contract monitoring
TRANSCRIPT
Contract MonitoringContract Monitoring
Who, what, when and why?Who, what, when and why?
Contract Monitoring DefinedContract Monitoring Defined
Continual Continual processprocess ensuring ensuring compliance with the terms and compliance with the terms and conditions of the contact - conditions of the contact - arrangement; typically consisting of arrangement; typically consisting of three components;three components; AdministrativeAdministrative
Terms/conditions of contract (insurance, Terms/conditions of contract (insurance, internal processes, HR)internal processes, HR)
FiscalFiscal Invoices; billed amount within contract, Invoices; billed amount within contract,
ProgramProgram Client eligibility, medical necessity, Client eligibility, medical necessity,
outcomesoutcomes
What’s new, we already do this…What’s new, we already do this…
[I think] most experience is in [I think] most experience is in managing contracts for discreet fee-managing contracts for discreet fee-for-service arrangements; psychiatric for-service arrangements; psychiatric services and one payer…State/GR.services and one payer…State/GR.
Sub-Contracting federally Sub-Contracting federally reimbursed services [with state reimbursed services [with state match] adds a whole new dimension match] adds a whole new dimension to contract management. to contract management.
Give me one good reason for Give me one good reason for Monitoring & Managing Contracts!Monitoring & Managing Contracts!
Case & PointCase & PointKrizek, MD (psychiatrist) (1997):Krizek, MD (psychiatrist) (1997): 1986 to 1992 submitted 8,002 false 1986 to 1992 submitted 8,002 false
claims resulting in $245,392 claims resulting in $245,392 overpayment. Wife was billing. overpayment. Wife was billing.
False claims: two issues; medically False claims: two issues; medically unnecessary and up-coded. unnecessary and up-coded.
90844 versus 9084390844 versus 90843 ““Seriously deficient” record keepingSeriously deficient” record keeping Some claims over 21 hours.Some claims over 21 hours. ““Failed utterly” to review bills submitted Failed utterly” to review bills submitted
on his behalf…reckless disregard. on his behalf…reckless disregard. $5,745,000.$5,745,000.
Really…are they serious?Really…are they serious?
The The American Recovery and Reinvestment Act of 2009 (Recovery Act) provides the Department of (Recovery Act) provides the Department of Health and Human Services (HHS), Office of Health and Human Services (HHS), Office of Inspector General (OIG), with $17 million in Inspector General (OIG), with $17 million in funding for oversight and review. The Recovery funding for oversight and review. The Recovery Act provided an additional $31,250,000 to OIG Act provided an additional $31,250,000 to OIG for the purpose of ensuring the proper for the purpose of ensuring the proper expenditure of funds under Medicaid.expenditure of funds under Medicaid.
OIG will assess whether HHS is using the OIG will assess whether HHS is using the $165.4 billion in Recovery Act funds in $165.4 billion in Recovery Act funds in accordance with legal and administrative accordance with legal and administrative requirements and is meeting the accountability requirements and is meeting the accountability objectives defined by the Office of objectives defined by the Office of Management and Budget.Management and Budget.
Back to “what’s new?”Back to “what’s new?”
We have traditionally been in We have traditionally been in the role of proving up our good the role of proving up our good work. Our contract monitoring work. Our contract monitoring process focused on internal process focused on internal controls; QM, Finance etc.controls; QM, Finance etc.
LPND puts us in the role of LPND puts us in the role of proving up ‘their’ work.proving up ‘their’ work.
Again, we take the money.Again, we take the money.
Come on…it is just DSHS!Come on…it is just DSHS!
Who paid you to Who paid you to do what and what do what and what do they expect in do they expect in return?return?
Private Private FoundationsFoundations
StateState IRSIRS DOJDOJ GAOGAO OIGOIG CMSCMS
Hi-Tech ActHi-Tech Act HIPPAHIPPA FCAFCA STARKSTARK
What needs monitoring?What needs monitoring? Relations Relations Performance to include;Performance to include;
Program/service deliverablesProgram/service deliverables Fiscal/financial Fiscal/financial Record – keepingRecord – keeping BillingBilling
SystemsSystems Quality ManagementQuality Management Utilization ManagementUtilization Management Human Resource ManagementHuman Resource Management Corporate ComplianceCorporate Compliance
How are other folks doing?How are other folks doing?
March 2004; OIG assess the Ryan March 2004; OIG assess the Ryan White Care Act Title I & Title II White Care Act Title I & Title II [HRSA] grantees’ monitoring of ‘sub-[HRSA] grantees’ monitoring of ‘sub-grantees’grantees’
Findings: Findings: monitoring is limitedmonitoring is limited, 15 , 15 of 20 grantees of 20 grantees did not have did not have comprehensive documentation comprehensive documentation demonstrating consistent demonstrating consistent monitoring activities.monitoring activities.
OIG recommended HRSA…OIG recommended HRSA…
Set standards for monitoring sub-Set standards for monitoring sub-grantees that, at a minimum require grantees that, at a minimum require a formal agreement, program report, a formal agreement, program report, fiscal report and schedule of site fiscal report and schedule of site visits.visits.
Require grantees to report how they Require grantees to report how they monitor their sub-grantees in monitor their sub-grantees in accordance with these standards as accordance with these standards as part of every applicationpart of every application
Increase efforts to monitor grantees Increase efforts to monitor grantees oversight of sub-grantees…oversight of sub-grantees…
OIG Grants Oversight OIG Grants Oversight FrameworkFramework
RequirementsRequirements ReportsReports ReviewsReviews EnforcementEnforcement
Who: What does a contract Who: What does a contract manager look like?manager look like?
Is there a job title?Is there a job title?
Should not be Should not be one person but one person but a coordinated a coordinated effort to include;effort to include; RelationsRelations QMQM FinanceFinance ComplianceCompliance
It is not a job, it It is not a job, it is a processis a process
EqualityEquality
All providers within a network are reviewed All providers within a network are reviewed and treated the same by the LMHA/QM.and treated the same by the LMHA/QM.
The same measures used for one provider The same measures used for one provider is used for the provider of the same service is used for the provider of the same service whether they are external or internal. whether they are external or internal.
If a provider is accredited or licensed by If a provider is accredited or licensed by another regulatory authority the scope of another regulatory authority the scope of the authority review may change. the authority review may change.
Can the provider demonstrate good Can the provider demonstrate good standing with an accrediting and/or standing with an accrediting and/or licensing body? If so, can all or some of licensing body? If so, can all or some of the provider services be ‘deemed’?the provider services be ‘deemed’?
WhenWhen
Reviews may occur pre and Reviews may occur pre and post contract/opening.post contract/opening.
Reviews occur post Reviews occur post contract/opening as regularly contract/opening as regularly scheduled reviews, scheduled reviews, unannounced reviews or focus unannounced reviews or focus reviews. reviews.
MonitoringMonitoring
All materials required of the RFP have been All materials required of the RFP have been received and reviewed by the center contract received and reviewed by the center contract holder. The proposal is complete. holder. The proposal is complete.
Financial stability of the potential provider has Financial stability of the potential provider has been reviewed and determined to be sound.been reviewed and determined to be sound.
The contract holder notifies QM that a The contract holder notifies QM that a preliminary review of the provider capacity to preliminary review of the provider capacity to meet standards and contract requirements may meet standards and contract requirements may be scheduled.be scheduled.
QM assigns the contract review and schedules QM assigns the contract review and schedules with the provider a date and time to conduct the with the provider a date and time to conduct the review. review.
The purpose of the review is twofold:The purpose of the review is twofold: Basic structure exists to meet contract?Basic structure exists to meet contract? Willingness to meet contract? Willingness to meet contract?
Post Contract ReviewPost Contract Review Immediate responsibility for compliance rests with Immediate responsibility for compliance rests with
the provider. All providers are required to the provider. All providers are required to demonstrate a process for internal accountability of demonstrate a process for internal accountability of data and fidelity to service provision. This process is data and fidelity to service provision. This process is shared with the provider’s contract holder, manager shared with the provider’s contract holder, manager and QM. and QM.
All provider services should be reviewed on an All provider services should be reviewed on an ongoing basis by their manager and contract holder. ongoing basis by their manager and contract holder.
All providers are placed on the QM review schedule All providers are placed on the QM review schedule for external validation of internal methods of for external validation of internal methods of accountability and service fidelityaccountability and service fidelity
All reviews are conducted with an established All reviews are conducted with an established protocol developed by QM which may also be used protocol developed by QM which may also be used by the provider, the provider’s manager/contract by the provider, the provider’s manager/contract holder for internal management purposes.holder for internal management purposes.
On at least an annual basis the provider’s On at least an annual basis the provider’s compliance with service standards, records compliance with service standards, records standards, training, health, safety and advocacy standards, training, health, safety and advocacy standards is verified by QM standards is verified by QM
Post Contract contPost Contract cont
Reviews may be triggered by data Reviews may be triggered by data reviewed of ongoing service information reviewed of ongoing service information received by the manager and QM from the received by the manager and QM from the provider. provider.
High risk or persistent questions of service High risk or persistent questions of service compliance may warrant an unannounced compliance may warrant an unannounced or focus review of the provider.or focus review of the provider.
Focus review are normally conducted by Focus review are normally conducted by QM, however, a focus review may be QM, however, a focus review may be requested of the provider as formatted by requested of the provider as formatted by QM or the manager. QM or the manager.
Integrate: Internal & ExternalIntegrate: Internal & External
Ideally, the same process of review occurs for Ideally, the same process of review occurs for internal and external monitors. internal and external monitors.
The contract holder would monitor the provider’s The contract holder would monitor the provider’s adherence to contract requirements as an internal adherence to contract requirements as an internal manager would monitor the compliance of an manager would monitor the compliance of an internal provider’s adherence to performance internal provider’s adherence to performance contract requirements. contract requirements.
Oversight and validation of this process is Oversight and validation of this process is conducted through QM. Risks to performance conducted through QM. Risks to performance contract requirements are identified as are contract requirements are identified as are corporate program compliance risks associated with corporate program compliance risks associated with state and federal healthcare compliance state and federal healthcare compliance requirements. requirements.
The summary of data and reviews is collated, The summary of data and reviews is collated, analyzed and shared with the Executive Director, analyzed and shared with the Executive Director, Executive Staff and Center Board on a quarterly Executive Staff and Center Board on a quarterly and annual basis. and annual basis.
What to monitor.What to monitor.
The review process is formatted and has a The review process is formatted and has a protocol.protocol.
The review process includes:The review process includes: Physical site reviewPhysical site review Policy and procedures reviewPolicy and procedures review Record structure reviewRecord structure review Staff training and credentialing reviewStaff training and credentialing review Debriefing with potential providerDebriefing with potential provider Plan of Improvement if neededPlan of Improvement if needed Scheduling technical assistanceScheduling technical assistance Formal review report to potential provider and Formal review report to potential provider and
contract holder recommending LMHA action.contract holder recommending LMHA action.
Steps to take:Steps to take:
Develop policy – procedureDevelop policy – procedure Designate coordinator and Designate coordinator and
appropriate department/staffappropriate department/staff Designate provider relationsDesignate provider relations Develop audit instrumentsDevelop audit instruments Develop monitoring calendarDevelop monitoring calendar Credentialing process tool Credentialing process tool
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