BH Oversight Committee

Review of the Flow Chart –

Comments/concerns:

ü Reimbursement for hospital stays during which the diagnosis changes from primary medical to under the ASO & MCOs: The hospital would have prior authorizations for both medical and BH so reimbursement should not be an issue, although some issues will come up in the micro billing details. The Depts. are willing to sit down with the hospitals to discuss this further now or we can see what problems develop and work to solve those problems.

o Dr. Walia stated if is important to transfer patients from medical to psychiatric floor as quickly as possible. Dr. Schaefer stated that 1) this could be included in the reporting measures and 2) the ASO would ensure that the child is getting the most appropriate BH care (?through a performance measure).

ü Sheila requested that time-lines be defined for Prior authorization and continuity of care as noted in the flow chart. Mark Schaeffer noted that the RFP has these timelines, which he believes includes initial authorization within an hour and re-authorizations by end of the business day. The Work Group could recommend 1) that these same timelines/guidelines in the RFP be adopted in the ASO contract ( and recommend the DSS/MCO HUSKY contracts include the same timelines) and compliance be monitored by the DSS/DCF, 2) there be an established communication process between the ASO and MCO when either entity knows the diagnosis for services will change (e.g. medical to BH).

o Dr. Geertsma wants to be assured that the child will be allowed to stay in the hospital even if the issue is not resolved by end of business. Dr. Schaefer suggested that the authorization continue regardless of which organization gave it (either ASO or MCO) until the issue is resolved. Then the authorization can be retracted and the other organization issue a retro-authorization or the authorization can be continued, depending on how the issue is resolved. (?WG recommendations)

o Dr. Geertsma noted that protective stays are a problem and that there is no quick way to get DCF to solve this problem. Mark stated that if it is medical, then you have to go to the MCO or DCF. He also suggested we find out how many times this might happen (? UM measure).

ü PCP service codes & MCO reimbursement: Dr. Geertsma expressed concern that PCPs will use codes that are beyond their area of expertise. (9024* codes involve an expert opinion). Dr. Schaefer agreed and stated that the MCOs will not pay a psych diagnosis with a psychiatric procedure code.

ü Primary Care BH Referral Assistance – Under EPSDT the State has the responsibility, which the State has delegated to the MCOs and potentially to the ASO, to assist member timely access to services. Options include:

o The ASO will set up a web-based BH provider search system so that a primary care office can initially identify a BH provider within the patient’s geographic proximity, without going through the ASO.

o The PCP can give the client the ASO number for the client to call for names of BH providers or the PCP can contact the ASO and help the client with appointment assistance.

o The ASO member services should provide members assistance by giving them the names of BH providers in the network and request the member contact the ASO if they cannot secure an appointment. Dr. Schaefer suggested that, “the PCP office may search provider directory” be added to the TPD.

ü Primary Care Notification of patient’s BH services– PCPs often do not know when their patient has been hospitalized or seen in the ED for a BH problem. Dr. Schaefer stated that it would be most efficient for the ASO to send out a notification immediately unless their client request that notification not be sent. Clients should have the option to opt out of the PC notification. This should be referred to the agency in-house counsel.. Karen Andersson stated that we should get the opinion of a few families as well. Dr. Schaefer will provide more detail on primary care notification at the next meeting.

ü Appropriate level of care- psychiatry/PCP BH management: Dr. Walia stated a psychiatrist may discharge a client when the psychiatrist believes that the client only needs psychotropic medication that would now be delegated to PCP management.

ü A member handbook will be created once the ASO contract negotiations are final and that this workgroup can be helpful to ensure that the member handbook informs families of how to contact the ASO. Another goal is educating providers, both specialty and MCOs’ PCP and other ‘allied professionals’ to help their clients access the ASO and various levels of care.

ü Due Process: There is a dispute as to how to interpret the federal laws for due process. Rose stated what is done with the current HUSKY program. Mark stated that KidCare will follow the same policy and procedures that are currently being done under the current HUSKY system and suggested we address this issue at another meeting.

Next Meeting: April 4, 2005 9:00 – 11:00, at DSS.

Conference call number: 888-625-1623 Pass Code # 51733

Agenda items Coordination of Benefit

Dispute of Authorization Process

Pharmacy