work Plan. Annual evaluation of the UM Program and UMC functions. Monitor practice patterns, over and underutilization of all practitioners. Patient Rights, including ethical issues, complaints, and grievances. Pharmacy and clinical trials programs through Pharmacy Administration and/or Health Plan reporting
Chairperson
The Physician Chairperson presides over the UM Committee.
UM Medical Director The ECHO Medical Director, Utilization is a current California licensed physician, credentialed by the Credentialing Department. The Medical Director responsibilities are as follows: • Reports to the Chief Medical Officer and Governing Board • Reviews outpatient requests, concurrent, retroactive reviews and clinical accuracy • Reviews inpatient cases, transfers and complicated cases • Attends UR/Case Management meetings • Involvement in criteria development • Reviews all denials based on medical appropriateness • Is available by phone to discuss referrals/denials with requesting physicians 61
• To supervise and support the review activities of the UM/QM Committee. Physician advisors will be available to the UM staff on a daily basis • To provide day-to-day supervision of assigned UM staff; participate in staff training; monitor for consistent application of UM criteria by UM staff, for each level and type of decision; monitor documentation for adequacy; and is available to UM staff on site or by telephone • To perform retrospective peer review on clams in variance with ECHO criteria • To perform peer review and practice guideline audits to determine practitioner utilization of and compliance with at least two (2) established Practice Guidelines. Results will be reported to the Quality Management and Care Management Committee. • To review physician and/or member/patient appeals and grievances as indicated by review findings • To coordinate education workshops for physicians and/or their office staff • Provide one-on-one physician education
• The Medical Director will be a voting member of the UM Committee • To request only the information reasonably necessary to determine medical necessity. Physician Reviewer Responsibilities {outpatient} • Reports to the Chief Medical Officer • Reviews outpatient requests, concurrent and retroactive reviews • Reviews claims if needed • Reviews all denials based on medical necessity • Is available by phone to discuss referrals/denials with requesting physician • Review medical necessity and appropriateness • Educate medical staff regarding the UM/QM program • Consult with specialty physicians and Health Plan Medical Director when necessary to achieve optimum results • Serves as a member of the UM & QM Committee and a resource for criteria development referral patterns/under and over utilization • Educate PCP, Specialists and/or Behavioral Health provider with guidelines, criteria and network processes • Review quality issues with the QM department and Committee • Written utilization review protocols/criteria are clearly documented and available to participating physicians/members/public when requested • Use a current criterion that include but is not limited to: CMS Criteria, National (Medicare) Coverage Determination (NCO), Local Coverage Determination (LCD), Local Coverage Medical Policy Article, Medicare Benefit Policy Manual, Health Plan Specific Criteria, written coverage decision of local Medicare contractor, Milliman (MCG), Behavioral Health guidelines and physician-to-physician review 62
Physician Committee Members
The physician members consist of at least three (3) Committee Certified Primary Care Physicians (Family Practice, Internal Medicine) licensed in the State of California, credentialed by the Health Plan's Credentialing Department; they are invited /selected by the UMC Chairperson and serve a two (2) year-term. Attendance of at least three (3) voting members is considered a quorum, in order to hold a valid committee meeting. Quality Improvement Committee Chairperson (Only if delegated)
The Quality Improvement Committee Chairperson is a current State of California licensed physician, credentialed by Health Plan's Credentialing Department. The Quality Improvement Committee Chairperson is a "voting" member for all clinical and administrative issues. The Quality Improvement Committee Chairperson (if delegated) is actively involved in the resolution of the quality review, Peer Review, and credentialing processes.
The Director or designee of UM
• Is a Registered or Licensed Vocational Nurse currently licensed in the State of California
• ECHO verifies the current licensure or certification of staff whose job description requires licensure or certification upon hire, and thereafter no less than every year.
• (S)He is responsible for the direction, management, and compliance to standards for all operational actives within the UM Department.
• (S)He is invited by the UMC Chairperson and serves during the term of employment.
• Additionally, (s)he is responsible for monitoring and analyzing internal and external data trends and patterns that affect the quality and cost of care and service delivery.
Case Managers A. Ambulatory (RN/LVN) I. Reports to the UM Manager/Director 11. Works with Medical Director on a daily basis Ill. Case manages catastrophic, High Risk, SNP, SPD and ACM members
IV. Participates in care management rounds, subcommittees and in-services
63
B. Inpatient Outpatient (RN/LVN) I. Reports to the UM Manager/Director II. Works with the Medical Director on a daily basis Ill. Conducts concurrent and retroactive review of inpatients (inpatient) IV. Conducts referral review process to ensure that appropriate criteria and clinical notes have been applied prior to medical director review. May approve some services where Nurse approval is in place. (outpatient) V. Participates in case management rounds, subcommittees and in-services
UM Coordinator A. Reports to the UM Manager/Director B. Collects data for review for determination: 1. Eligibility 2. Benefits 3. Criteria needed 4. Physician notes/conversations C. May approve some services where auto approval is in place. May not deny or make clinical decisions D. Assists clinical staff with STAT and emergent requests as needed E. Assists Case Manager with discharge planning F. Faxes monthly logs to the health plans: (compliance) 1. ESRD 2. Hospice 3. AIDS 4. SNF 5. Transplant
UM Committee Ad Hoc Members
Invited members of the management staff (Provider Relations, Contracting, Claims (if delegated) or ancillary providers as required (i.e. pharmacist)
Chairperson Responsibilities
The Medical Director UM is the UMC Chairperson and presides over the UMC. UM Chairperson responsibilities are as follow:
A. Implementation of the UM Plan and criteria on a yearly basis B. Attendance of all UM Committee Meetings C. Approval of the agenda prior to all UM meetings D. Acts as an educational resource on utilizing issues for all physician members E. Resolve differences of opinion between requesting and on-call physician regarding any and all referrals 64
F. Represents the organization regarding utilization issues by telephone and in meetings with contracted health plan representatives
Meetings and Participation
The purpose of the UMC is to provide a mechanism for evaluation and management of utilization issues and to promote physician education and participation in the development of the appropriate UM process.
The UMC meets on a regularly scheduled basis, no less than quarterly. The UMC is open to contracted health plan representatives on a pre-scheduled basis who may be dismissed during certain discussions or activities. Urgent issues will be addressed immediately and not held for committee meetings.
Active participation on the committee includes consistent meeting attendance and involvement in discussion of agenda items, to include but not limited to:
• Establishing practice guidelines • Monitoring indicators • Analyzing bed day reports and assisting in problem resolution as requested by the Committee. • Referral process • Concurrent review and discharge planning as appropriate • Review hospital bed days and pattern analysis • Recommend effective strategies for improving the quality of care • UM information that is relevant to QM will be identified and reported to the QM Committee
No compensation or incentives are provided to practitioners or other individuals for conducting utilization review for denials of coverage or services. Utilization decisions are made solely on medical appropriateness of care and service.
ECHO does not award any type of incentives to practitioners or other individuals for conducting utilization review decisions that may result in underutilization.
Minutes
Separate minutes will be documented, dated and signed by the committee Chairperson and maintained for each sub-committee utilizing the ECHO standard format. Minutes will reflect attendance and absences at each meeting, committee discussions, action plan(s), and implementation with assigned time frames and responsible person. All UMC activities will documented to include, but not limited to, authorization review, clinical appeals, audits, studies,
65
review of policy and procedures, new medical technology assessments and recommendations, transplant cases quality issues, credentialing process and peer review issues.
The UMC minutes from the previous committee meeting will be reviewed by the committee members for accuracy and content at the beginning of each UMC. Upon approval, the UMC Chairperson or designee will sign/date the minutes.
UMC minutes are protected from discoverability and held in the strictest of confidence. The minutes will be available for confidential review by contracted health plans in conjunction with pre-delegation and/or annual delegation review. All reviews must take place at the ECHO office and no copies of minutes will be made or disseminated to other than UMC/Executive Committee attendees. Minutes are filed in the UMC binder and/or electronically stored in a secure area/or Server and accessible to the Medical Management staff only.
Affirmative Statement A. UM decisions are based only on appropriateness of care and service and existence of coverage B. UM affirmative statements regarding incentives will be signed by all UM decision maker and will be signed each year by all employed and new employees upon hire.
Reporting The UMC reports to the Executive Committee on at least a quarterly basis. Reports are submitted to reflect all activities of the UM Department. Recommendations and directives are carried out as appropriate and reported back to the Executive Committee and UM Committee.
UM reports include the following but are not limited to: 1. Monthly Bed Days reports 2. Weekly/Monthly Health Plan reports 3. Provider and Member Satisfaction Surveys 4. Referral trending for over/under utilization by PCP and specialist by network 5. Readmission report (monthly) 6. lnterrater Reliability for UM criteria, clinical and non-clinical (annually) 7. QM reporting, tracking and trending 8. Referral turnaround time (monthly for committee) (weekly for internal) 9. Referral pended report by coordinator and nurse (weekly) 10. Monthly ER tracking by provider, network and member 11. Denial reporting (daily for internal) (monthly for committee) 12. Quarterly reporting of utilization management activities to required health plans, including process to electronically report on the number and types of appeals, denials, deferrals, and 66
modification to the appropriate staff 13. Health Plan specific - ICE collaborative Quarterly, Semi-annually, annually
Department Goals
1. Bed days • Commercial Acute Bed Days - 150/K • Senior Acute Bed Days - 750/K • Commercial SNF Bed Days - 21/K • Senior SNF Bed Days- 834/K 2. ER Utilization • Commercial - 133 PMPTY • Senior - 394 PMPTY 3. Denial Rate • 5% or less • Outliers will be reviewed at the UM/QM meetings and corrective actions addressed 4. Turnaround Time • ICE timeliness adopted and adhered to • Department goal is 5 days for commercial and senior for non-urgent referral • STAT's and Urgent referral goal is same day when possible or within 24hrs
Voting Rights
Each physician member has one (1) equal vote, only physicians have voting privileges on issues of appropriateness of care, clinical standards or quality of care.
All approved action is by a majority vote.
In the event that the UMC is unable to constitute a quorum for voting purposes because of a conflict of interest, alternative member(s) will be selected as needed at the discretion of the Chairperson.
Quorum For voting purposes, a quorum is defined, by the organization's Bylaws, as three (3) physician members and is required to pass any clinical recommendations and/or determinations. Physician attendance by teleconference or web-ex is acceptable
UM POLICY AND PROCEDURE REVIEW PROCESS
67
The UMC reviews any/all proposed UM Policies and Procedures. The UMC will discuss the Policies and Procedures for additions, deletions, and/or corrections. The physician members will vote for approval. The Policies and Procedures will be filed in the UM Policy and Procedure Online Manual. The Policies and Procedures are available to all UM staff through the ECHO secure network online as specified in the Policy and Procedure distribution list by providing hyperlink access to the policies online.
UM ANNUAL APPROVALS
The follow is approved at least annually: included but not limited to:
• UM Program Description • UM Work Plan with Quarterly reviews and approvals • UM Policies & Procedures • UM Clinical Review Criteria • Inter-rater Tools and Survey Results • Provider Satisfaction Survey Results • Member Satisfaction Survey Results • Any additional items as deemed by the UM Committee/Executive Committee
The UM Program is evaluated annually to assess effectiveness of the program and determine revisions needed for the following year. The UM Program Evaluation is reviewed and acted on annually by the UM Committee. The review includes items such as, but not limited to the following: • Member complaints • Member grievances and appeals as reported to ECHO by any contracted payor • Results of practitioner satisfaction feedback • Practitioner complaints • UM telephone-answering response-time statis • UM decision-making statistics and timeframe adherence
The UM Program Evaluation identifies issues that might limit the equitable access of members to the health care program and provides recommendations for improvement. The UM Program evaluation is submitted to the UM Committee for review, action and follow-up. The UM Program Description is also reviewed and updated annually, based at least in part on the findings of the annual evaluation.
ECHO collects and reviews information on: • Inpatient care; including number of admissions per 1,000, bed days per 1,000, average length of stay, day utilization by level of care, readmission patterns • Outpatient care; variance of high-cost outpatient procedures, individual group referral transactions per member • Continuity and Coordination assessments including behavioral health • Physician reviewers and Clinical Staff Inter-rater reviewer reliability studies are conducted and presented / reviewed annually If deficiencies noted, the UMC acts on opportunities for
68
improvement, if applicable. • Denial file audits • Over/Under Utilization • Member and Provider Satisfaction with the UM process • Health Care Service Plan Interface (HMO Interface) ECHO interfaces with Health Plans on a routine basis to effectively manage utilization. This interface may occur on a person-to-person basis, referencing printed materials or web site contacts.
ECHO is not delegated to manage appeals, complaints and grievances, requests that are experimental/ investigational, or technology assessments by contracted plans.
Health Plans may send staff to attend meetings on a pre-approved basis. The Health Plan staff may attend the part of the meeting which covers members assigned to their plan. The staff must sign a confidentiality statement prior to attending the meeting
Reports Presented Reports will be presented to the UM Committee. All policies and procedures are reviewed and approved by the UM Committee as appropriate, and the Committee of Directors.
Improvement interventions, as a result of performance measurement activities will be disseminated to all appropriate parties throughout the network, newsletters, or other selected modalities.
UM Decisions The Senior Physician ensures the organizational objective to have qualified clinicians accountable to the organization for decisions affecting its members. CLINICAL CRITERIA FOR UM DECISIONS: Medicare, Medi-Cal, Commercial
Evidence based, nationally accepted criteria are utilized when authorizing services. In addition, the member's needs: age, co-morbidity, complications, home environment, treatment progress and psychosocial situation are also taken in to consideration
Application of the criteria shall be based on the needs of individual patients and characteristics of the local delivery system. Criteria are objective and based on medical evidence and are consistent with National Coverage Determinations- (NCO) (Medicare LOB), Local Coverage Determinations- (LCD) (Medicare LOB), Health Plan coverage guidelines./ Medical Policy, and Nationally accepted, evidenced based criteria, such as Apollo, MCG, etc., CHSC, DHCS, etc. per CA Health and Safety Code section 1367.01(f)- Medi-Cal Criteria utilized in decision making are made available to provider and members upon request. The Hierarchy Criteria Medicare Advantage Review Order of Use is as Follows:
o CMS- National Coverage Determinations (NCO)
69
o CMS- Local Coverage Determinations (LCD) o Health Plan Criteria I Medical Policy o Apollo/MCG (Milliman Care Guidelines) APPLICATION OF CRITERIA
The senior Physician shall oversee the application of the criteria will depend upon the member's age, co-morbidities, and progress in treatment, psychosocial situation, home environment, network resources and support system. The decision-making for UM is based only on appropriateness of care and service and existence of coverage.
Assessment of staff and physician reviewer performance in the Application of the criteria shall be performed and evaluated through the use of the Inter-rater Reviewer Reliability Survey of each UM Staff member and physician reviewer.
Access to complete criteria can be obtained by practitioners or members
by contacting the Medical Director or the UM Department, by telephone of fax.
PRIOR/PRE-AUTHORIZATION REVIEW
Routine Prior/ Pre-Service Review includes but not limited to the following: durable medical equipment, injectables, out of network services, physician to physician services, diagnostic and therapeutic outpatient services and elective inpatient admissions.
The Provider transmits the request to the UM department electronically, via fax, or via telephone. All requests are date and time stamped upon arrival into the department, either electronically by the system or fax machine, or manually, if needed. /UM Coordinator/ RN assesses the completeness of the request and if incomplete contacts the requesting provider to ask for additional information within the mandated timelines. The UM Coordinator also verify the member eligibility and benefit. The UM RN/LVN reviews the request if not on the auto-approved protocol list for approval, assesses the availability of benefits (dependent upon the patient's HMO benefit plan), determines if factors are present (extreme age, other co-morbidities, lack of support system) and compares the clinical indications to the appropriate criteria. At the completion of the review the pre-service nurse determines:
If benefits are not available for the proposed service, the nurse forwards the request to the Medical Director for a possible benefit denial Benefits exist but the member's condition doesn't meet the requirements for the benefits to be available, the case is referred to the Medical Director for possible medical necessity denial Benefits exist, and the patient meets medical necessity criteria, the case is approved. When a contracted provider is not available members are referred to a non- contracted provider
SECOND OPINIONS
70
The UM Department reviews all requests for a "Second Opinion". The Primary Care Physicians (PCP) or Specialty Care Physicians (SCP) submit all requests for a "Second Opinion" in an Authorization Request form, to the UM Department. All requests will be reviewed for medical necessity and referred to an appropriately qualified health care in- network professional by the Medical Director UM and/or designee.
When second opinion cannot be provided within the network, and/or the member requests an out- of-network (or out-of-health plan network), and refuses to accept redirection in-network, the second opinion will be re-directed to the appropriate Health Plan to facilitate an out-of-network authorization referral. This process is to provide a consistent and timely review of Second Opinion requests for health plan members. The turn-around time of all second opinion referrals shall not exceed 14- calendar days.
CONCURRENT REVIEW
The Inpatient Nurse reviews all acute admissions as appropriate, during business working days, based on medical necessity
The review process may include chart review, data collection, and review of care plans and initiation of discharge planning. Member progress and/or treatment are electronically documented. Discharge planning begins on the day of admission for unscheduled inpatient stays. Elective inpatient stays; discharge planning needs may be identified prior to the hospitalization and coordinated through the pre-service authorization process.
The Inpatient Nurse follows the patient through all inpatient levels of care.
The Inpatient Nurse conducts out-of-area as appropriate and out-of-network reviews telephonically with the facilities' concurrent review nurses.
Concurrent reviews are provided to the Health Plans on a pre-arranged contractual agreement review. All contracted health plans will be notified of inpatient admissions as stipulated in the agreement. RETROSPECTIVE REVIEW
UM Medical Director or Designee and the Inpatient Nurse shall confirm appropriateness of services utilized the designated appropriate level of care, length of stay, and medical necessity. Review of all pertinent medical information is necessary to make the appropriate determination.
The UM Department performs retrospective review on authorization requests as appropriate that have not been pre-authorized. A decision and notification is required within 30 calendar days from receiving all necessary information.
CASE MANAGEMENT 71
Case Management Program - please refer to Ambulatory Case Management Program Manual
DISEASE MANAGEMENT
Disease Management Program - If delegated, please refer to the Disease Management Program Manual
DISCHARGE PLANNING
All inpatient cases as noted above will be monitored for Discharge Planning needs as appropriate. The Inpatient Nurses will coordinate Discharge Planning with the facility Case Managers utilizing network contracted practitioners and ancillary services.
Discharge planning is initiated on or before admission. When a discharge need cannot be met or available through contracted providers, the Inpatient Nurse will contact the appropriate health plan to confirm availability of a Plan Contracted Provider to facilitate post- discharge care coordination and management.
ADDITIONAL COMMUNICATION WITH HEALTH PLANS
Reports will be sent to each health plan per requirements and may include but not be limited to:
Encounter data - submitted via tape/electronically to health plans on a monthly basis. Denial letters - all denial letters are sent to the appropriate health plan, per that health plan's guidelines. Admission and Bed Day Reports - to all health plans monthly, if requested. Utilization data - upon request monthly. Thresholds are set to identify under- and over-utilization, including behavioral health, and annually these are compared with known thresholds for the same products Data falling outside the thresholds is analyzed and corrective action plans developed End Stage Renal Disease Reporting - to all health plans monthly, if requested. 72
Clinical decision making - the Medical Director will routinely contact the Health Plan Medical Director to discuss cases, appeals decisions, the appropriate use of new technologies, etc. Coordinate senior transportation - done with health plan social services and case management department, if needed on a case by case basis. And ongoing activities, identified trends in medical management of care and whether the program has met its goals and objectives for the year and if not recommend incorporating changes to the subsequent UM Program Description COMMUNICATION SERVICES
The UM Department will provide access to staff for members and practitioners seeking information about the UM process and the authorization of care
ACCESS TO STAFF
UM Staff are available 8:00 AM - 5:00 PM Monday through Friday, EXCLUDING HOLIDAYS OBSERVED BY ECHO, for inbound calls or toll-free calls regarding UM issues. Staff identify themselves by name and title and company name when initiating or returning calls regarding UM issues.
ECHO offers TDDITTY and offers language assistance for members to discuss UM issues
On-call staff is available after hours 7- days per week. The staff can send outbound communication regarding UM inquiries during normal business hours, unless otherwise agreed upon.
A Toll-free number is available. UM can accept calls regarding UM issues 24- hours per day- 7-days per week.
Per CA Health and Safety Code section 1367,0t(i)
TIMELINESS OF UM
ECHO utilizes the Ice for Health (ICE) CMS and Medi-Cal Turnaround Timeframes (TAT)
DENIAL NOTICES
Denial notifications will be sent to the member requesting physician, referred to provider, and health plan in writing within State/Federal timeliness Standards. Reason for denial, criteria utilized, Evidence of Coverage alternative treatment plan, and the appeal process is clearly defined in understandable language. The letter templates by product line from the Health Plans are utilized to ensure that
The description of the appeal rights includes the right to submit written comments, documents or other information relevant to the appeal.
73
Explanation of the appeal process includes the right to member representation and timeframes for deciding appeals
If it is related to an urgent denial, a description of the expedited appeal process is described. The letter shall include the health plan address, telephone number of the California Department of Managed Health Care (DMHC) toll-free telephone number.
Denial decisions are made by the Medical Director, UM. If the medical necessity denial is not within the scope of the education I experience of the Medical Director/designee, he/she will request opinion of a Broad Certified Specialist in that specific specialty. The, case manager/nurse reviewer or UM Coordinator may make benefit denials when no medical interpretation is required and must be signed by the appropriate physician. There is clear documentation and communication of the reason for each denial so that the practitioners and members receive information sufficient to understand and decide about appealing a decision to deny care or coverage.
The requesting practitioners are notified of the policy for making physician reviewer is available to discuss any UM denial decision and how to contact the physician reviewer
POLICIES FOR APPEALS IF DELEGATED
The appeals process provides the members and providers an opportunity to appeal a denial.
If requested to do so, the member shall be given access to and copies of all documents relevant to the appeal.
All Appeals received from the Health Plan will be reviewed by the Medical Director or designee and the ECHO Medical Director of UM.
All pertinent information regarding the appeal is obtained from appropriate practitioner prior to review.
All appeals information, including copies of correspondence, medical records and pertinent documentation will be submitted to the Health Plan within five (5) working days.
RECONSIDERATIONS OF DENIAL DETERMINTIONS:
The Member and/or Practitioner may request a reconsideration of a denial determination from the IPA/ECHO
If the original denial determination is upheld the reconsideration will be forwarded to the plan for the appeals process. GRIEVANCES
74
All complaints and grievances are referred to the Health Plan Customer Services Department for processing. If a potential quality of care issue is identified, Quality Improvement will be contacted to assist in the resolution.
MEMBER AND PRACTITIONER SATISFACTION
At least annually, ECHO will participate in an annual survey of both members and practitioners that includes questions regarding the UM process.
Results of satisfaction survey information will be used by ECHO to improve satisfaction with the UM process. EMERGENCY SERVICES Review- if delegated by the Plan Emergency Services Review- when Emergency Services are delegated by the Plan Any/all emergency service claims will be reviewed by the Claims Department, ER Claims Coder and/or UM Department, Medical Director UM and/or the Chief Medical Officer. The CMO I Medical director of UM or other appropriate practitioner reviews presenting symptoms as well as the discharge diagnosis for emergency services. including ER denials issued through an automated claims system.
The information obtained during emergency services will be utilized to track and trend afterhours access to medical care, identify potential Case Management re-educate the members on the need for preventative care and access to their Primary Care Practitioner (PCP) after hours, weekends, and holidays.
Emergency Room visits will be reviewed based on the Emergency Room
Progress notes, signs, symptoms and treatment. Emergency Room visits will be approved for payment on the basis of "prudent layperson" definition of "emergency" and medical screening examinations.
ENSURING APPROPRIATE UTILIZATION
Review of Health Data is a standing UMC agenda item.
Elements to review are agreed upon annually. Composite reports are reviewed and compared to industry benchmarks. If an unfavorable trend is noted, a focus study will be initiated through a sub-committee.
As part of the annual activities, the UMC ensures that a statement to all their providers, members, and employees affirming that:
75
UM decision making is based solely on appropriateness of care and service and existing coverage
The organization does not specifically reward individuals for issuing denials of coverage or services.
Financial incentives for decisions makes do not encourage decisions that result in underutilization.
UM Staff and Providers receive notice of Financial incentives at least annually
CONTINUITY AND COORDINATION OF BEHAVIORAL HEALTH
If delegated by the plan:
The following are mechanisms which ECHO has established to assure continuity and coordination of care:
Establish a referral and authorization system to review the continuity and coordination of care between referral practitioner, behavioral health practitioners, and referral -practitioners both internal and external to the organization. Coordinate and exchange information between medical practitioners, Behavioral health practitioners and practitioners in an effective, timely and confidential manner, including patient- approved communications Develop and implement a treatment authorization form specifically for behavioral health Monitor, track and trend behavioral health authorization forms to promote the appropriate diagnosis, treatment, and referral of behavioral health disorders commonly seen by the primary care physician. Monitor patterns of encounters, referrals, or hospital days to determine appropriateness of care. Where issues leading to improvement are identified, develop and implement a plan of action and accountabilities Using pharmacy data, evaluate use of psychopharmacological medication to increase appropriate use and/or decrease inappropriate use. Track, trend, and analyze data for feedback to practitioners. Coordinate timely access for appropriate treatment and follow-up for individuals with coexisting medical and behavioral disorders. Identify patients in the acute care setting who are at risk for a behavioral health disorder. These patients will be managed by a Case Manager who will coordinate a referral to the health plan's designated behavioral health contractor. Monitor, track and trend behavioral health authorization forms and provide feedback to primary care physicians. Coordinate with Behavioral Health Specialists to identify an opportunity for improving coordination of behavioral health with general medical care. In coordination with Behavioral Health Specialists, monitoring, tracking, and trending of behavioral health issues with feedback to the practitioner. Where issues leading to improvement are identified, Quality Improvement will be notified to develop and implement a plan of action and accountabilities. CARVE OUT
76
When Behavioral Health is a "carve out", the case will be referred to the appropriate designated Health Plan Behavioral Health contractor. Long Term Care
Members will be evaluated for long term medical needs by the Nurse and the Primary Care Physician (PCP). Criteria for long-term care eligibility will be based on intensity of service/severity of illness. When the member meets or will meet the criteria for long term care, the member will be admitted to the appropriate facility.
Transitional Care Unit (TCU) Intermediate Care Facility (ICF) Sub-acute Care Facility Rehabilitative Care Facility Skilled Nursing Facility (SNF)
When a member does not meet the criteria for long-term care, the member will continue to be managed by the Case Manager and the Primary Care Physician (PCP).
Major Organ Transplants as Non-Delegated vs. Delegated
Members who may potentially require a major transplant will be evaluated by the Plan's Case Management department in coordination with the member's Primary Care Physician and Specialist as appropriate when this process is not a delegated function
Coordination of Care
Applies To: A. The Elite Care Health Organization (ECHO) Staff/IPA/Medical Group, Contracted Providers and Practitioners shall follow the procedures set forth in this policy. POLICY:
A. ECHO complies with the CMS standard for continuity of care for new and existing members going through transitions of care (TOC) by having a consistent person or unit responsible for supporting the member and managing care transitions
DEFINITION:
A. To provide guidelines for the U M employees in managing safe care transitions, identifying planned and unplanned transitions, and avoiding fragmentation of care. Activities include but
77
are not limited to, educating the member/member’s representative, and coordinating services for members at high risk for problems with care transitions or fragmentation.
PROCEDURES:
Identifying Planned Transitions
1. A planned transition is an anticipated change in the member’s level of care or change of primary care or Health Plan/ IPA / Medical Group membership: a. Where notification that a planned transition is about to happen occurs when requests for authorization of elective inpatient admission/procedure(s) are received from the Primary Care Physician (PCP) or specialist, or when the provider directs transition to a more or less acute setting b. Contracted facilities are required to identify and report members scheduled admissions to an inpatient care setting within 24 hours or next business day of admission. Contracted facilities may fax or provide notification via telephone c. UM staff will enter the inpatient admission in the UM system and provide notification to the reviewer for initiation of coordination of care plan with appropriate individuals. d. UM Nurse accesses the UM reporting system for a daily planned admission report for identification of planned transitions e. Planned transitions include: i. Elective hospital admissions ii. Elective skilled nursing facility admissions iii. Elective acute rehabilitation admissions iv. Elective Long Term Acute (LTAC)
Identifying Unplanned Transitions
1. Unplanned transitions are unanticipated changes in the member’s level of care or change of PCP or Health Plan/IPA/ Medical Group membership: a. Contracted facilities are required to notify all admissions within 24 hours or next business day. Contracted facilities may fax or provide notification via telephone. b. The notification shall be entered in the medical UM system and notification is forwarded to the UM Nurse for initiation of coordination of a plan of care with appropriate individuals c. UM Nurses may be notified of unplanned transitions of care through the following included but not limited to: i. Non - contracted facility notification ii. Daily inpatient census iii. Home Health contracted vendors iv. Pre-service, concurrent, and retrospective review process v. Health Plans internal staff may also notify of the new authorization requests as applicable. 1. UM Nurses will notify involved provider(s) or facility of an extension of benefits or coverage until member’s care delivery is completed.
78
Management of Care:
1. Inpatient management review occurs within one working day of notification of admission 2. The plan of care is tailored to each individual and takes the member’s unique health status into consideration a. The UM Nurse develops and/or updates the plan of care.
Transition:
1. ECHO is responsible for providing safe, efficient transitions and appropriate notification to the receiving setting. 2. The transition of the care from one care setting to another must occur within one business day of notification of the transition to ensure that the member’s care continues in a safe and effective manner. 3. For planned and unplanned transitions, the UM nurse will ensure facilitation of the discharge and transfer process. a. Arrangements for a receiving practitioner/provider will be made. b. Availability of a required bed and/or services(s) in receiving the setting will be arranges. 4. The member’s care will continue to be covered until care is concluded or the member is discharged. 5. The care plan will accompany the member to the receiving setting. 6. The UM Nurse will monitor that a discharge plan was implemented and psychosocial and health needs are met through a. Post Hospital Discharge member follow-up calls i. UM Nurse calls the member upon discharge from the inpatient setting to confirm a solid discharge plan, educate and screen for additional gaps in care that may benefit or require assistance from Case Management intervention ii. Medication review ensuring member has appropriate medication. iii. Call provides opportunity to communicate information with responsible person to assist with ongoing care and service. 7. For new members transitioned from a different medical group or health plan, ECHO will coordinate with the Health Plan a transition of care plan to reduce the potential for interruption in treatment or therapy.
Communication
1. The UM Nurse works collaboratively to systematically identify fragmented care for members with acute needs and to: a. Clarify diagnosis, prognosis, therapies, daily living activities; enforce treatment plans and orders; b. Discuss member’s course of progress and needs; c. Identify plateaus, improvements, status regressions and depression; d. Communicate with the member and/or responsible party about the care transition process and changes to the member’s health status/or and care plan.
79
e. Advise facility and/or interdisciplinary team of the extension of benefits until member’s care is completed with the member’s discharge from the facility 2. The UM Nurse develops and facilitates discharge planning upon notification of an admission to a facility. Discharge planning needs are assessed and continuity of care is facilitated through coordination between the facility, interdisciplinary care team and other contracted providers as needed to ensure a timely and safe discharge. 3. When the attending physician has determined that the member no longer requires inpatient stay and authorizes discharge, the discharge and/or care transition process must be communicated to the member and a written discharge plan provided at the time of discharge that is understandable to the member and/or his or her family/responsible party by the facility representative.
80
Quality Management A. Quality Studies Medical Records Access
APPLIES TO: B. This policy applies to all ECHO clients and their membership. POLICY: A. ECHO performs a variety of quality studies that meet contractual and regulatory requirements and are relevant to the ECHO Member population B. All Providers, Health Plans, and Hospitals must provide access to Members’ medical records for use in quality studies. DEFINITIONS: A. Any contracted organization to perform or provide Member medical record access for use in Quality Studies. PROCEDURES: A. Quality Studies 1. ECHO performs quality studies to meet requirements of California Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS) and the National Committee for Quality Assurance (NCQA). These studies cross over total ECHO Membership. 2. ECHO utilizes NCQA’s Healthcare Effectiveness Data Information Set (HEDIS) methodology for all applicable quality studies. F or studies not addressed by HEDIS, ECHO uses a format approved by the agency requesting the study 3. In order to complete these studies according to required methodologies, ECHO must gather information both from administrative data (i.e., encounter data) and Members’ medical records. B. Medical Record Access 1. The California Civil Code, Section 56.10 allows for the release of medical records to health plans for the purposes of medical data processing, quality of care assessment and other research purposes. C. Primary Care Physician (PCP) and Hospital Notification 1. ECHO notifies PCPs and hospitals if any of their Members have been selected for inclusion in a quality study. 2. Notification includes a description of the study purpose and requirements as well as a list of the Members whose records are needed and the method of data collection 3. ECHO collects medical record data in one of the following ways, depending on the nature of the study and the location of the PCP’s office or hospital: a. ECHO staff may make appointments with the PCP’s office or hospital to visit the site for the purpose of medical record review and/or data collection. Data 81
collection includes making photocopies and/or scanning selected medical records for audit purposes. b. ECHO may request that the PCPs office or hospital retrieve the requested records and mail, fax or email records to ECHO. Under this method, PCPs or hospitals may be reimbursed a fixed amount per record for mailing and copying costs.
D. Confidentiality: 1. ECHO maintains compliance with HIPAA requirements with all Member medical record information, including information used for the purpose of a quality study. 2. ECHO maintains strict confidentiality when using Member records for quality studies. 3. Members’ identities are not disclosed in quality study results. 4. ECHO maintains medical records in locked cabinets that are accessed only by ECHO authorized personnel 5. Abstracted data is archived and saved for a period of time determined by the study on a secure server.
B. IPA QUALITY MANAGEMENT
APPLIES TO:
A. This policy applies to all ECHO client and their membership.
POLICY:
A. ECHO is responsible for conduction the Health Plan Quality Management (QM) Program and is required to have certain QM structural components as noted below: 1. ECHO will insure that the current QM program and QM Policy and Procedures are available annually for review by the MG members and practitioners through our website. 2. The QM Program Description outlines the structure and content of the QM Program, including the QM Committee and related activities. 3. QM Program activities must meet Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), and ECHO standards. 4. ECHO QM Committee is responsible for oversight and annual approval of the QM Program Description, Work Plan and Annual Evaluation. 5. QM Committees are responsible for monitoring, measuring, and evaluating the quality, effectiveness, safety, coordination and appropriateness of the care provided by Practitioners to Members for the purpose of continued quality improvement 6. ECHO must have adequate QM staffing to support QM Program and related activities 7. QM Programs must be accountable to the QM Committees.
B. ECHO monitors Program Structure and implementation of QM activities through ECHO standards.
82
PROCEDURES:
A. Responsibilities – ECHO has adopted a health care delivery structure that includes QM Program activities required of contracted Delegate Medical Groups or Hospitals (Providers). Details are noted in both the Agreement between ECHO and Providers and the ECHO Provider Policy and Procedure Manual. Activities related to medical services include: 1. Quality Management: a. Quality Structure – ECHO is responsible for conducting the Health Plan QM Program. ECHO is also required to have a structure in place that monitors quality activities, including a formal Committee structure and sufficient personnel in place to perform QM activities. b. Develop, evaluate and implement the QM program c. Identify problems utilizing the following clinical and service indicators Patient/Provider Surveys (annually0 Site Surveys Patient Grievances Quality Audits Utilization Management Peer Reviews Access/Availability Other monitor appropriate, i.e. pharmacy, case management and discharge planning d. Quality Studies - ECHO is responsible for performing quality studies to maintain compliance with CMS, DHCS, NCQA requirements, and ECHO standards. In addition, Delegates are required to perform a minimum of two (2) quality studies for their Membership per year. One study must be in the area of access; the other study should be an area pertinent to the Delegate, ECHO Membership served by the Delegate, and quality issues identified by the Delegate. Study results must be made available to PCPs and ECHO Members upon request. ECHO has the right to mandate the type of access study required if the Plan has identified quality or access issues. e. Peer Review – ECHO must perform peer review and id required to have a Peer Review Committee made up of physicians’ representative of the network that provides peer review of any Practitioner noted to have potential quality issues. Peer Review Committees are responsible for reviewing Provider, Member, or Practitioner grievances and/or appeals, Practitioner related quality issues and other peer review matters. In addition, the Committee performs oversight of the Credentialing Program and activities, grievance and appeals processes with recommendations for modification as necessary. Data utilized to identify candidates for peer review include: quality studies by ECHO, grievances received by ECHO, utilization and/or encounter data, and other data sources. f. Clinical Data – ECHO is responsible for providing Member experience and clinical performance data in order for them to conduct quality studies and perform all functions. This data will be provided upon request and agree to specific quality studies where ECHO has the necessary data
83
2. Utilization Management (UM) – ECHO UM process should have sufficient administrative capacity with accompanying policies and procedures to meet all ECHO, DHCS, CMS and NCQA standards for UM activities. Refer to Section 14, “Utilization Management,” for more information. 3. Credentialing/Recredentialing -ECHO’s responsibility for credentialing and Recredentialing of participating Practitioners, as identified in Section 5, “Credentialing and Recredentialing.” This includes a signed attestation by the Medical Director that states all Practitioner-required reviews were conducted. ECHO’s Chief Medical Officer and Medical Director review all Practitioners (PCPs and Specialists) individually for quality related issues prior to assignment of Members. The ECHO Peer Review Subcommittee performs peer review for Practitioners referred by the Chief Medical Officer and Medical Director for potential quality of care concerns. ECHO also performs Credentialing/Recredentialing functions for those Practitioners whom are directly contracted with ECHO. 4. Care Management (CM) - CM of Members including: case finding, assessment of needs and care coordination, referral to outside agencies, and all other necessary CM activities.. 5. Practitioner Education - ECHO share Provider education and training responsibilities including: orientation to ECHO Members, delineation of ECHO policies and procedures pertinent to the Practitioner, site and medical record audit preparation, specialized support and training such as Preventive Services and health education. ECHO provides network wide training on a variety of subjects including preventive services, ECHO policies and procedures, case management, and health education. PCP’s are also required to be aware and require use of certain forms, supplied by ECHO on the Provider website, to their Practitioners including: Perinatal Risk Assessment Forms, Individual Health Education Behavioral Assessment (IHEBA) forms, etc. Health Education – ECHO actively works to improve the health and welfare of Members. T hose Members with chronic conditions are identified through pharmacy data, referral information, and other reporting measures. ECHO notifies the CM department for the purpose of individualized CM and referral to appropriate health education programs. ECHO works collaboratively with Providers and Practitioners to identify and educate these Members. ECHO provides certain network-wide Health Education programs to all Members. ECHO supplies Delegates and PCPs with health education brochures, materials, forms and a Provider Resource Directory. Refer to Section 15, “Health Education” for more information. 6. Medical Records Maintenance – ECHO is responsible for establishing and distributing medical record standards to Providers and Practitioners. ECHO is required to monitor physician offices for compliance. Practitioners are required to maintain policies and procedures consistent with ECHO requirements. 7. Preventive Care and Non-Preventive Care Guidelines - Practice Guidelines are developed by ECHO using current published literature, current practice standards, and expert opinions. They are based upon specific medical issues commonly found within ECHO’s enrolled Membership. Delegates are expected to monitor Practitioner’s care related to clinical guidelines as applicable. ECHO measures its performance against at least four (4) of its standards on a n annual basis, two of which relates to Behavioral Health. Standards are reviewed and updated by ECHO at least every two (2) years, or earlier, if necessary. 8. Access Standards – PCP’s are required to adhere to ECHO standards for availability and accessibility of services. Refer to Section 9, “Access Standards” for more information. ECHO 84
ensures the standards for appointment availability, after-hours access, Practitioner wait time, physician site hours, emergency service availability, medical triage both during and after hours, proximity of specialists and hospitals, and follow-up care through studies and audits. ECHO is required to perform access studies on their Practitioners to ensure they meet requirements. B. Assessment and Monitoring: To ensure that IPA have the capacity and capability to perform required functions, ECHO has a rigorous pre-contractual and ongoing assessment and monitoring system. Details of these activities with standards, tools and processes are found in the Provider Services Policies. 1. Annual Audit - ECHO performs an annual Audit on all contracted providers using an audit tool that reflects current NCQA, DHCS, CMS, and ECHO standards. C. Quality Management Committee: 1. The QM Committee is an interdisciplinary committee with participation from the ECHO appointed Practitioners who represent network physicians. The QM Committee is responsible for developing, implementing and overseeing the activities in the QM Program. 2. ECHO’s description of the QM Committee must include the following: a. Role b. Function c. Structure that includes organizational structure and reporting responsibility d. Membership e. Terms of Service f. Voting Rights g. Quorum Definition h. Meeting Frequency i. Minute format and storage; and j. Committees associated with oversight of delegated activities. 3. ECHO’s description of the QM Committee must include how the following actions are performed: a. Recommending policy decisions b. Analyzing and evaluating QM Activity findings c. Ensuring Practitioners participation in the QM Program through planning, design and implementation or review d. Implementing needed actions; e. Ensuring needed follow-up f. Maintain signed and dated meeting minutes. 4. The QM Committee must meet at least quarterly and follow a prescribed agenda. 5. The QM Committee discussions, conclusions, recommendations, and actions must be documented in the signed Committee minutes. 6. The QM Committee is responsible for monitoring, measuring, and evaluating the effectiveness of care provided to its Members. D. Quality Management Program Annual Evaluation: 1. The QM Annual Evaluation may be included on the QM Work Plan or in a separate document. The Annual Evaluation must evaluate the performance on planned QM Activities described in its QM Program Description and Work Plan, including all activities. The Annual Evaluation must include the following: 85
a. A description of completed and ongoing QM activities that address quality and safety of clinical care and quality of service; b. Trending of measures to assess performance in the quality and safety of clinical care and quality of service; c. Analysis of the results of QM initiatives, including barrier analysis; and d. Evaluation of the overall effectiveness of the QM Program, including progress toward safe clinical practices. E. Continuity and Coordination of Care: ECHO CM and coordination of care activities to contracted providers F. Confidentiality: Providers are required to restrict member medical records access to those Practitioners and associated staff with a legitimate reason to view the files. Records must be maintained in a protective and confidential manner and not be readily accessible to unauthorized persons or visible to the public. Providers and Practitioners must maintain procedures to ensure appropriate records processing to prevent breach of confidentiality. 1. Medical Records Release - Medical records contain confidential information that must not be released to any party other than the PCP without the expressed written consent of the Member or legal representative. The PCP must maintain procedures for obtaining such written consent prior to release of records copies. 2. Members’ Right to Confidentiality - Members have the right to confidentiality of medical information. All Provider contracts and subcontracts include the provision to safeguard the confidentiality of Member health records and treatment in accordance with applicable state and federal laws. Release of Member medical information may be necessary to protect the health of the Member and/or for coordination of services between Practitioners, specialists, or other health care providers of service. 3. Education of PCP Staff Regarding Confidentiality Issues - Providers must educate physicians and associated staff regarding confidentiality issues. Signed confidentiality statements are required for participation in the ECHO Practitioner network and monitored as part of the facility review process. Referral or access to sensitive services requires the maintenance of high standards of confidentiality. Members requiring family planning services, treatment for sexually transmitted diseases, abortion information and/or treatment, and HIV testing or are requesting assistance with highly sensitive issues, must be treated with respect and consideration for confidentiality. 4. Conflict of Interest - ECHO is required to perform Peer Review within their organization. Should a significant Practitioner problem or quality issue arise that cannot be resolved at this level; Delegate QM Committees may refer the issue to the ECHO Peer Review Subcommittee for resolution. Should an issue arise involving care provided by a physician member of the QM Committee or any Subcommittee, that physician is replaced by a substitute until the issue is resolved. The member involved in the issue has all rights normally given to anyone with a case presented to the Committee or Subcommittee. ECHO Committee members are required to sign a confidentiality and conflict of interest statement. 5. Confidentiality Policy - ECHO retains oversight for Provider confidentiality procedures through the ECHO QM Committee and Peer Review Subcommittee. As a condition of participation in the ECHO network, all contracted and subcontracted Providers retain signed confidentiality forms for all staff and provide education regarding policies and procedures for maintaining the confidentiality of ECHO Members. 86
6. Provider Confidentiality Procedures – ECHO has policies and procedures for maintaining the confidentiality of Members. 7. Informed Consent for Treatment - Practitioners must obtain appropriate written consent for treatment prior to actual procedure performance. Refer to Policy 7C, “Informed Consent,” for more information. G. Provider Participation: 1. Provider Information – It is required to inform network Practitioners of guidelines, policy and procedure changes, and other important information. Delegate methods of Practitioner education or notification are evaluated annually during Delegation Oversight Audits performed by ECHO Medical Services staff. Practitioners are informed through the ECHO Provider Newsletter, letters, memorandums, distribution of updates to the Provider Manual, and training sessions. Delegates are notified through letters, memorandums, Provider Manual updates training sessions for specific issues and Joint Operations Meetings. 2. Provider Cooperation: ECHO requires that Delegates and Hospitals cooperate with ECHO QM Program studies, audits, monitoring, and quality related activities. Requirements for cooperation are included in hospital and Provider contract language that describes contractual agreements for access to information. H. IPA and Hospital Contracts - The ECHO Capitated and Per Diem Agreements contain language that designates access for ECHO to perform monitoring, and require compliance with ECHO QM Program activities, standards, and review system. 1. Provider Agreements include the following provisions: a. IPA is subject to, and agrees to participate in the ECHO QM Program, with regular ECHO monitoring and evaluation of compliance with QM Program standards and ECHO policies and procedures, including participation in Member grievance and/or appeal resolution. b. IPA shall provide access at reasonable times, upon demand by ECHO, to inspect facilities, equipment, books and records including Member patient records, financial records pertaining to the cost of operations and income received by Delegate for Medical Services rendered to Members. Delegate shall ensure that Providers allow ECHO to access and use Provider performance data. c. Physicians shall cooperate with ECHO’s QM Program and, upon reasonable request, shall provide ECHO with summaries of or access to records maintained by Delegate and required in connection with such programs, subject to applicable state and federal law concerning the confidentiality of medical records d. ECHO shall not impede open Practitioner-patient communication. Members are allowed to participate with doctors in decision-making about their own health care including the ability to talk with their doctor about their medical condition regardless of cost or benefit. 2. Hospital contracts include provisions for the following: a. Hospital agrees to participate with ECHO in the ECHO QM Program, with regular ECHO monitoring and evaluation of compliance with QM Program standards and ECHO policies and procedures, including participation in Member grievances and resolution. Hospital shall also provide access to ECHO utilization review and case management personnel for the purpose of conducting concurrent review and case management on Members who are receiving Hospital Services. 87
b. Hospital shall implement an ongoing QM Program and shall develop procedures for ensuring that the quality of care provided by Hospital conforms with generally accepted hospital practices prevailing in the managed care industry. Hospital shall develop written procedures for remedial action whenever, as determined by the QM Program, inappropriate or substandard services have been furnished, or services that should have been furnished have not been furnished. c. Hospital shall provide access at reasonable times, upon demand by ECHO, to inspect facilities, equipment, books and records including Member patient records and financial records pertaining to the cost of operations and income received by Hospital with a five (5) working day prior written notice of any such inspection. Hospital shall ensure that Providers allow ECHO to access and use Provider performance data. d. Hospital shall cooperate with ECHO’s QM Program and, upon reasonable request, provide ECHO with summaries of or access to records maintained by Hospital and required in connection with such programs, subject to applicable state and federal law concerning the confidentiality of medical records. I. Monitoring Activities: ECHO performs a series of activities to monitor IPA functions including the following: 1. Member or Practitioner Grievance Review: ECHO performs review, tracking, and trending of Member or Practitioner grievances and appeals. I EHP reviews individual grievances and their resolutions for Delegate policies or procedures, actions, or behaviors that could potentially negatively impact health care delivery or Member health status. 2. Focused Audits: ECHO performs focused audits of Practitioners as indicated whenever a quality or clinical issue is identified. 3. Membership and Physician Satisfaction Surveys: ECHO performs Member and physician satisfaction surveys to assess their satisfaction with the physicians and MSO. J. Resources and interdepartmental interface- Resources and interdepartmental interface shall include the following but are not limited to: 1. Utilization Management Department 2. Customer Service Department 3. Credentialing Department 4. Network Management/Contracting Department 5. I.T Department 6. Behavioral Health Designated Provider 7. Quality Management Medical Director
88
PROVIDER NETWORK
A. IPA Medical Director Standards
APPLIES TO:
A. This policy applies to all IPA’s providing care to ECHO Members.
POLICY:
A. The Medical Director identifies IPA gaps in primary and specialty care coverage And ensures access to care for ECHO Members. He or she maintains an open Professional relationship with the IPA physician network. B. The medical Director is highly encouraged to network with ECHO and other Medical Directors to stay current with recent managed care/industry trends and best practices And act as the communicator back to their organization. C. The Medical Director serves as the physician liaison between the IPA, health plan, skilled Nursing facilities (SNFs), hospitals and other network providers. D. The Medical Director should be involved in tracking and trending of potential fraud, Waste and abuse involving ECHO Members and Providers. E. The Medical Director shall serve as chair for clinical committees such as Credentialing Utilization Management (UM), Quality Management (QM), or Peer Review committees, As applicable. F. The Medical Director should promote innovative solutions toward achieving the Triple Aim for ECHO Members. G. Preferences should be given to hiring Medical Directors with Primary Care experience.
PROCEDURES:
Utilization Management
A. The Medical Director timely and personally review all potential authorization denials And partial approvals (modifications) for: 1. Correct clinical decision making; 2. Correct application of ECHO approved criteria using the hierarchy appropriate To the line of business per Policy 14, A, “Utilization Management Delegation And monitoring”, and; 3. Use of denial languages that is simple and at the appropriate grade level, Ensuring that both the denial reason and specific criteria not met are Understood by the ECHO Member.
89
B. The Medical Director provided his or her wet signature on all denials and partial approvals (modifications) due to lack of medical necessity. C. The Medical Director is immediately available for any urgent or expedited decisions. D. The Medical Director provides clinical expertise for Members requiring complex medical care, higher level of care and out of network services. E. The Medical Director consults with IPA physicians to ensure correct utilization of UM criteria and initiates outreach to Providers showing a pattern of inappropriate authorization requests. F. The Medical Director ultimately ensure that ECHO members receive any medically necessary services including cases when criteria language appears vague or non-specific.
Quality of Care:
A. The Medical Director: 1. Is immediately available to consult on all complex care management and care coordination cases as needed: 2. Reviews all Provider and IPA grievances for adverse trends or potential Quality of Care (QOC) issues. 3. Reaches out to Providers as necessary to ensure timely response to grievance inquiries 4. Has input on all QOC cases with understanding of community standards for medical care. 5. Has oversight of the IPA Quality Improvement process, policy and strategy; and 6. Has fundamental understanding of National Committee on Quality Assurance (NCQA) metrics, Medical (or Medicare) regulations and is involved in the IPA metric improvement strategy.
90
PROVIDER NETWORK
B. Leave of Absence
APPLIES TO:
The Elite Care Health Organization (ECHO) Staff/IPA/Medical Group, Contracted Providers and Practitioners shall follow the procedures set forth in this policy.
POLICY: A. IPAs must ensure adequate coverage for PCP’s on leave of absence for less than (2) Weeks. B. IPA’s must submit written coverage plans to ECHO for any PCP that is scheduled to be on a leave of absence greater than two (2) weeks. C. D. In general, leaves of absence by PCP’s greater than ninety (90) days require transfer of Assigned Members to another PCP. E. A leave of absence is defined as a complete absence from the PCP practice for medical, personal or other reasons, including vacation.
PROCEDURES:
A. IPA’s must ensure an adequate plan of coverage for all PCP’s absent from their practice for less than two (2) weeks. Adequate coverage must include: 1. Use of a credentialed ECHO PCP in the appropriate specialty for the practice, Either at the PCP site or at another approved ECHO PCP site. 2. The covering PCP must be available at the original PCP site or another ECHO Approved site, at least sixteen (16) hours per week. 3. If coverage is not provided at the same office, a process for informing Members Of the coverage PCP’s name, phone number and office address utilizing the Assigned PCP’s phone number (e.g., voice message) and site (e.g., signs, notices) Must be in place. B. PCP’s planning a leave of absence greater than two (2) weeks must inform their IPA at Least sixty (60) days in advance. C. IPAs must submit a written coverage plan to ECHO no less than two (2) weeks prior to the PCP’s leave date for all PCP’s whose leave of absence is greater than two (2) weeks. The Coverage plan must include at a minimum: 1. Use of credentialing ECHO PCP in the appropriate specialty for the practice, either at the PCP site or at another approved ECHO PCP site. 2. If the covering PCP is not at the same location as the PCP on leave, the plan for informing members of the covering PCP’s name, phone number and office address. 3. The timeframe coverage is needed 4. Any significant change in schedule or hours of coverage from the original PCP site. D. For PCPs on a leave of absence greater than ninety (90) days, the IPA must submit either: 1. A plan for reassigning Members to another credentialed ECHO PCP with supporting Documentation as to why this is the best interest of the Members and including a Plan for interim coverage. 91
2. A specific request to keep the assigned Members with the original PCP with Supporting documentation as to why this is in the best interest of the Members and Including a plan for interim coverage. E. If a PCP has an unexpected leave of absence or leaves the practice without providing notice, the IPA may submit a non -ECHO credentialed PCP as part of the coverage plan if the following information for the covering PCP is submitted to ECHO within three (3) working days of the unexpected leave of absence: 1. Copy of Provider application 2. Copy of current DEA. 3. Copy of current malpractice certificate. 4. Copy of current medical license. 5. Copy of supervising PA certificate, if applicable. F. IPAs must provide Echo a written Member transfer plan within (5) days when a PCP leaves his/her practice without timely notice. 1. If the IPA plans to have current Members transferred to the covering PCP who Is not credentialed for participation in the EHCO network, complete credentialing Information must be submitted to ECHO within four (4) weeks of the original event. G. ECHO reviews all of the above submitted plans and either approves, denies, or request Additional information within five (5) working days of the receipt of the information from the IPA. If the coverage plan is denied, ECHO may determine reassignment of the Members. H. PCPs must complete an ECHO PCP leave of absence coverage form at the time of Recredentialing so that ECHO has a record of who will provide services during the PCP’s future leave of absence. The PCP must advise the PSR of any changes to this plan if they occur in the interim.
92
PROVIDER NETWORK
C. IPA Reported Provider Changes – Provider Termination
APPLIES TO: The Elite Care Health Organization (ECHO) Staff/IPA/Medical Group, Contracted Providers and Practitioners shall follow the procedures set forth in this policy.
POLICY:
It is the policy of ECHO to ensure that if a provider’s contract is discontinued members may continue access to the provider. It is the company’s policy to ensure notification to members regarding the termination of their Primary Care and/or their Specialty Physician. If a provider’s contract is discontinued members may continue access to the provider without interruption of a covered medically necessary treatment plan that is in process.
PROCEDURE:
1. Once the termination date of a provider is known, ECHO’s IPA manager or designee Is responsible for notifying the Health Plan as well as the Utilization Management (UM) and Credentialing staff. 2. The senior IPA manager and/or designee take steps to limit the influx of new patients to the terminating physician(s). 3. The UM staff creates a request to the information systems department for a list of all members who: a. Have had service from the provider within the last three (3) months b. Members seen two or more times within the past six (6) months c. Are currently receiving services d. Most authorizations are valid for one hundred and twenty (120) days, however, for certain conditions an authorization may have an extended period of days. e. Have an open authorization but have not yet initiated the service. f. Have an open authorization for OB care 4. The obtained list of these patients is shared with the Health Plan in order to allow for member notices of the change/provider termination 5. Members, who are in the middle of care, will be notified at least thirty (30) days in advance. Members are instructed on how to transition their care to a new specialist within the network. 6. Members who have referrals but have not yet seen the terminating specialist, the UM staff will coordinate with member and obtain appointments and authorizations for a new specialist. 7. A list of the members that were sent notices as well as a sample letter sent will be forwarded to the Health Plan QI Department for auditing purposes 8. At the request of the member, the member may be provided completion of covered services by a terminated provider if the member was receiving services from the terminated provider for the following conditions (according to Health Plan’s guidelines and verification of eligibility): a. An acute condition-completion of covered services shall be provided for the duration of the acute condition. b. A serious chronic condition-completion of covered services shall be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer/transition to another provider consistent with good professional practice. Completion of covered services shall not exceed 12 months from the contract termination date.
93
c. If applicable, a pregnancy is defined as three trimesters of pregnancy and the immediate postpartum period. i. Completion of the covered services shall be provided for the duration of the pregnancy and the immediate postpartum period. (A pregnancy must have been diagnosed and documented by the terminated provider prior to termination of the agreement) d. Terminal illness-Completion of covered services will be provided for the duration of the terminal illness, not to exceed twelve (12) months. e. If applicable, Newborn Care-Completion of covered services will not exceed twelve (12) months from the provider termination date or beyond the child’s third birthday. f. Surgery or other procedure: i. Performance of the surgery or procedure had been authorized and documented by the terminated provider to occur within 180 calendar days of the agreements termination date. 9. The coverage is not provided if the provider in question left the organization voluntarily, does not agree to comply or does not comply with the same contractual terms/conditions in effect prior to termination (unless otherwise negotiated), or was terminated for a medical disciplinary cause, fraud or other criminal activity. 10. When a provider terminates or is terminated, ECHO will notify the Health Plan within ninety (90) days of the termination date, or upon notification from the provider. 11. Reinstatement letters will be sent to members in those rare instances when a terminated specialist is reinstated into the network within 90 days of the termination
94
CLAIMS PROCESSING
A. Sorting and Batching Claims
APPLIES TO: The Elite Care Health Organization (ECHO) staff shall follow the procedures set forth in this policy.
POLICY:
ECHO shall employ the process outlined in this policy to sorting and batching claims that are received in the mailroom via correspondence from any entity.
PROCEDURE:
Sorting Process: The ECHO assigned mail processing staff shall separate the claims and correspondence that is received on a daily basis
The assigned staff shall place incoming Claims mail as separated per Claim mail as follows:
Bin #1: All incoming Claims – Documents identified as an actual Claim Double date stamp claims will be batched separately and processed as priority. Bin #2: All claims related correspondence, not identified as a Claim.
Internal Mail Delivery Schedule to the Claims Department. Bin #1 and Bin #2 shall be hand delivered to the Claims Supervisor or assigned designee by 11AM each business day.
Receiving Certified Mail: Any Certified Mail that is received by ECHO will be assigned mail processing staff for further processing.
For tracking purposes, the assigned mail processing staff is required to obtain the signature of any individual who received certified mail.
This signature will be documented on the “Certified Mail Log” which indicated that this correspondence was received and delivered by the mail processing Staff as instructed by the United States Postal Service.
Receiving Faxes: Faxes received in the Claims department shall be sorted for further processing by the assigned Claims department staff.
The assigned Claims staff shall access Claims eFax system daily at 12 noon and 4 pm for incoming faxes received via eFax.
Any faxed correspondence that meets or exceeds the definition of a claim submission will be processed as such should this correspondence contain any one of the following characteristics: CMS1500 form UB04 form Appeal or provider dispute Contested claim submission
95
Misdirected claim submission Medical records UB04 ERISA PDS
Claims and other documents mailed out: Mail clerk will mail out provider checks, misdirected claims, PDR letters, Member denial letters, etc.
Handle mail return: The mail room clerk will contact the provider for undeliverable mail for correct address and have the provider provide their W9 to confirm the address.
CLAIMS PROCESSING B. Claims Encounter Data Reporting
APPLIES TO: The Elite Care Health Organization (ECHO) staff shall follow the procedures set forth in this policy.
POLICY:
ECHO submits the required encounter data as stipulated by specific Health Plans.
PROCEDURE:
1. Once an Agreement between IPA/Medical Group and a Health Plan is executed, the ECHO IT department established Health Plan Specific Encounter Data Reports or a Monthly Claims Scorecard, as requested by the specific Health Plan, is generated and sent to each Health Plan via referred communication as stipulated in the Agreement. 2. The data elements are Health Plan specific. This may include but not limited to the following: a. Claims Received b. Claims Adjudicated c. Percentage of clean claims processed within 30 days. d. Average days to process claims e. Number of claims with interest paid f. Dollar amount of interest paid g. Claims inventory 3. Unless otherwise indicated by the Health Plan, ECHO shall follow this protocol: a. The claims encounter data is reported on the Health Plan specific template. i. The format (may be reported on an 837 file or a flat file depending on the Health Plan requirement). ii. The data submitted represents service date or paid date, based upon the Health Plan guidelines. iii. Encounters are reported by Health Plan by Line of Business b. All encounter data is submitted via the ECHO/IPA/Medical Group Encounter FTP folder. c. All encounter file submissions have a corresponding Encounter File Transmittal Form via Email
96
d. Each encounter file contains all capitated claims processed for that data month e. ECHO shall follow the specific Health Plan requirements for documenting/correcting: i. Duplicate files ii. Historical additions iii. Corrected Encounters iv. Rejected Encounters f. Should there be no encounter data to submit, the Provider Contracting Manager notifies the Health Plan via the Health Plan specific preferred method of communication. 4. ECHO certifies the accuracy and completeness of encounter data submission concurrently with each file submission. The Chief Executive Officer or delegated staff certifies the data prior to transmission
CLAIMS PROCESSING C. Correct Claim Determinations
APPLIES TO: The Elite Care Health Organization (ECHO) Staff/IPA/Medical Group, Contracted Providers and Practitioners shall follow the procedures set forth in this policy.
POLICY:
ECHO will make correct claim determinations, which include developing the claim for additional information, when necessary, for Services obtained from a non-contracting provider when the services were authorized by a contracted provider or the MAO; Ambulance services dispatched through 911 Emergency Services; Urgently needed services; Post-stabilization care services; and Renal dialysis services that Medicare members obtain while temporarily out of the service area.
PROCEDURE:
1. If the contracted provider has referred a member to a non-contracted provider for service, that claim must be paid. 2. If a member is out of the service area and receives care under certain circumstances, those claims must be paid. 3. In order to determine when to deny such claims, claim development is required as defined below. When there is no referral or prior authorization for the service(s) rendered:
SCENARIO AUTHORIZATION CLAIM ACTION REQUIREMENT(s) a. Claim is received from out Need to determine the reason If all other edits are passed, this of area provider not for the services, If claim is for claim must be paid. contracted with dialysis, ambulance, and IPA/Medical Group. emergency – claim cannot by denied for no authorization
97
b. Claim is received for No authorization is required. Same as above emergency ambulance transport dispatched by way of 911. c. Claim is received for dialysis No authorization is required. Same as above that is deemed to be out of the service area. d. Claim is received from a Review claim to see if referring If the referring provider is non-contracted provider provider is present; determine if contracted, claim must be paid. referring provider is contracted. If not present, need to make Verify the name and NPI of the documented attempt to contact referred by provider in field 17 servicing provider before claim and 17a or 17b on the CMS1500 can be denied. The process must include at least one phone call, fax, or mail to obtain the name and provider of the referring provider. If the servicing provider is the same as the referring provider on the field 17, the claim may be denied. This would mean that the non-contracted provider had referred the member to him or herself. e. Claim is for emergency No authorization is required. Claims for emergency services services are not subject to review. ECHO will not request medical records for all lower level codes billed – those will be auto paid. However, if fraudulent billing is suspected ECHO may request medical record for review. All higher codes (99285 and above) are subject to review by Medical Director.
98
CLAIMS PROCESSING D. Timely Payment of Non-Contracted Providers Clean Claims
APPLIES TO: The Elite Care Health Organization (ECHO) Staff/IPA/Medical Group, Contracted Providers and Practitioners shall follow the procedures set forth in this policy.
POLICY:
ECHO shall comply and pay 95% of “clean” claims from non-contracting providers within 3 calendar days of receipt.
PROCEDURE:
1. The Claims department is responsible for timely adjudication of non-contracted provider clean claims. 2. The Claims department must pay 95% of “clean” claims from non-contracting providers within 30 calendar days of receipt. 3. The count days stars with the claim receipt date and ends when the check mail date 4. Outlined below is the process flow for the timely payment of non-contracted providers’ clean claims:
Non-Contracted provider claim is
received
yes Is this a Clean no Claim?
95% of all clean claims All such claims must be paid must be paid or denied or denied within 60 days of within 3o days. receipt of the claim.
yes no Calculate STOP Claim paid timely? Interest Due
99
CLAIMS PROCESSING E. Claim Denials
APPLIES TO: The Elite Care Health Organization (ECHO) Staff/IPA/Medical Group, Contracted Providers and Practitioners shall follow the procedures set forth in this policy.
POLICY:
If ECHO denies payment, the written denial notice (CMS-Integrated Denial Notice [IDN]), or an MA health plan Regional Office-approved modification of the IDN, must be sent to the member. The written denial must clearly state the service denied and the denial reason.
For each claim that is either denied, adjusted or contested, the payer shall provide an accurate and clear written explanation of the specific reasons for the action If ECHO denies a request from a non-contracted provider, ECHO will notify the non-contract provider of the specific reason for the denial and will provide a description of the appeals process. Non-contracted providers will include a signed Waiver of Liability (WOL) form holding the enrollee harmless regardless of the outcome of the appeal. NDP letters must be sent within 60 days of receipt for any non-clean claim. ECHO may contest or deny a claim, or portion thereof, by notifying the provider in writing that the claim is contested or denied within 45 working days after the date of receipt of the claim by ECHO. – MediCal
PROCEDURE:
1. If a claim sis to be denied in whole or in part, for a contracted provider, an Explanation of Payment must be sent to the provider with this information. 2. Since the contracted provider cannot pursue the member for payment, the member has no liability and no notice needs to be sent to the member of the denial. 3. If the claim is from a non-contracted provider, both the provider and the member must receive written notice of the denial that include appeal rights language approved by CMS
GUIDANCE DETAILS NOTES a. A non-contracted provider may pursue the member for payment of their claim; they have no contract with the health plan that prevents them from doing so. b. If the non-contracted The Appeals Department will The Appeal cannot be opened or provider wishes to appeal provide the non-contracted processed until the signed the group’s denial, they provider who wishes to file such waiver form is received from the must waive their right to an appeal with a Waiver form. noncontracting provider pursue the member for payment of the same claim
100
c. ECHO will use the CMS Health plan/delegated entity approved Integrated Denial may add a cover sheet with of Payment to explain the their logo, member name and services being denied and address and provider name and the reasons for the denial address. and appropriate appeals and WOL language for non- contract providers. d. Appropriate contact Health plan/delegated entity information must be may use an Explanation of inserted into the Notice of Benefits (EOB) for member – in Denial of Payment addition to the Notice of Denial of Payment.
101
COMPLIANCE A. Auditing and Monitoring
APPLIES TO: The Elite Care Health Organization (ECHO) Staff/IPA/Medical Group, Contracted Providers and Practitioners shall follow the procedures set forth in this policy.
POLICY: An important component of the Compliance Program is the use of audits and/or other evaluation techniques to monitor compliance and assist in the reduction of identified problem areas. The Elite Care Health Organization Compliance Office will establish a process to ensure that our operations and programs are in compliance with applicable laws, regulations, policies, procedures, and the code of conduct.
PROCEDURE:
1. The Compliance Officer is charged with ensuring this policy is carried out, and will report the overall results of these reviews to Elite Care Health Organization management on a regular basis and to the Elite Care Health Organization Board of Directors at least annually. 2. Ongoing auditing and monitoring efforts will focus on the following areas as appropriate. All billing for services rendered to ensure accurate coding and sufficient chart documentation to substantiate the claims submitted for reimbursement. Compliance with laws, regulations, policies, procedures, and the code of conduct relating to referral arrangements, coding, claim submission, reimbursement, supervising physicians in teaching settings. Compliance with specific rules and policies that have been the focus of particular attention by third pay payers, regulatory agencies, Special Fraud Alerts, audits and settlements at other institutions. Areas of concern identified by any internal processes, including the hotline operation, external auditor, etc. 3. Errors or overpayments discovered as a result of the ongoing auditing and monitoring will be disclosed to Elite Care Health Organization management and legal counsel; resulting in the prompt return of any overpayment as deemed appropriate, with appropriate documentation and a through explanation of the reason for the refund. 4. When monitoring discloses program deficiencies, appropriate immediate corrective action measures shall be implemented. 5. The Compliance Officer will work with management to develop an annual auditing and monitoring plan to address identified risk areas related to compliance with laws and regulations, as well as organizational policies, procedures, and the code of conduct. 6. Ongoing auditing and monitoring efforts shall include: interviews with management responsible for operations (e.g. coding, claim development and submission, patient care, and other related activities); reviews of medical and financial records and other source documents as deemed necessary that support claims for reimbursement in order to ensure accuracy of claims.
102
103