BH Oversight Committee
Coordination of Care Work Group
Meeting Summary: April 4, 2005
(Next Meeting: April 18 @ 1-3PM at the Hartford DSS, 11th Floor)
Present: S.Amdur (Chair), M. Schaefer & R. Ciarcia (DSS),), L. Berkowitz, D. Consiglio Anthem), C. Catrone (SBHC), K.Colvin (CHNCT), J.Panzo(PONE), A.Kamm (DCF), MA.Fischer (HN), L. Pierce (VOI), S.Toubman, V.Veltri.
Handout Updates: PCP Notification, Timelines for PA/concurrent review, Determination Primary DX.
Coordination of Benefits
¬ Patient continued access to care during conflict of medical/behavioral health primary diagnosis: If the MCO & ASO are unable to "reach a timely resolution and/or refer the matter (conflicting determination as to whether medical or behavioral health is primary) to DSS, the entity (that initially authorized) the request must provide authorization until the matter is resolved."
o WG Recommendation: add in `admission' and `concurrent' reviews section "All times are measured from the time the Contractor receives all information deemed reasonably necessary. (DSS added this in the document DETERMINATION OF PRIMARY DIAGNOSIS SUMMARY after the meeting).
¬ Standard information required of providers for authorization: Providers are generally aware of the level of information needed for `medically necessary' psych inpatient authorization/continued hospitalization. However, information required of providers beyond what is "standard" for a level of care could result in an authorization delay when a provider cannot or does not comply with what may perceived by the provider as an arbitrary request for additional information. Given there will be practice guidelines developed, the WG recommended the agencies and ASO:
o Develop standard information per level of care that identify specific indicators for that level of care, thereby including the provider as a partner in working with the family and ASO to secure the appropriate level of care.
o Include the Medicaid definition of "medical necessity" for material documenting appropriate levels of care.
Dispute Resolution Process
There were two issues noted, with the example of a dispute occurring in off-hours:
· The hospital/ED believes hospitalization is appropriate, but this level of care is denied by the MCO. The hospital can:
o Admit and seek retroactive authorization after discussion with payer's Medical director.
o Off hours hospital practitioner would contact the payer reviewer, even though that reviewer may be out-of-state for authorization.
o Expedited appeal can be filed with the payer, however that may take a few days to resolve.
o The hospital ED can implement the 24-hold provision.
· The parent of a child in a BH crisis disagrees with discharge from hospital/ED to community level of care because of concern about the safety of having the child/youth at home. The immediate resolution could include:
o Child could be admitted under administrative admission, which is covererd under State reinsurance.
o There should be a provisional authorization for 24 hours until the disposition issues can be resolved.
· Work Group Recommendations
o DSS establish a provisional authorization process for 24 hours, determined on a case-by-case basis, which allows family to be connected to community collaboratives, EMPS and other needed services.
o DSS establish a telephonic immediate appeal process with the authorization entity.
The discussion focused on approvals of temporary drug supplies when there is no prior authorization for non-formulary and/or formulary drugs that require such authorization initiated by the prescribing provider. The DCF has tracked psychotropic drug denials. Specific existing policy issues in DSS/MCO contract were noted:
· "..the MCO shall have a prior authorization process to permit access, at a minimum, to all medically necessary and appropriate drugs covered for the Medicaid fee-for-service population". This may require Prior Authorization based on medically necessity.
· Under EPSDT provisions, MH drugs deemed medially necessary should be available to HUSKY members; however Prior Authorization (PA) may still be required.
· The Pharmacy is required to provide the temporary supply of a drug if PA is not readily obtainable. At the pharmacy end, failure to provide temporary drugs may occur because:
o The pharmacy does not differentiate a member's enrollment in a health plan's commercial versus Medicaid line of business.
o Pharmacy staff, in particular part time staff, may not be aware of the Medicaid HUSKY policy.
o The pharmacy has no assurance the temporary drug cost will be reimbursed by the payer.
· Pharmacy reports to the Medicaid Council show significant variation among HUSKY MCOs in providing temporary drug supplies. The DSS stated they have been working with the MCOs on resolving the deficits in consistently applying the DSS policy. The WG recommended:
o That the DSS & MCOs come to a resolution of this issue prior to the implementation of the BH restructuring.
o The DCF provide information to the WG on the psychotropic drug denials for their clients.
o The DSS provide a report on frequency of medication rejection at the pharmacy (client leaves without the script being filled).
o DSS provide a report on any mental health drugs excluded from the MCO formularies.
The Pharmacy issues also pertain to quality of care and access to care and as such may be referred to the QA Management & Access Work Group for recommendations for the ASO analytic process in appropriate prescribing of psychotropic medications that reflect `best practices'. The DCF protocols developed for prescribing and managing psychotropic medications for DCF children should be considered in this process.
Next meeting: Follow up
· The work group was asked to review the transitional document areas on medications, MCO/ASO coordination.
· Prior WG group of summary of recommendations to date (to be developed).
· DSS report on pharmacy rejection of scripts - those not filled upon client submission of script.
· Progress in resolution of temporary drug supply process with MCOs.
· Identify psychotropic drugs on/off each MCO formulary.
· Status of policy on 1) provisional 24 level of care authorizations when there is an authorization dispute, either between the provider & payer or family & provider and 2) telephonic expedited appeal when there is a dispute for PA or concurrent service authorization..
Next Coordination of Care Work Group meeting is April 18 at 1-3 PM at the Hartford DSS building, 11th floor.