Coordination of Care Work Group Recommendations

Chair:  Sheila Amdur

Updated 5/4/05

Ø      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).

Ø      Define time lines for prior authorization (PA) and continuity of care

The Work Group recommended

o       The timelines in the RFP be adopted in the ASO contract: decision for PA communicated to the provider by telephone within 60 minutes of the request for hospital admission, PHP, IOP, inpatient detox.  Concurrent reviews decision within 60 minutes or before 5 PM .  The decision for all other service concurrent review requested by the provider shall be made within 2 business days of the request. 

Ø      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.

Ø      Dispute Resolution Process

There were two issues noted, with the example of a dispute occurring in off-hours:

1)      The hospital/ED believes hospitalization is appropriate, but this level of care is denied by the MCO and 2) 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.

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

Ø      Pharmacy

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.  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.

5/3 WG update:

• At May 25^th meeting continued review of pharmacy data, further recommendations for access.
• The Work Group suggested that DSS/MCO contract negotiations could include the automatic override for temporary drug supplies, development of a single PA drug form, common drug formulary among the 3 plans that have formularies.

Ø      Reimbursement for hospital stays during which the diagnosis changes from primary medical to psychiatric under the ASO/MCO management:  The Work Group suggested:

o       The DSS/DCF discuss this reimbursement issue further with hospitals to ensure there is an appropriate process in place, based on the flow chart.

o       The timeliness of transfer of patients from medical to psychiatric services upon diagnosis change should be monitored within the ASO.

Ø      Primary Care BH referral assistance:  The Work Group recommended that the departments add to the ASO contract that the ASO will offer appointment assistance to members either at the time of the request for BH network referrals of when the member calls back with further assistance needs.

Ø      Primary Care Provider notification of their patient’s BH services.  The work group recommended that the departments clarify the role of the ASO in notifying PCPs in contract language.

5/3 WG Meeting update:  families have agreed that the integration of medical & BH system is important, providing a process for written consent for BH service information to be shared with the PCP.  The departments suggested some possible vehicles for this within the ASO.

Ø      Coordination of MCO/ASO Case Management:  The work has reviewed the work flow chart provided by the agencies.  One suggestion was that the ASO directly contact the DCF Health Advocate for DCF children. (see attached work flow sheet reviewed at the Care coordination WG and the DCF Work Group).

Ø      Transportation:  coordination with MCO & ASO for BH services – 5/3/05  Transportation to BH services, the responsibility of the MCOs, does affect access to services.  The WG suggested:

o       Transportation access be a focus area for monitoring in the 1^st year of the carve-out.

o       Identify specific questions related to transportation access for the BH member satisfaction survey.

o       The HUSKY transportation information grid was reviewed again at the Medicaid Council Consumer Access meeting 5/4/05: 1) clarified that the provider identify the “reason” for special transportation services, rather than using term “medical reason”, 2) will request information from MCOs on provider arrangements for ongoing multiple week services for BH and 3) clarified that special transportation for members with BH special needs can be requested by the MH provider.