CMA Roster versus NYS Mediciad Analytics Performance Portal (MAPP)
Despite efforts by NYS, Lead Health Homes and Care Management Agencies, approximately 5% - 10% of many CMA's Rosters are still not showing in MAPP, thereby preventing billing. This is caused by a number of complex issues including difficulty transferring a new enrollment that is assigned to another provider in MAPP, communication barriers when facilitating a transfer, complications relating to clients in "outreach hiatus" status, lack of standard policies and procedures, and inadequate training at both the CMA and HH level about process and roles. See addendum for detailed solutions more specifics on the issues (PDF).
Lost to follow-up / Re-engagement Policy
Lead Health Homes and CMA’s are in need of clarification on policies regarding billing for activities conducted to re-engage enrolled Health Home members who are lost to follow up. The lack of clarity has resulted in different interpretations of what constitutes billable re-engagement activity. Re-engagement of ‘lost to follow up’ members has historically been an expected and required function of case management, and it is a critical part of retaining clients in care. Some recent interpretations of billable and non-billable re-engagement activities, including not billing for home or field visits that do not result in face to face contact with the member, will limit the CMA’s ability to carry out costly re-engagement activities that are likely to retain members in care.
Many lead Health Homes have interpreted the State’s Lost to Follow Up guidance, and programmed their billing software, in a manner that prevents CMA’s from being reimbursed for re-engagement activities that do not result in direct contact with clients, regardless of whether those activities are made in good faith or are ‘progressive’ in intensity.
iHealth has requested guidance that will support our continued efforts to re-engage lost to follow up clients, help them stay connected to care, and provide the lead Health Homes with guidance needed for them to evaluate the quality of services being delivered and ensure compliance with standards. We have recommended developing a re-engagement policy to address this issue more thoroughly. See additional recommendations attached.
Managed Care direct access to Lead HH’s Care Management Data Systems
iHealth and its members encourage managed care organizations to partner with lead health homes to obtain direct access to lead HHs care management data systems. This is important to facilitate the plans access to their member's assessment and care plan records and to understand the care management activities that are being conducted. Currently plans obtain this information by reaching out to front line care managers directly. This approach is more labor intensive for the care manager who has already provided this information via the HH's care management data system (GSI, Relevant, etc). Limiting direct contact between the plan and the front line care managers to addressing gaps in care instead of "updates" refocuses everyone on the outcomes desired.
Quality and Performance Measures Input
Care management agencies have learned a great deal since the Health Home Program's inception. It is important to continue to seek their counsel as the lead Health Homes and our state partners continue to develop and refine quality and performance measures, policies and procedures, workflows and standardized forms.
High, Medium and Low (HML) Functional Indicator Questionnaire Process
Currently an HML Questionnaire must be completed for every HH member, every month. iHealth has always advocated for this questionnaire to be required less frequently. Once a response to an HML question enhances someone's rate, it is likely that this person will require enhanced services for a period of months. Indicators such as HIV viral load are also not measured by physicians monthly. When considering homelessness, incarceration, inpatient hospitalization for mental health, active substance use, individuals will generally require enhanced services for an extended period of time. For the purposes of rate setting and documentation, updating the HML questionnaire every six months should be sufficient.
iHealth has continued to advocate with lead Health Homes and data/technology vendors to streamline and improve processes relating to HML and required documentation for HML responses. Vendors must include a mechanism to carry over the past months responses with a click of button to limit work. It is also critical that an algorithm be built around the complex set of documentation requirements to alert front line care managers to documentation deadlines or gaps. Finally, iHealth is requesting additional training for care managers on the latest documentation requirements.
Contracting Gaps Between Lead Health Homes and Managed Care Organizations
CMAs must work with their lead HHs to ensure that all of the members they currently have enrolled are also in managed care plans that are contracted with that lead. The plans are expected to become part of the billing process in October, 2017 and at that time, if a Health Home Member is enrolled through a lead HH that is not contracted with their managed care plan, it will not be possible to bill for HH services. If this issue occurs prior to October, 2017, there is a workaround to get billing through.
HIV Viral Load Suppression and Standards
iHealth recommends that lead Health Homes and data / technology vendors include the tracking of viral load suppression indicators and standards of care for HIV clients through policies and procedures and system enhancements. Much of this information is available in local RHIOs (Healthix) so we must find ways to pull in data automatically whenever possible. Click here to see NYS's Ending the AIDS Epidemic.
Care Plan Updates and Billable Encounters
iHealth encourages Lead HHs and data / technology vendors to develop technology solutions to support the need to link care plan updates to billable encounters. This could be accomplished by making a more direct link between the progress note and the care plan. As a care manager enters their progress note, they should be able to link that encounter easily to one or more care plan goals. This prevents the care manager from having to enter duplicate information in a progress note and then separately in the care plan. Until such options are available, a care plan update should not be required for an encounter to be billable.
The requirement for front line care managers to obtain documentation confirming eligibility for the Health Home Program is challenging as medical providers are not incentivised to provide this documentation. Fortunately, there are many places where eligibility information already exists. Efforts should continue to obtain eligibility confirmation from sources such as PSYCKES, RHIOs, hospital or medical partners, performing provider systems, and local government agencies. Finding ways to automate the exchange of this information will signicantly ease the burden on the care manager and the clients they work with.