DRAFT: BH Oversight Committee Work Group Focus Topics & Action
(Updated
5/9/05)
Topic/Focus Area |
Work Group |
Action/Recommendations
|
|
Coordination of Care between BH ASO & MCOs: 1) Coordination of benefits medical & psych diagnoses dispute/change 2) Off hours dispute resolution 3) Establish standard info required of providers by level of care for PA or concurrent review authorization. 4) PA & continuity of care ASO decision timelines. 5) Co-management –co-occurring Dx. 6) NOA coordination between ASO/MCO |
Coordination of Care WG (CCare WG) |
1) The initial authorizing entity must provide authorization until dispute resolved. Times measured from when contractor receives all info that is deemed reasonably necessary (CCare WG added)to make PA, concurrent review authorization. 2)
CCare WG & DSS agreed to “provisional auth within 24
hours, telephonic appeal within 24 hrs. 3)
Per CCare WG, DSS work with ASO & Provider Advisory WG for
such uniform PA information standards. 4)
ASO PA decision to BH provider in 60 minutes, Concurrent Review
decision in 60 minutes or end of business day. 5)
CCare WG will review ASO/MCO flowchart 5/3: suggestion monthly
co-management meetings between ASO/MCO be >frequent in transition. |
Primary Care BH referrals |
CCare WG |
ASO to offer appointment assistance to member, PCPs have access to BH network web site, BH referral through MCO/ASO |
PCP/BH interaction |
CCare WG |
Further discussion of PCP notification of BH services, Psychotropic meds, within ASO contract, consideration legal view, member recognition of role of PCP in overall quality, coordination health care. |
ASO Intensive Case Management |
1)CCare WG 2)DCF WG |
ID triggers for ASO CM (both WGs) |
Pharmacy |
1)CCare WG 2)DCF WG |
1) Member access to scripts, temporary drug, medication denial psychotropic meds (MCO PBM), BH ASO aware? May 3, reports from DSS, DCF on formularies, recommend DSS resolve temporary drug process before carve-out |
Clinical Management, appropriate treatment guidelines
|
1)Provider Advisory, 2) DCF WG |
|
DCF children/coordination with DSS/ASO
|
1) DCF WG2) QA WG |
2)ASO Performance targets/monitoring
would be applied to all members
(see attached 8 indicators ID in the BH QA WG_ |
|
Care Coordination 1) ASO/MCO 2) Within KidCare & ASO, MCO |
1)CCare WG 2) DCF WG |
1)
review at CCare WG 5/3 meeting 2)
Review at 5/3 DCF WG |
Service Access |
1)QA WG2)DCF WG |
1) Monitoring indicators2) Consideration for DCF Voluntary Services, DCF children, the uninsured, DCF transitioning youth to DMHAS |
Transportation: Coordination with MCOs |
1)CCare WG 2)DCF WG |
Discuss, recommendations @ 5/3 WG meeting |
State Agencies’ Responsibility of Monitoring Quality Services
|
1)QA WG2)DCF WG |
1) DCF Flow sheet to be reviewed at 5/27 meting |
New System: Communication
with families?
|
DCF WG
|
|
BH Quality Management & Access Work Group: Recommendations for ASO Critical Indicators
Ø
Access to Care:
o
Global penetration (increase)
o
Access for underserved groups/regions (increase)
Ø
Emergency
Department utilization:
o
Global composite indicator
(decrease)
o
Frequency of visits for BH
problems (decrease)
o
Return visits, i.e. return
within 48 hours (decrease)
Ø
F/U
after Residential or Inpatient Discharge:
o
Appropriate F/U services engaged at
7 and 30 days (> “X” % of population; increase from base line)
o
Maintained in appropriate outpatient treatment
(> “X” % of population maintained
> “T” time; increase from base line)
Ø
Readmission to Inpatient of
Residential Treatment:
o
Inpatient discharges admitted within 30, 60, 90 and
180 days (reduced by “X”)
Ø
Treatment
Authorization Process:
o
Timeliness of UM decision
making
o
Timeliness in passing authorization data to fiscal
agent
o
Timeliness in correcting authorization info errors
o
Accuracy in passing authorization data to fiscal
agent
o
Accuracy in importing claims data from fiscal agent.
Ø
Provider
Satisfaction:
o
Global provider satisfaction (> than “X”
percent)
o
Pre-Authorization Process:
accurate & error free, clear, fair, rapid
o
Care-manager Performance:
adherent to level of care and treatment criteria, knowledgeable, polite,
timely in returning calls
o
Ease of obtaining
authorization for higher levels of care
o
Appeals process: fair, timely, efficient, user
friendly; retrospective denials (?)
o
Payment process: accurate, timely, errors corrected
quickly
o
Paperwork and Reporting:
simple, efficient, adequate
o
Ease of use 7 availability of
necessary administrative information
Ø
Member
Satisfaction:
o
Global member satisfaction (> than “X” percent)
o
Global patient satisfaction (> than “X”
percent)
o
Global family member satisfaction (> than “X”
percent)
o
Adequate and timely care
provision by level of service
o
Coordination of services
o
Provider relations & grievance process
o
Psychoeducation
o
Ease of use & availability
of necessary administrative information
o
Cultural sensitivity
Ø
Completion of Local Area Development Action Plans by 3/1/06 (the ASO is responsible for recruiting providers of various
levels of care, assessing service gaps by geographic areas, and develop an
action plan to reduce gaps).