external quality review of the hoosier healthwise and ... ... external quality review of...

Download External Quality Review of the Hoosier Healthwise and ... ... External Quality Review of Indiana¢â‚¬â„¢s

Post on 28-Jan-2021

0 views

Category:

Documents

0 download

Embed Size (px)

TRANSCRIPT

  • External Quality Review of Indiana’s

    Hoosier Healthwise Program and

    Healthy Indiana Plan for the

    Review Year Calendar 2009

    Final Report – November 30, 2010

    3030 North Third Street, Suite 200 Phoenix, AZ 85012 (602) 241-8520 www.burnshealthpolicy.com

  • FINAL REPORT External Quality Review of the Indiana Hoosier Healthwise Program and Healthy Indiana Plan

    Burns & Associates, Inc. November 30, 2010  

    ACKNOWLEDGMENTS

    This report was written by Burns & Associates, Inc.

    Mark Podrazik, Principal, EQR Project Manager

    The CY 2010 External Quality Review team included the following individuals who served as both reviewers and report contributors:

    Steven Abele, Senior Consultant, Burns & Associates, Inc.

    Dr. Judy Beckner, Subcontractor, Kachina Medical Consultants Cindy Collier, Subcontractor, Cindy Collier Consulting, LLC Rae Bennett, RN, Subcontractor, Brightstar Healthcare, Inc. Linda Gunn, Ph.D., Subcontractor, A.G.S. Consulting, Inc.

    Dr. CJ Hindman, Subcontractor, Kachina Medical Consultants

    Technical assistance was also provided by the following Burns & Associates staff:

    Jesse Eng, SAS Programmer Ryan Kelly, Consultant Barry Smith, Consultant

    Burns & Associates, Inc. would like to thank the staff at Anthem, MDwise and Managed Health Services for their assistance in providing documentation and assistance in planning for the onsite portion of this review. We would also like to thank the staff at the Office of Medicaid Policy and Planning for their assistance during the course of this study.

    This report is available at our website at

    www.burnshealthpolicy.com

    Inquiries may be sent to mpodrazik@burnshealthpolicy.com

    3030 NORTH THIRD STREET , SUITE 200 PHOENIX, AZ 85012 (602) 241-8520

  • FINAL REPORT External Quality Review of the Indiana Hoosier Healthwise Program and Healthy Indiana Plan

    Burns & Associates, Inc. November 30, 2010  

    TABLE OF CONTENTS

    Executive Summary Section I: Overview of Indiana’s Medicaid Managed Care Programs

    Introduction .......................................................................................................................... I-1 Benefit Package ................................................................................................................... I-2 MCOs Contracted in the Hoosier Healthwise and Healthy Indiana Plan ............................ I-4 Profile of Hoosier Healthwise and Healthy Indiana Plan Members .................................... I-5

    Section II: Approach to this Year’s External Quality Review

    Background .........................................................................................................................II-1 External Quality Review in CY 2010 .................................................................................II-1

    Section III: Review of Cultural Competency Initiatives

    Introduction ....................................................................................................................... III-1 MCO Approaches to Cultural Competency ...................................................................... III-3 Best Practices .................................................................................................................. III-10 Areas of Opportunity ...................................................................................................... III-10

    Section IV: Review of MCO Efforts to Address Program Integrity

    Introduction ....................................................................................................................... IV-1 Review of Credentialing and Recredentialing Activities .................................................. IV-2 Review of Activities to Detect Fraud and Abuse .............................................................. IV-6 Best Practices .................................................................................................................. IV-12 Areas of Opportunity ...................................................................................................... IV-12

    Section V: Review of Access and Availability of Providers

    Introduction ........................................................................................................................ V-1 GeoAccess Analysis........................................................................................................... V-2 Location of Actual Services ............................................................................................... V-5 Distance Test in a Sample of Cases ................................................................................. V-10 Appointment Availability ................................................................................................ V-11 24 Hour Availability ........................................................................................................ V-13 Conclusion ....................................................................................................................... V-15

    Section VI: Analysis of Retrospective Authorizations, Claim Denials and Claim Disputes

    Introduction ...................................................................................................................... VI-1 Methodology .................................................................................................................... VI-1 Findings and Observations from the Review of Retrospective Authorizations and Claim Denials ............................................................................................................................. VI-5 Findings and Observations from the Review of Claim Disputes ................................... VI-12

  • FINAL REPORT External Quality Review of the Indiana Hoosier Healthwise Program and Healthy Indiana Plan

    Burns & Associates, Inc. November 30, 2010  

    Section VII: Validating Performance Measures Introduction ..................................................................................................................... VII-1 Performance Measure #1- Provider Claim Disputes ...................................................... VII-2 Performance Measure #2- 24 Hour Availability Audit ................................................... VII-5 Performance Measure #3- Inpatient Utilization (Maternity) .......................................... VII-7 Performance Measure #4- Emergency Room Utilization ............................................... VII-8 Performance Measure #5- Member Pregnancy Identification ........................................ VII-9 Performance Measure #6- POWER Account Employer Participation ......................... VII-10

    Section VIII: Validating Performance Improvement Projects

    Introduction ................................................................................................................... VIII-1 Anthem Performance Improvement Project #1: Planning for Follow-up Care after Hospitalization with a Behavioral Health Diagnosis ..................................................... VIII-2 MHS Performance Improvement Project #1: Follow-up Care after Hospitalization with a Behavioral Health Diagnosis ........................................................................................ VIII-4 Anthem and MHS Performance Improvement Project #2: Breast Cancer Screening ... VIII-6 Anthem Performance Improvement Project #3: Lead Screening .................................. VIII-8 MHS Performance Improvement Project #3: Timely Prenatal and Postpartum Care .. VIII-9 MDwise Performance Improvement Project #1: Follow-up Care for Children Prescribed ADHD Medication, Initiation Phase ........................................................................... VIII-12 MDwise Performance Improvement Project #2: Adolescent Well Care Visits .......... VIII-13 MDwise Performance Improvement Project #3: Comprehensive Diabetes Screening VIII-14

    Appendix

    Appendix A: EQR Guide Appendix B: Authorization/Claim Denial Review Tool

  • FINAL REPORT External Quality Review of the Indiana Hoosier Healthwise Program and Healthy Indiana Plan

    Burns & Associates, Inc. i November 30, 2010  

    EXECUTIVE SUMMARY Indiana’s Office of Medicaid Policy and Planning (OMPP) has implemented two managed care programs using Section 1115 waiver authority. The Hoosier Healthwise (HHW) program covers children, pregnant women, and low-income families. As of the end of Calendar Year (CY) 2009, there were nearly 750,000 enrollees in the program—608,793 children and 139,410 adults. The other program is the Healthy Indiana Plan (HIP), which was introduced in January 2008. As of the end of CY 2009, the HIP had 45,701 adult enrollees. The HIP covers two expansion populations:  Uninsured custodial parents and caretaker relatives of children eligible for Medicaid or

    the Children’s Health Insurance Program (CHIP) with family income up to 200 percent of the Federal Poverty Level (FPL) but are not otherwise eligible for Medicaid or Medicare (the “HIP Caretakers”)

     Uninsured noncustodial parents and childless adults ages 19 through 64 who are not

    otherwise eligible for Medicaid or Medicare with family income up to 200 percent of the FPL (the “HIP Adults”)

    In 2010, the OMPP hired Burns & Associates, Inc. (B&A) to conduct a

Recommended

View more >