LOUISIANA MENTAL HEALTH REHABITATION Pelican Project

1
LOUISIANA MENTAL HEALTH REHABITATIONPelican
Project

• Joe Kopsa, MA, JD
• Section Chief Program Integrity
• DHH Privacy Officer
• James Hussey, M.D.
• Program Director
• Mental Health Rehabilitation Services

2
Rules of the game

• Part 1

3
Rules, Objectives, Players

• Applicable Rule Regs
• MHR Program Purpose
• MHR Services
• MHR Providers
• MHR Stakeholders

4
Applicable Rules Regs

• Optional Service
• Federal Rules
• 42 CFR 4450.130
• State Plan Amendment (SPA)
• Any Willing Provider
• State-wideness
• Freedom of Choice
• State Rules
• Promulgated Rule (MHR State Regulation)
• Provider Manual
• Program Integrity Regulation (SURS Rule)

5
The MHR Program

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

6
The MHR Program

• MHR Services
• Screening Assessment for Medical Necessity
• Community Support
• Counseling (Individual, Group, Family)
• Psychosocial Skills
• Medication Management
• Parent/Family Intervention (Intensive)
• Psychosocial Skills Training Group (Adult)

7
The MHR Program

• Agency Providers
• Owners (Public or Private)
• Managers
• Clinical Service Delivery Staff
• Licensed Mental Health Professional (LMHP)
• Mental Health Professional (MHP)
• Mental Health Specialist (MHS)

8
Program Stakeholders

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

9
The Problem

• Part 2

10
The Problem(s)

• Uncontrolled Program Costs Growth
• Few Demonstrable (positive) Outcomes
• Advocacy Center Concerns
• Critical Media
• Angry Providers
• Sympathetic Legislators
• Limited Budget
• Optional Program

11
Uncontrolled Program Costs Growth

• Program Cost
• Per Year
• 38,890,461
• 49,053,440 21
• 57,874,936 16
• Two year growth rate 31

• Recipient Growth
• Per Year
• 4,824
• 6115 21
• 7164 15
• Two year growth rate 33

12
Programmatic Issues

• Yearly Cost per recipient
• 2003 8,061.87
• 2004 8,021.81
• 2005 8,071.17
• September 2003 Advocacy Letter
• Mental Health Advocacy Group Complains to
  Secretary
• MHR Agencies blame Medicaid Rates

13
Summary of Advocacy Center Complaints September
2003

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

14
Summary of Advocacy Center Complaints Continued

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

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Initial Solution
16
Pelican Project

• Conduct a 100 review of all MHR Providers
• Monitoring Reviews
• Payment and Record audits

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The Tasks

• Monitor and Audit 131 MHR Providers
• Pre-Pelican
• Monitoring of Providers was two years behind
  schedule
• MHR Monitoring Process
• Detailed and lengthy review (30 days/50 pages)
• Onsite review and copying
• Provider and recipient interviews
• Staff Resource Issues

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The Task

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

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Obstacles

• Part 3

20
Obstacles

• Program Organizational Complexities
• Cumbersome Overly-inclusive MHR Administrative
  Monitoring Process
• Cultural Issues

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MHR Table of Organization
DHH Secretary
Under Secretary
Deputy Secretary
Medicaid Director
OMH Assistant Secretary
Program Operations
Program Integrity
MHR
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Cultural Obstacles

• MHRGoals
• Preservation of Program
• Increased Quality, Accountability, Efficiency
• Program Improvement
• Program Operations Goals
• Preservation of Program
• Cost Containment
• Quality Services
• Program Integrity Goals
• Sanctioning Providers

23
Cultural Obstacles

• Approaches
• MHR
• Policy Monitoring
• Program Operations
• Policy
• Program Integrity
• Backend auditing

24
Overcoming Obstacles

• Part 4

25
Overcoming Obstacles

• Joint High Level Meetings
• Secretarys representative
• Medicaid Directors representative
• OMH Asst. Secretarys representative
• MHR
• Program Operations
• DHH Legal
• Provider Meetings

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Working Taskforce

• Weekly Meetings
• MHR staff
• Program Operations staff
• Program Integrity staff
• DHH Legal staff

27
Overcoming Obstacles

• Modifications in monitoring process
• MHR
• Monitoring protocols were modified
• All MHR monitoring reports were sent to Program
  Integrity upon completion of the Monitoring
  Report
• Program Integrity reviewed the monitoring report
• MHR Providers with Programmatic issues sent back
  to MHR Monitors
• MHR Providers with potential fraud and abuse
  issues were taken over by Program Integrity

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Overcoming Obstacles

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

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Overcoming the Obstacles

• Modification in Processes
• Program Integrity
• Six member audit team dedicated to MHR audits
• Six month Audit period to determine if expanded
  audit period should be used.
• Only ten Recipient records reviewed

30
Program Integrity Audit Protocols

• Criminal Fraud Referral to MFCU
• Health Safety Immediate action to move
  clients
• Civil Fraud/Abuse Full PI Audit
• Waste 6 month audit
• Technical billing errors or minor program
  violations Refer back to MHR Monitoring

31
Program Integrity Audit Findings

• Undocumented Services
• Documentation does not support service billed
• Services not covered or on Service Plan
• Altered records
• Unqualified staff
• Services billed for while Recipient was
  hospitalized

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Part 5

• RESULTS

33
Pre-Pelican Project Results
34
Pelican Project Results
35
Results Over Two Year Period

• Fiscal Integrity
• Cost Avoidance
• 64,797,452
• 180 PI Cases
• 49 Recoveries
• 585,604.54
• 14 Referrals to MFCU
• Exclusions
• 5 MHR
• 5 PI

• Programmatic Integrity
• Bi-weekly Meeting MHR, PI, PO and Legal
• Administrative Service Organization

36
Network Profile Summary

• Total MHR Providers 57
• Providers with Isolated Deficiencies 31
• Providers with Open Complaints 7
• Providers with EFT Holds 0
• Pending Administrative Appeals 0
• Providers with possible AG issues 4
• Providers Accredited 57
• Newly Enrolling Providers 3-6

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Part 6

• Lessons Learned

38
Lessons Learned

• Own the problems.
• Hold yourself more accountable than the
  providers.
• Establish excellent honest rapport with
  principal stakeholders. (Providers/Medicaid/Legal/
  /PI/AG/DHH/OMH/MHR)
• Focus on deficiencies CLEARLY articulated
  Supported in Rule.
• Focus on Health, Safety Fraud first, then
  follow up on lesser issues through Administrative
  Actions.
• Standardize ALL procedures and processes
• Summarize and report findings clearly
  regularly.
• Dont ask for it unless you know what to do
  with it.