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					Illinois Fee for Service


     Provider Training
  November 29 & 30, 2005
Agenda
 DMH Overview of Field Test
  process/recommendations and plan for fee
  for service implementation
 Understanding the categories and associated
  rules of funding in fee-for-service
 Fee for service revenue projection tool
 Measuring and reporting productivity
 Compliance ―nuts and bolts‖


                     P ARKER
                     D ENNISON
                                 &
                      Associates, Ltd.
Financial Components of DMH
Contracts
 FFS Medicaid—persons and services eligible
  for Medicaid reimbursement
 FFS Non-Medicaid—persons or services not
  eligible for Medicaid reimbursement
 Capacity grants
     Originally structured to allow all providers to
      continue to have some grant based funding
     Will be re-structured to support services that
      are not well-funded by FFS

                          P ARKER
                          D ENNISON
                                      &
                           Associates, Ltd.
FFS Reimbursement
 Based on FY05 claims submitted through July
   17% of providers billed 90%+ of FFS
    Medicaid/Non-Medicaid contract amounts
   Medicaid billing increased approximately 9%
 Based on FY06 claims submitted for the first
  quarter
     Nearly 40% of providers have billed less than
      50% of prorata Medicaid+Non-Medicaid
      contract allocations
     Impacts deposits into the 718 fund and
      ultimately, ability to pay providers
                         P ARKER
                         D ENNISON
                                     &
                          Associates, Ltd.
FFS Reimbursement
 Medicaid reimbursement
     Only part of DMH contracts subject to federal
      financial participation (FFP)—50% in IL
     Federal rules apply and impose several state-
      wide requirements (consistent services, state-
      wide access, billable activites, etc.)
 Billing of both Medicaid/Non-Medicaid
  allocations important
     Amounts not billed may be subject to
      reallocation
                         P ARKER
                         D ENNISON
                                     &
                          Associates, Ltd.
FFS Revenue Projection Tool
 Excel spreadsheet available after 12/1
    http://www.dhs.state.il.us/mhdd/mh/sri/
    http://ParkerDennison.com/Page.html until available on
     DMH website
    Two versions
       FFS Revenue Projection Tool sample.xls

       FFS Revenue Projection Tool blank.xls

    Designed to assist providers with projecting revenue
     and monitoring key variables in FFS environment
       Productivity

       Staff mix and allocations to services/sites

       Service mix

       Medicaid penetration rate



                           P ARKER
                           D ENNISON
                                       &
                            Associates, Ltd.
FFS Excel Model
 8 sheets (tabs along the bottom)
    3 require data entry—Bkgrd, Staffing, Svc Mix (blue
     areas only)
    Remaining 5 provide instructions, calculations or
     summaries
 Annual calcuations/projections
 Up to 10 cost centers or sites
    Can mark as Not Used if fewer or want to simply and
     run as entire agency
    Based on how agencies structure budgets or manage
     operations

                            P ARKER
                            D ENNISON
                                        &
                             Associates, Ltd.
FFS Excel Model
 Bkgrd—Data entry (pg 12)
     Name of agency
     Names of cost centers/site
     Medicaid penetration rate—percentage of
      clients eligible for Medicaid out of total DMH
      clients
     Other MH revenues—DMH and HFS physician
      revenues are entered as annual totals
     DMH contract allocations—MCD, NMCD and
      Capacity
                        P ARKER
                        D ENNISON
                                    &
                         Associates, Ltd.
FFS Excel Model
 Staffing—data entry (pg 9-11)
    Numbers/types of direct service staff
       Total and by cost center/site (check total in Col C)

       Only physician time not billed to HFS

    Productivity rates by staff by cost center/site
       Run model two ways—actual and productivity
         standards
    Hours in group per week per staff person
    Onsite/Offsite percentages for individual and group
    Work schedule
       Work hours/week

       Average vacation/sick/holiday per year

       Average number of weeks that groups operate



                              P ARKER
                              D ENNISON
                                          &
                               Associates, Ltd.
FFS Excel Model
 Svc Mix—data entry (pg 8)
     Average percentage of each type of service
      delivered by cost center or site




                        P ARKER
                        D ENNISON
                                    &
                         Associates, Ltd.
FFS Excel Model
 Instructions (pg 17)
    Assumptions

 Rates—actual hourly on/offsite rates as of 11/1 (pg
  13 – 14)
      At A41—Effective hourly rates based on ratios of
       professional staff. (pg 15)
      Can use these rates to compare to unit costs
      Excluded services—not used frequently or priced on
       hourly basis
 Billable time—converts staffing info into billable hours
  (pg 5 – 7)
                            P ARKER
                            D ENNISON
                                        &
                             Associates, Ltd.
FFS Excel Model
 Cost Ctr Detail—calculates revenues by cost
  center/site based on billable time and
  effective rates (pg 2- 4)
     Subtotals revenues by cost center/site
     Totals NMCD services
     Allocates Medicaid/Non-Medicaid revenues
      based on penetration rate on Bkgrd
     Subtotals individual and group hours and
      revenues
     Computes average hourly individual and group
      rates
                        P ARKER
                        D ENNISON
                                    &
                         Associates, Ltd.
FFS Excel Model
 Summary—show total revenues by cost
 center/site and percentage of total revenue
 (pg 1)
     Adds capacity grants
     Adds other DMH/HFS revenues from Bkgrd
     Show reconciliation of DMH contract
      allocations




                      P ARKER
                      D ENNISON
                                  &
                       Associates, Ltd.
Suggestions
 Rename file with agency name
 Do not enter data except in designated areas—cells
    are not protected
   Do not modify formulas—will impact integrity and
    accuracy of the model
   Ignore div/0 errors
   Email with errors
   Be aware of obvious errors
       Check totals—ok or error
       Reasonableness—average hourly rates on Cost Ctr
        detail
                            P ARKER
                            D ENNISON
                                        &
                             Associates, Ltd.
Suggestions
 Compare actual to standards
     First, enter performance data based on FY05
      actual data (service mix, productivity rates,
      etc.)—name as actual
     Then, enter performance standards
      (productivity, group size, etc)--name as
      standard
     Revenue difference is from improving to
      standards in all areas based on existing staff
      and rates
                         P ARKER
                         D ENNISON
                                     &
                          Associates, Ltd.
Suggestions
 Small agencies
     Run as a single cost center with agency totals
      in the column(s) for staffing, service mix, etc.
 Simplify service mix
     Reduce number of services to ACT, Case mgt
      MH, TBS and Therapy
     Should understand revenues if some services
      are assessment, tx planning


                          P ARKER
                          D ENNISON
                                      &
                           Associates, Ltd.
Suggestions
 Consider costs
     Number of staff/percentage of staff not
      allocated to direct service
     Compare total costs by cost center/site to total
      revenues
     Compare hourly rates by cost center/site to
      total revenues




                         P ARKER
                         D ENNISON
                                     &
                          Associates, Ltd.
Suggestions
 What are the variables that will impact your
  agencies total revenues and ability to draw
  down DMH contracts?
     Medicaid penetration
     Productivity rates
     Number of staff allocated to direct service
     Modify variables and assess impact



                         P ARKER
                         D ENNISON
                                     &
                          Associates, Ltd.
Next Steps
 No updates are promised
 If being used actively, modifications and
  additional training possible
     Update rates for 1/1/06 changes
     Modify for new services planned for late 2006
     Add costing modules




                         P ARKER
                         D ENNISON
                                     &
                          Associates, Ltd.
Steps to Develop Productivity
Reporting
 Management structures to support
  improvement
     Supervision assistance
     Performance evaluations
     Disciplinary action
 Management agreement for definition of
  productive time and productivity targets
     What counts?
     What is the target?
     What is the denominator—paid or available?
                        P ARKER
                        D ENNISON
                                    &
                         Associates, Ltd.
Steps to Develop Productivity
Reporting
 Productive time
    Convert variable billing codes into standard units—
     usually 15 minutes
    Group time—use relationship between individual and
     group rates to establish productivity credit (3-4
     consumers = 1 group unit)
 Productivity targets
    55 - 65 % for community based services
    65 – 75% for office based services
    90%+ census or attendance for other services based
     on staffing ratios




                           P ARKER
                           D ENNISON
                                       &
                            Associates, Ltd.
Steps to Develop Productivity
Reporting
 What‘s the denominator?
     Recommend available hours—staff
      understand requirements when working
     Paid time less vacation, holidays and portion
      of sick time
     No reduction for travel, training, etc—taken
      from difference between 100% and target
     Typically 1700 -1800 hours per year


                         P ARKER
                         D ENNISON
                                     &
                          Associates, Ltd.
Steps to Develop Productivity
Reporting
 Timely billing data--billing system should be
  data source
     Days from service to data entry to billing
     Parallel systems are inefficient and error prone
 Efficient structures to capture necessary
  data/develop reports after initial set-up
     Reports should be automatic or fully resourced
     Available weekly, or at least monthly
     Summarized by supervisor or team
                         P ARKER
                         D ENNISON
                                     &
                          Associates, Ltd.
Productivity Improvement Plans
   Must have management support
   Expect the ―stages of productivity grief‖
   Timely, user friendly reporting
   Targeted supervision
       Starts with scheduling/planning
       No show management
       Documentation
       Incremental improvement targets
 Balance ―pressure‖ with data to assure productivity is
    ―real‖


                             P ARKER
                             D ENNISON
                                         &
                              Associates, Ltd.
Productivity Barriers
 Lack of management support
 Poor data or data integrity questions
     Must be time limited process
 Unfriendly or untimely productivity reports
 Poor or inconsistent supervision
 Documentation
 Inflated caseloads



                        P ARKER
                        D ENNISON
                                    &
                         Associates, Ltd.
                           Staff to Average Team Productivity

       5.50



       5.00



       4.50
Hour




                                                                          F--Staff name
                                                                          Blue Team Avg
       4.00



       3.50



       3.00
              October   November December January      February   March




                                             P ARKER
                                             D ENNISON
                                                         &
                                              Associates, Ltd.
Compliance
 Compliance with what?
     State versus Provider Responsibilities
 BALC audits as an indicator of provider risk
 Common provider compliance issues
 Methods of provider risk minimization




                         P ARKER
                         D ENNISON
                                     &
                          Associates, Ltd.
Compliance with What?
 Primary Documents
    Rule 132
    State Manuals/Policy Statements
       Provider Manual

       Program Book

       Mental Health Medicaid Manual

    Medicaid State Plan
       As represented in Rule 132

 Secondary Documents
    State Medicaid Manual (Federal)
    OIG Audit Case Findings (most weight to more recent)

                           P ARKER
                           D ENNISON
                                       &
                            Associates, Ltd.
Who is Responsible for What?
 State primarily responsible for:
    Ensuring up to date Medicaid State Plan
    Consistency between Rule(s) and State Plan
    Up to date Provider Manual/Program Books
    Demonstrating a system that reasonably supports
     compliance (i.e., internal controls, monitoring)
 Provider primarily responsible for:
    Compliance with Rule 132, state policy manuals,
     provider contract requirements
    Internal controls
    Quality assurance

                           P ARKER
                           D ENNISON
                                       &
                            Associates, Ltd.
State Audit Activities—BALC
 Audit against Rule 132 only (does not
  review against Program Manual, MH
  Medicaid manual, or contract)
 Audits Medicaid billing only (does not
  review non-Medicaid billing or non-
  Medicaid clients)
 No review of Medicaid coordination of
  benefit requirements (including Medicare)
 No review of medical necessity
 No review of eligible or target population
  requirements

                       P ARKER
                       D ENNISON
                                   &
                        Associates, Ltd.
State Audit Activities—BALC
 Minimal qualitative review (nature of service
  beyond formal Rule).
 Minimal review of correlation between
     Assessed issues/needs and treatment plan
     # units billed and amount/content of notes
      (except egregious)
 Reviews only occur every 3 years if minimal
  problems, approximately every 18 months for
  moderate issues



                        P ARKER
                        D ENNISON
                                    &
                         Associates, Ltd.
Common Provider Issues
 Upcoding (skills training versus TBS,
  individual versus group)
 Billing for non-contracted service (activity
  therapy)
 Billing for service not on treatment plan
 Billing client centered consultation for staff
  supervision
 Miscoding location – on/off site (10%
  differential)
 Miscoding of credential (rate differential)


                        P ARKER
                        D ENNISON
                                    &
                         Associates, Ltd.
Common Provider Issues
 Treatment plan gaps/lapses but billing
  submitted
 Overlapping service times (may be allowed
  but should be reviewed for validity)
 No evidence of authorization/approval (ACT)
 Diagnosis not current and/or not all 5 axis
 No currently assessed need for a given
  service/intervention (especially TBS
  groups/indv)
                      P ARKER
                      D ENNISON
                                  &
                       Associates, Ltd.
Common Provider Issues
 Delivering services at a site that meets DHS
  criteria for required certification but no
  certification completed
 Double dipping (billing case management to
  Medicaid but also having it covered under
  HUD contracts)
 Multiple client records for the same client
  (inconsistent filing, no evidence of single
  treatment plan, no evidence of coordination,
  duplicate services between sites)
 No sign-in or documentation of daily
  attendance for PSR/day
                      P ARKER
                      D ENNISON
                                  &
                       Associates, Ltd.
Common Provider Issues
 Phone calls – always onsite
 Staffing ratios exceeded – groups > 1:15 (no
  attendance log)
 Documenting to Medicaid excluded services
  (transportation, vocational, education)
 Services inconsistent with program/service
  definitions or allowable activities under Rehab
  Option (camping, ball games, etc)




                       P ARKER
                       D ENNISON
                                   &
                        Associates, Ltd.
Provider Readiness Findings
(Provider Readiness Assessment - IL Field Test Evaluation, March 22, 2005)

 92% of agencies did NOT do a FFS implementation plan
 41% of agencies did NOT train their staff on new service
    taxonomy
   28% of agencies did NOT train their staff on Rule 132 changes
   39% of agencies are NOT providing periodic training on updates
    or clarifications
   52% of agencies do NOT have system to monitor and supervise
    consistency with service definitions
   41% of agencies do NOT have a system to ensure a current
    treatment plan covers all billed services
   33% of agencies do NOT have a system to ensure a service
    note for each billed service
   72% of agencies do NOT have a system to internally monitor
    medical necessity

                                     P ARKER
                                     D ENNISON
                                                 &
                                      Associates, Ltd.
Methods of Provider Risk
Minimization
 Policies and procedures
 Training
 Evaluation
 Internal Controls/Monitoring
 Feedback/Supervision/Problem Resolution




                      P ARKER
                      D ENNISON
                                  &
                       Associates, Ltd.
Policies and Procedures
 Implement Rule 132!
    Self assess (http://www.dhs.state.il.us/mhdd/mh/sri/)
    Have a plan or checklist
    Update policies and procedures
           Nature of service/allowable services
           Assessment
              Update assessments and diagnosis
         Treatment planning
         Documentation

         Charge ticket/billing flow

      Update program documents
         Descriptions

                                P ARKER
                                D ENNISON
                                            &
                                 Associates, Ltd.
Training – A ‘System’ Not an Event
 ~ One Time Staff Trainings Rarely Change Practice ~
 Rule 132
 Service/program requirements
 Policies and procedures
 Billing flows
 Risks and accountabilities
 Train line supervisors
 Training should include:
      Overview
      Practical, concrete, small bites
      FAQ/Help Desk
      Supervise & feedback

                              P ARKER
                              D ENNISON
                                          &
                               Associates, Ltd.
Evaluation of Compliance Risk
 Are expectations clear?
 Have systems been revised to achieve new
  results?
 Are supports in place to increase success?
      Training/orientation
 Are internal controls in place to catch errors?
 Is ongoing monitoring, feedback, and
  improvement support present and
  demonstrating change (i.e. supervision)?
                          P ARKER
                          D ENNISON
                                      &
                           Associates, Ltd.
Internal Controls/Monitoring
   System Edits or Billing                                       Qualitative Reviews
          Controls                                            --Large initial sample size until
                                                                  demonstrated compliance
 --100% until demonstrated compliance
                                                          --Targeted programs, staff, indicators
     --MIS, billing staff, support staff
                                                             --Clinically knowledgeable staff
 Contracted services
                                                     Consistency with service
 Service on treatment plan                                    definition
 Coding of credential                                        Miscoding location
 Treatment plan gaps                                         Currently assessed need
 Overlapping service times                                   Staffing ratios
 Assessment/diagnosis                                        Documenting to Medicaid
  updates/all five axis                                        excluded services
 PSR log match to billing
 Authorizations

                                           P ARKER
                                           D ENNISON
                                                       &
                                            Associates, Ltd.
Supervision
 Supervisors are ‗front line‘ in assuring compliance
 Key knowledge and skills
    Rule 132, service definitions, other compliance
     documents
    Understand ‗compliance‘ oriented supervision
    How to give feedback
    How to track, follow up

 Key tools
    Shared checklists
    Reports
    Peer support/problem solving

                            P ARKER
                            D ENNISON
                                        &
                             Associates, Ltd.
For More Info on Audit Issues and
Medical Record Reviews
Articles by Mary Thornton & Associates, Inc.
  (http://bhcollaborativesolutions.com/Page4.html)


 OIG Work Plan for Fraud and Abuse Focuses on
 Behavioral Health (Mary Thornton, 2005)

 Protecting Yourself from an Adverse Federal
 Audit (Mary Thornton, 2005)



                        P ARKER
                        D ENNISON
                                    &
                         Associates, Ltd.

				
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