An Assessment of The New York State Behavioral Health System’s Readiness to Transition to Medicaid Managed Care

Abstract

New York State has one of the most richly funded Medicaid programs in the United States. In an effort to achieve the triple aim New York State is undergoing a significant redesign of its Medicaid program including transitioning nearly all Medicaid funded behavioral health services into Medicaid managed care. In preparation for this transition, a state funded technical assistance center assessed the behavioral health care system’s readiness to undergo this reform across 11 domains. Between September and November, 2014, the TA center electronically distributed a readiness survey to 897 mental health and substance abuse agencies: 313 (n = 269, 33%) organizations completed the assessment. As a whole, the sample felt partially ready to transition; analysis by domain revealed agencies were most ready to interface with managed care providers, and least ready to collect and evaluate outcome data. Significant differences in readiness were found depending by organizational characteristics (number of programs, licensure, and region). In anticipation of large-scale reforms, states would benefit from an initial needs assessment to identify gaps in knowledge and skills, which in turn, can then guide preparatory efforts and provide needed supports to facilitate major changes in service delivery and billing.

Appendix

Managed Care Technical Assistance Center Medicaid Managed Care (MMC) Readiness Assessment Tool

This MMC Readiness Tool is designed to provide organizations with 11 categories of processes, practices and change management activities needed to effectively prepare for and function during the early stages of a business relationship with a Managed Care organization. When completed, the self-assessment tool offers a snapshot of the organization’s current level of readiness as well as an assessment of the need for technical assistance. This tool may be helpful as a planning resource to guide organizations in their preparation and decision making activities. Statements presented will be answered either as Yes/No or on a scale from 1 to 5 as defined below:

• 5 = We are definitely ready right now (we currently have the needed knowledge, resources, infrastructure, and plans in place)

• 4 = We are mostly ready (we are unlikely to need technical assistance to get this done on our own in a timely manner)

• 3 = We are moderately ready (we may or may not need technical assistance to get this done on our own in a timely manner)

• 2 = We are somewhat ready (we are likely to need technical assistance to get this done in a timely manner)

• 1 = We are not at all ready (we will definitely need technical assistance and guidance to get this done in a timely manner).

The Managed Care Technical Assistance Center strongly suggests that an agency bring its leadership team together and respond to the series of statements collectively. The discussion will not only assure that the answers are an accurate reflection of managed care readiness, but may also represent the beginning of your planning process to address any opportunities identified during the conversation.

Readiness item	Readiness rating (1–5) or yes/no
Understanding MCO priorities and present managed care involvement
Your organization currently holds contracts with one or more managed care organizations	Yes or no
Your organization has identified a point person in the organization who is responsible for understanding MCO priorities; directing agency policy and interactions	Yes or no
Your organization knows which managed care organizations reimburse for services you provide in our service region	Yes or no
Your organization has held meetings with leadership of the MCOs to understand their expectations and discuss opportunities to work together on system priorities	Yes or no
Your agency/facility leadership team knows and understands the array of BH services provided within your system	Yes or no
Your organization’s board is actively involved in planning for the transition to managed care	Yes or no
Your organization’s board would benefit from technical assistance specifically targeted for board members	Yes or no
Rate your organization’s readiness to meet with MCO leadership to understand their expectations and discuss opportunities to work together on system priorities
Rate your organization’s readiness to market services to an MCO
MCO Contracting
The organization has identified an individual to be responsible for providing oversight to MCO contracting	Yes or no
Rate your organization’s capability to understand the requirements of the managed care contracts you have
Rate your organization’s capability of assessing compliance with the requirements of the managed care contract you have
Rate your fiscal staff’s capability of assisting with pricing issues during contract negotiations
Rate your fiscal staff’s ability to readily compare actual to anticipated revenue and expense by contract
Rate your organization’s understanding of CMS compliant codes that will be used for billing
Communication/reporting (services authorization, etc.)
Your organization has a designated liaison responsible for communication and reporting with the MCOs	Yes or no
Your organization knows the reporting requirements for the MCOs in your region with which you contract	Yes or no
Your organization knows the name and contact information for the Provider Relations Department for each MCO with which you contract	Yes or no
Rate your organization’s knowledge of the MCO data exchange requirements and the required formats for submission
Rate your organization’s knowledge of the steps for member verification for each plan and who within the plan to contact when questions arise
IT system requirements
Your organization has determined whether there are specific IT system requirements with which you will need to comply when working with the MCOs	Yes or no
Rate the capability of your organization’s IT system to handle the following functions
∙ Centralized scheduling
∙ Clinical data with a meaningful use certified electronic health record (treatment plans, medication prescribing and management, progress notes, etc.)
∙ Submission of claims electronically (using both 837i and 837p billing formats)
∙ Financial accounting and revenue cycle management tools
∙ Reporting
∙ Quality assurance
Rate the capability of your IT system to integrate functions for client information; services utilization and financial information, including payer type by client
Your IT infrastructure meets HIPAA security standards and your access controls adequately mitigate the risk of breaching PHI	Yes or no
Rate the capability of your organization to run formatted and ad hoc reports from your electronic health record and billing applications
Your organization understands the clinical information that must be available /maintained for the members you are serving	Yes or no
Your organization is connected to the Regional Health Information Organization (RHIO) for your service area	Yes or no
Rate the capability of your IT system to report out client and services information to all major payers
Level of care (LOC) criteria/utilization management practices
Your organization has an individual responsible for knowing MCO requirements and procedures regarding communication of level of care for each MCO	Yes or no
Your organization has an individual responsible for knowing MCO requirements and procedures regarding utilization management practices for each MCO	Yes or no
If yes to above statement, this individual has information concerning LOC and utilization management for each MCO in your region	Yes–partially–no
Rate your organization’s readiness to meet MCO service authorization requirements, including time frames
Rate the capability of your clinical supervisors to understand the MCO utilization management requirements and supervise staff to practice accordingly
Rate the capability of staff members in your organization to understand and effectively meet MCO LOC and utilization management expectations
Rate your staff members’ capability to articulate the clinical need for services, including the ability to translate psycho-social issues, such as homelessness, into a clinical need
Regular training is provided to assure a current understanding of LOC and utilization management expectations	Yes–partially–no
Your organization is capable of assessing whether staff are able to effectively work within the LOC/UM expectations established by the MCO	Yes–partially–no
Your organization has a mechanism for providing feedback to/having discussions with MCOs concerning LOC, UM, denials and appeals expectations	Yes–partially–no
Rate the capability of your organization to monitor ongoing authorizations and prompt staff to seek initial and re-authorizations when appropriate
Your organization has an individual responsible for knowing MCO requirements and procedures for obtaining authorizations for covered services	Yes or no
Your organization has an individual responsible for knowing MCO requirements and procedures for transition of care	Yes or no
Member services/grievance procedures
Your organization has assigned a person to be responsible for understanding MCO member services expectations	Yes or no
Your organization has assigned a person to be responsible for understanding MCO complaints, grievances and appeals processes	Yes or no
Rate your organization’s ability to train staff regarding MCO Member Services
Rate your organization’s ability to train staff regarding MCO complaints, grievances and appeals processes
Interface with physical health, social support and health homes
Rate your organization’s ability to effectively interact with physical health providers on behalf of the recipients you serve
Rate your organization’s ability to effectively interact with social services providers on behalf of the recipients you serve
Rate your organization’s ability to effectively interact with health homes on behalf of the recipients you serve
Your organization works closely with inpatient and/or detox providers to coordinate linkages and transition to and from levels of care	Yes or no
Your organization has contracted with one or more health homes	Yes or no
Quality management/quality studies/incentive opportunities
Your organization has an individual responsible for managing the quality assurance/quality study expectations of MCOs	Yes or no
Your organization has sufficient staff assigned to the QA function	Yes or no
Staff members in your organization have been made aware of the MCO quality expectations and QA procedures have been shared with staff	Yes or no
Rate your organization’s understanding of QARR and HEDIS measures for Physical Health and Behavioral Health services
Rate the capability of your organization’s clinical practices to meet established MCO quality assurance/quality study expectations
Rate the capability of the organization’s QA function to closely tie to your management information system
Rate the capability of your supervisors and clinical staff to receive and then act on regular QA reports
Rate the capability of the organization’s QA function to maintain records of managed care appeals and suggest strategies for improving relationships and/or modifying service delivery to reduce denials
Patient satisfaction surveys or Perception of Care tools are a function of your organization’s QA process	Yes or no
Finance and billing
Your organization has an individual (or a financial management consultant) who has experience billing MCOs	Yes or no
Rate the ability of your organization to submit clean claims to MCOs on a timely basis
Your organization understands the appeals process for denials of claims	Yes or no
Rate your organization’s ability to appeal denied claims: read remittances and resubmit
Rate the ability of your organization to accurately capture and report the unit costs of services being reimbursed by the MCOs by program and location
Rate the ability of your organization to translate unit costs into episode of care costs
Rate the ability of your organization to monitor the differential between the medicaid payment and your cost, by service type as well as by episode of care
Rate the capability of your organization to regularly communicate cost, revenue, and service value information to all staff
Rate the success of your revenue cycle management infrastructure, building on the service delivery process, to capture and collect every dollar owed to the organization by all payers. Good process would include monitoring and addressing billing collection issues on a daily or weekly basis
Rate the capability of your business office to conduct internal service audits to ensure that documentation of services in patient records can withstand an external audit
Rate the capability of your organization’s corporate compliance process: does it include a bullet-proof compliance plan led by a designated compliance officer and supported by internal monitoring and auditing?
Access requirements
Rate the familiarity if your organization with managed care plan requirements for timely access to services
Rate the capability of your organization to demonstrate that it can meet managed care plan requirements for timely access to services
Do you have a system in place to identify the payor source at the point of service?	Yes or no
Demonstrating impact/value (data management and evaluation capacity)
Your organization has identified, trained, and provided the appropriate software application support to an individual responsible for data analysis	Yes–partially–no
Rate the ability of your organization to collect data related to the volume of services provided
Rate the ability of your organization to collect data related to the clinical impact on the consumers of services provided (quality of care)
Your organization considers both internal as well as external data sources (such as Medicaid claims viewed through PSYCKES) as you look for evidence of your clinical impact	Yes or no
MCO quality expectations have been shared with staff members	Yes or no
Clinical staff members routinely review data being collected about key service delivery processes and clinical outcome measures	Yes–partially–no
Rate the ability of your organization to demonstrate the value of your services (the cost/quality equation) to payers compared to benchmarks
Your organization has the necessary information to understand the outcomes and related measures that define success for the MCOs with which you work	Yes–partially–no