UM WORKSHOP SUMMER 2006
July 24th – Walnut Creek Marriott July 26th – Woodland Hills Marriott July 27th – Irvine Marriott
Sponsored by: The Blue Cross of California Foundation
2006 ICE UM Workshop
8:00 9:00 9:15 9:35 10:30 10:50 12:00 1:00 1:45 2:30 3:15
Registration Welcome and Introductions Standardized UM Referral Forms Commercial UM Tools and Templates Denial Reasons, UR Criteria and DMHC Requirements Commercial Case Review Exercise Lunch CMS Tools and Templates CMS Case Review Exercise Grijalva: Expedited Appeals Q&A
Upon completion of this program, participants will be able to: Describe the elements of the new standardized referral and direct referral specialty forms. Describe the elements of the ICE Commercial Pre-service Denial Notice (PSDN) template. Understand the instruction guides for the standardized referral forms and PSDN. Implement internal organizational processes for monitoring and identifying opportunities for improvement. Identify the 3 critical elements of a denial reason following interactive review of DMHC requirements. Produce at least 2 denial reasons that incorporate the DMHC requirements during group work time. Identify the recent revisions to the ICE Commercial and CMS/MA template and tool revisions. Identify the purpose of each ICE Commercial and CMS/MA notice and be able to use the notices correctly. Identify appropriate reasons for extensions of the decision time frame. Identify the differences between standard and expedited initial organizational determinations. Describe Lumetra’s role in working with patients, providers, and physicians to ensure appropriate implementation of the expedited appeals process that maintains patient quality of care while avoiding premature discharges or unnecessary continuation of stays. 12. Demonstrate key steps in the expedited appeals process, including those addressing the physician’s responsibility, and those involving delivery of proper patient notification. 13. Identify how the Part A Payer interfaces in the expedited appeals process. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Provider approved by the California Board of Registered Nursing, Provider Number 9735 for 5.5 contact hours. Special thanks to Blue Shield of California for their support in serving as the continuing education provider for this program.
Sharon L. Brown, RN, MHA Health Net of California, Medical Program Manager Sharon received her Masters in Health Administration from Chapman University and has a BSN from Michigan State University. She is a licensed R.N. in California and Texas with over 32 years of healthcare experience. Of those, 15 years have been in managed care administration with more than 10 years in UM/QM and CM in a capitated insurance setting. She has over 5 years management experience with successful staff development, skilled knowledge of automated authorization systems, information analysis, regulatory oversight, educational presentations, project management, and team-building programs. Sharon is currently the Co-Lead of the ICE Service Denial Standardization Commercial Team. Theresa Clarke, RN, BA Blue Shield of California, Quality Compliance Manager In 2004 worked at a medical group educating staff and clinicians on updates for NCQA, legislation and other regulatory requirements for utilization management. Currently holds a position at Blue Shield of California as the Quality Compliance Manager accountable for planning, organizing, leading, monitoring, analyzing, interpreting, and implementing functions, activities, and principles of quality related to accreditation and regulatory requirements within Quality Compliance consistent with organizational policies and procedures. Carole Crawford, RN, BS, CPHQ PacifiCare, a UnitedHealthcare Company, Clinical Management Specialist Carole is a graduate of the University of Redlands with a Bachelor of Science degree in Business and Management. She is a Registered Nurse with more than 20 years experience in the clinical setting as a Critical Care Nurse and Hospital Supervisor. After leaving the acute care setting, she directed utilization management and quality management at an Independent Physicians Association. She also developed and instituted a comprehensive health education program for HMO members. For the past 11 years, she has worked at PacifiCare on the Clinical Management team. During this time she has been accountable for legal and regulatory oversight of delegated activities with contracted provider groups. These activities include, but are not limited to, Utilization Management, Quality Management, Quality Improvement, Credentialing, Appeals, Grievances, Peer Review and Medical Records Systems. Carole has been instrumental in the development of the content for and the presentation of the PacifiCare Quality Networking meetings and the Network Management Training held throughout the year. Carole earned her Certified Professional in Health Care Quality in 1995. Karen Driskill, RN, BSN Heritage Provider Network, Clinical Services Director Karen is a candidate for the Masters Degree in Healthcare Administration/Business Administration. She received her BSN from the University of Phoenix in 2003. Karen has 15 years combined clinical and managerial nursing experience and 10 years progressive experience in managed health care analyzing and developing processes. She designed and facilitated a medical group inpatient care management program that decreased complaints and appeals; developed Health Plan and Medical Group Denial Determination Training Programs that resulted in improved regulatory compliance; and Restructured, streamlined and managed regulatory compliance process for a limited Knox-Keene Medical Service Organization. Karen has a strong knowledge base in Quality and Utilization Management, National Committee on Quality Assurance and Utilization Review Accreditation Committee standards. Previously held positions include Utilization Management Manager at SCAN Health Plan, and Nursing Supervisor at South Bay Acute Dialysis. Karen is the Co-Lead of the ICE Service Denial Standardization CMS Team. Nathalie Gonzales, RN, ASN Blue Cross of California, Clinical Quality Auditor, Senior Nathalie is a 1988 graduate of Chapman University. She has been a Registered Nurse for 18 years, and has 21 years of healthcare experience. Her clinical background includes Cardiac Surgical ICU, Heart and Lung
Transplant ICU, and Emergency Room Nursing. Before leaving patient care, she worked in Home Health Nursing as well. Nathalie joined Blue Cross of California in 1996. During her 10 years at Blue Cross she has worked in both Utilization Management and Case Management. Nathalie joined the Regulatory and Accrediting Department in October of 2005. For 2 years she served as the Lead Nurse Case Manager of Commercial HMO and Medicare Operations. Her responsibilities have included, training of HMO and Medicare UM process, project management, process development and improvement, developing and implementing policy, performance management, and Medicare audit preparation and participation. Linda Griffin, RN, MS Blue Cross of California, Clinical Quality Auditor, Senior Linda is a graduate of the University of LaVerne with a Masters of Science degree in Health Administration. She has 22 years experience in the clinical setting as a Critical Care Nurse, Hospital Supervisor, and Utilization Management/Social Services/Discharge Planning manager. She has worked for Blue Cross of California for ten years. She started out working in UM for the State Sponsored Programs and transferred to the Quality Management department. For the last one and a half year she has worked as a Clinical Quality auditor for the commercial product. She has acted as a liaison for Blue Cross and members assigned to PMGs/IPAs. She has been responsible for development and updating of policies/procedures and audit tool for oversight of contracted organizations, reporting of due diligence requirements of Groups/IPAs and auditing areas of Utilization Management, Quality Management, Member Rights and Responsibilities and Credentialing at group level. She earned her Certified Professional in Health Care Quality in 1993. Wanda Hampe, RN, CPHQ PacifiCare, a UnitedHealthcare Company, Clinical Management Specialist Wanda has worked in managed care over the past 17 years and at PacifiCare for 12 years on the Clinical Management team. Focus of experience has been in regulatory oversight activities with contracted provider groups, QI activities, and provider education. While at PacifiCare, responsibilities have included provider audits, provider education, and interaction with provider groups related to performance with appeals, grievances, member satisfaction, and the PacifiCare provider report card, the Provider Profile. Auditing experience used to demonstrate PacifiCare's regulatory compliance includes Quality Improvement, Utilization Management, Medical Record Systems, Credentialing, and DHS Surveys. Past experience includes 5 years in Managed Care Quality Improvement and 3 years at a Medicare Intermediary in Medical Review and Provider Relations. Prior hospital experience over fourteen years was primarily spent on the surgical floor in RN and LVN positions. Estelle Hoch, RN, BA SCAN Health Plan, UM Consultant Estelle received her RN degree from Middlesex Memorial Hospital in Connecticut and her BA from the University of Redlands. Her 35+ years of nursing experience includes hospital nursing on medical-surgical, burn, gyn-oncology, and neonatal intensive care units. Since 1987 Estelle has been involved in managed healthcare in health plan, capitated hospital system, and medical group / IPA settings in staff and management roles. She was a hospital utilization review/discharge planning nurse, prospective review nurse and was the Director of UM, QI and Risk Management in a hospital system. She directed UM, QI and Credentialing functions for a start up IPA that grew from 3,000 to 30,000 members in two years. In addition to her case management experience, Estelle most recently worked in health plan / regulatory compliance, developing and training staff in the requirements, and implementing processes to improve compliance. She was team leader for the implementation of an automated referral authorization system, training staff, physicians and writing training manuals and is now consulting in UM processes. Estelle has been active in the ICE Service Denial teams since 1999 and enjoys new challenges. She is currently the Co-Lead of the ICE Service Denial Standardization Commercial and CMS Teams. Patricia Hokenson, RN, MSN Centers for Medicare and Medicaid Services (CMS) Division of Medicare Health Plans, Region IX, San Francisco, CA Nurse Consultant Patricia joined CMS Region IX in December of 1999 to support the implementation and monitoring of the Quality Improvement System for Managed Care (QISMC). Prior to CMS, she was a Medicare compliance
manager and regional compliance leader at a managed care organization. Additionally, her managed care industry background includes case management and quality improvement experience. Clinically, she has over 20 years of nursing experience that includes teaching in the BSN nursing program at San Francisco State University. Patricia received her basic nursing education in a diploma program at St. Joseph’s College of Nursing, San Francisco, and her Bachelor of Science in Nursing (BSN) from the University of San Francisco and her Master of Science in Nursing (MSN) from the University of California, San Francisco. Leigh Anne Maxwell, RN, CCRN Blue Cross of California, Clinical Quality Auditor, Senior Leigh Anne has been an Auditor for Blue Cross of California for the past year. During that time, she was the team leader for the 2006 UM Reviewer Guidelines and has initiated UM interventions with Provider Groups. In addition to providing individual assistance for various groups, Leigh Anne has taken on many projects to ensure and measure compliance with regulatory agencies. An RN since 1991, she is currently in her final year of BSN studies at California State University, Dominguez Hills and plans to pursue her masters in nursing education. Prior to working at Blue Cross, Leigh Anne assisted with discharge planning in the NICU at Dameron Hospital in Stockton. She has worked for American Medical Response facilitating repatriation for Kaiser Permanente and other health plans. In 1998, she helped institute an outpatient CHF clinic for a local cardiology group to reduce the readmission rates for class IV CHF. During that time, she was also a CCU charge nurse at John Muir, and a member of the Nursing Council and Safety Committee. Donna McIvor, RN, BSN Lumetra, Appeals Manager Donna received her BSN at D’Youville College in Buffalo, NY in 1981. Completed all coursework for an MSN in Community Health Nursing at D’Youville College in 1997. Past original member of D’Youville’s chapter of Sigma Theta Tau, the National Honor Society in Nursing. Asked to be a seated member of the Erie County Consumer Protection Board in Buffalo, NY for 4 years. Worked as an RN at Millard Fillmore Hospital for 8 years primarily in the Operating Room, but also in the Urology Clinic and ICU and 4 years experience as an RN in a high volume trauma hospital, Sheehan Memorial Hospital. Worked in the OR, ER, Recovery Room, and Burn Treatment Center. Worked for Social Security Disability for 16 years, started as an original employee when the office opened in Buffalo, NY in 1983 as a Disability Analyst and then promoted in the course of years to a Disability Hearing Officer for the last 3 years. Traveled NY State to hold hearings in many small upstate NY towns and cities as far east as Syracuse, down to the Pennsylvania line, and up to the border of Ontario, Canada. Came to California in 1999 to start working as an Executive Recruiter for the high tech start-up industry – eventually becoming an Account Manager for a Business Development and Marketing company for 5 years. Felt compelled to return to the health care arena – worked as the VP Marketing and Aesthetics RN for Women’s Care for Health for one year. Became certified in Laser Hair Removal, Botox injections, and insertion of collagen fillers. Presently, working for Lumetra, California’s Quality Improvement Organization (QIO) as the Appeals Manager since March 2005. Handling all types of appeals from the Grijalva cases to the newest BIPA appeals cases, HINNs and NODMARs. Managing a staff of 11 Appeals Specialists and recently added the Helpline staff. Have held 3 statewide Webex training sessions on the BIPA appeals process in February 2006, have spoken in 2 separate seminars, and gearing up to hold more 3 more training sessions on the BIPA and Grijalva appeals process. Kathryn Petroni, RN, ASN Blue Cross of California, Clinical Quality Auditor, Senior Kathryn has been with Blue Cross of California in the Regulatory and Accrediting Oversight Department as a Clinical Quality Auditor since 1999. Within the scope of this position she has been involved in revising
the Blue Cross of California Reviewer Guidelines on an annual basis. This involves researching regulatory requirements for NCQA, CMS, DMHC, and URAC and creating a corresponding indicator for the audit tool/guidelines. Provider Group education regarding regulatory compliance is ongoing. Kathryn has also been involved in training newly hired auditors. Previously Kathryn was employed by a home health agency as a case manager/discharge planner for routine medical and hospice care. She worked closely with patients and family members educating them regarding their care and health maintenance. Hospice families required on-going education and reassurance regarding hospice care, pain management, medication management, nutrition and the dying/grieving process. Prior to working in home health Kathryn was a staff developer. During the course of her employment she organized/created and conducted weekly CEU classes for CNAs, LVNs/RNs. She also created, implemented and managed a skin care and wound care program for the facility. Delilah Samson, RN, MPH, CPHQ Blue Cross of California, Clinical Research Manager Delilah received her Masters Degree in Public Health from California State University, Long Beach. In her current position as Clinical Research Manager, she is primarily responsible for monitoring and tracking of the Blue Cross of California DMHC-CDI Quality Undertaking activities and development and revision of departmental policies and procedures, audit guidelines and tools, and training of new staff. As a delegation oversight nurse during the past 10 years, she conducted UM, QM and Credentialing audits and collaborated with Physician Organizations in the development and enhancement of medical management activities to ensure compliance with Health Plan and regulatory and accrediting standards. Prior to joining Blue Cross of California, Delilah worked for the Department of Health Services, Los Angeles County for 16 years. She held various hospital-based administrative positions including Director of Risk Management, Nursing QI Assistant Director, and Clinical Risk Manager. Her clinical experience includes 8 years as a Neonatal Intensive Care Nurse and Labor & Delivery Staff Nurse. Delilah is currently the Lead of the ICE Service Denial Standardization Main Team and the QI-UM Required Reports Team. Beth Short, RN, BSHS, CPHQ PacifiCare, a UnitedHealthcare Company, Program Manager, Provider Audit Beth has worked in managed care since 1988 and at PacifiCare on delegation oversight since 1997. She has held a CPHQ since 1998 and held past InterQual CPUR. She is responsible for ensuring that the PacifiCare of California delegation oversight process is performed in a manner consistent with legal and regulatory requirements and accrediting standards. Ms. Short leads enterprise-wide development and implementation of audit tools, letters and data systems. She provides reporting and analysis of delegation oversight processes for regulatory and accrediting bodies. She trains staff on the accrediting and regulatory requirements relating to UM and is a past presenter for ICE. Beth’s previous experience includes performing UM and managing the UM department during 6 years at a large medical group with HMO, PPO and TPA business. She also worked as the UM nurse for 3 years at a regional trauma center of over 300 beds, with significant Medicare and Medi-Cal populations. Clinical experience included eleven years in NICU, PICU, Pediatrics and hospital-based outpatient clinics. Suzanne Zelazny, RN Blue Cross of California, Regulatory and Accrediting Oversight Performance Audit Manager Suzanne has worked in managed care since 1987. She was in charge of training and quality review at Prudential Healthcare in the UM and Case Management Department for point of service, PPO and indemnity products. She has been manager of Regulatory and Accrediting Oversight at Blue Cross of California since 1997 which includes oversight of HMO and Medicare contracted groups and entities in California, Colorado and Nevada as well as the internal audit process for various departments in UM, grievance and appeal and pharmacy. She received her RN Diploma from Buffalo General Hospital School of Nursing in Buffalo, NY. In her clinical days, she served as staff nurse in med-surg and as a preceptor for nursing students. Suzanne is the Lead of the ICE Standardized UM Referral Form Team.