preparing for managed care may 13, 2015 peggy elmer, lcsw senior clinical director- behavioral...

Preparing for Managed CareMay 13, 2015Peggy Elmer, LCSW Senior Clinical Director- Behavioral Health

Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

Our clinical visionCare AdvocacyThe purpose of Care Advocacy is intervention on behalf of individuals living with a health issue. We improve the experience of individuals living in communities we serve, using our managed care tools and our techniques to ensure services including treatment, support, rehabilitation, habilitation and prevention. We facilitate recovery, resiliency, wellness and wellbeing in the highest quality and most cost-effective manner.

Service System SolutionsThe purpose of Service System Management is to improve the structure of, access to and practice within systems of care. We use our network tools to improve healthcare systems for individuals living with a health issue in the communities we serve. The service system includes the contracted network, non-contracted providers and relationships with natural community supports.

Information Management and TechnologyThe purpose of Information Management and Technology is to empower staff, providers and individuals living with a health issue in the communities we serve, to create a more engaging, effective and affordable healthcare experience and to empower individuals in their pursuit of wellbeing.


Specialty Health Solutions

We build systems of care…..• We manage financial risk

• We manage provider networks

• We manage clinical care

• We ensure quality measures are achieved

Behavioral Health• Comprehensive

Behavioral Health • Medical/Behavioral

Integration• EAP and WorkLife• Community Based

Products

Complex Medical Conditions• Transplant Solutions• Kidney Solutions• Infertility Solutions• Bariatric Resource

Solutions

Physical Health• Chiropractic• Physical Therapy• Speech Therapy• Occupational Therapy• Alternative Medicine

Optum International• EAP• Wellness• Wellbeing• Technology Solutions• Network Management


Enabling Services

• Align incentives to promote quality results

• Invest in enabling success (technology, reporting, staff, incentives)

Streamline Business Practices

• Reduce the hassle factor, especially around payment and utilization management practices

• Engage providers with holistic programs and invest to enable change

Feedback and Engagement

• Use regular, consistent, and benchmarked information feedback for improvement

• Provide technology (e.g., electronic heath records) to support point-of-service information

Partner for Success

• Move from transactional relationships to collaborations

• Assess joint opportunities to better meet the needs of the market to create competitive differentiators

Engaging providers to influence member outcomes

Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 5

Why is Optum Promoting the Use of Peer Support and Services?

• We are committed to enhancing our Recovery Orientation - The Recovery Oriented System Indicator (ROSI) identifies peer support and the employment of peers as a central element to a recovery oriented system http://www.power2u.org/downloads/ROSI-Recovery%20Oriented%20Systems%20Indicators.pdf

• The Substance Abuse and Mental Health Service Administration (SAMHSA) has identified peer support as one of pillars of Recovery

http://mentalhealth.samhsa.gov/publications/allpubs/sma05-4129/

• The Surgeon General’s Office endorse the use of peer support http://www.surgeongeneral.gov/library/mentalhealth/toc.html#chapter4

• The President's New Freedom Commission identifies the use of peer to peer services as central to a transformed system http://mentalhealthcommission.gov/reports/Finalreport/FullReport.htm

• We are committed to seeing peers go back to work in meaningful and valuable roles

• It works!

http://www.power2u.org/downloads/ROSI-Recovery%20Oriented%20Systems%20Indicators.pdf

http://mentalhealth.samhsa.gov/publications/allpubs/sma05-4129/

http://www.surgeongeneral.gov/library/mentalhealth/toc.html

http://mentalhealthcommission.gov/reports/Finalreport/FullReport.htm

Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 6

Peer Coaching programs -The Optum experience

• Optum Research:

– enrollees in the WI PeerLink program showed a significant decrease of 71% in average # of acute inpatient days per month

– enrollees in the TN PeerLink program showed a significant decrease of 90% in average # of acute inpatient days per month

• Optum TX 70% reduction in hospital days• Optum Pierce: 125 people, 79.2% reduction in hospital

admission year over year $550,215 in savings.• NYAPRS data:71% percent of the people the Peer Bridgers

worked with were able to stay out of the hospital in 2009. • Recovery Innovations: 56% reduction in hospital

readmission rates.


Network Recruitment

• Optum offers a robust network of clinicians, agencies and facilities throughout New York State

• To serve consumers through FIDA, HARP and Mainstream Medicaid carve-in plans, we are actively identifying providers who offer the following services for recruitment:

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• Assertive Community Treatment (ACT)

• Case Management

• Community Integration Counseling

• Continuing Day Treatment

• Intensive Psychiatric Rehabilitation Treatment programs

• Home Health

• Mobile Mental Health Treatment

• OMH licensed Community Residences

• Opioid Treatment Services

• Peer delivered services

• Personalized Recovery Oriented Services (PROS)

• Positive Behavioral Interventions and Supports

• TeleHealth

• 1915i-like Home and Community Based Services


• The participation process begins with submission of the agency application

• Additional required application materials include: – Signed UBH Group Agreement

– Signed Disclosure of Ownership and Control Interest Statement

– The American with Disabilities Act (ADA) Attestation with 100% compliance

• Pre-contractual site audits Required for unaccredited agencies pursuing group contracts

– May be waived following Optum review of the agency’s most recent OMH and/or OASAS site audit results

• Approval by Optum Credentialing Committee

• Orientation to Optum clinical and administrative protocols via Provider Orientation Forums and webinars, or review of provider resources posted on www.providerexpress.com

Network Participation Requirements


What providers can do now

• Establish relationships with plans

• Providers can assess current population by plan type and determine which managed care organizations (MCO’S) that they will need to establish contracting requirements

• MCO’s must contract with providers who are serving 5 or more of their members to ensure continuity of care and avoid disruption of services.

• Do not wait for MCO’s to find you. Be proactive and start the process early

• Think about the person, NOT the program

• Clearly define your expertise

• Clearly define what you DO NOT do

• Use and share data


• For provider group agencies that employ both licensed professional and unlicensed paraprofessional staff to render services under the umbrella of the agency, Optum will execute group contracts with the agency as the contracting entity

• Group agencies must submit the Optum agency application, indicating the services being provided and the licensed clinical professionals on the staff roster

• The individual clinicians on staff do not need to be individually credentialed when they work for the agency under an Optum group contract

Credentialing of Group Agencies


Joining the Optum Network

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Network Requirements - Agencies

1. Must complete an application documenting business/clinical structure

2. Must be in good standing with state and federal regulatory bodies

3. Must be accredited by an Optum-recognized accrediting body (e.g., Joint Commission, COA, CARF, AOA):• If not accredited by an Optum-recognized body, a site audit is conducted

prior to credentialing• In lieu of site visit, Optum may accept certification from CMS or State

Agency if reviewed within last 3 years

4. Must have insurance with following minimums per occurrence / aggregate:• Professional liability insurance - $1 million/$3 million minimum• General liability insurance - $1 million/$1 million minimum

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Agency Application and Credentialing Process

• Agency submits a completed Agency Application to the Network Manager

• In addition to the completed application, the following documents should be submitted:

– Copies of current state license(s)/certificates for all services the Agency provides

– Accreditation status

– Professional and general liability insurance certificates

– Form W-9 (one for each Tax ID under which Agency bills)

– Policies and procedures on:• Intake/Access Process to Behavioral Medicine • Quality Improvement Plan

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Agency Application and Credentialing Process

• Upon receipt of completed application and required documents, Optum reviews materials to assess network need and Agency eligibility

• If an unaccredited Agency, a site audit is scheduled to assess:– Type and quality of programming

– Types of staff providing services

– Staff competencies

– Treatment documentation standards

– Physical environment

• Eligible Agencies’ applications are forwarded to the Credentialing Department

• Credentialing is generally completed within 180 days of receipt of completed application and required documents

• The Agency is notified within 10 days of the Credentialing Committee’s decision

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Recredentialing

• Optum recredentials agencies at least once every 36 months:

– State law or client requirements may require a different recredentialing cycle

• Very similar to initial credentialing, including Primary Source Verifications and notification to you of any discrepancies found during the process

• It is important that you maintain current demographic information with Optum

• To update the Agency’s information, use the Provider Express secure “Transactions” feature or contact your Network Manager

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Important Reminders

• Between credentialing cycles, please remember to:

– Update Optum with any changes to the Agency’s demographic information such as:• Tax ID number• Changes or renewals of licenses • Renewal of insurance

– Notify Optum if the Agency is unable to take new referrals (for example, due to full practice)

– Notify Optum of any action that could potentially result in the suspension, sanction, revocation or restriction of your license

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Peer Support Credentialing – Required Qualifications

• State Certification, in states where it exists.

• In states where certification is not required, the staff must have completed peer support training from an approved program and passed an exam.

• The training program must be completed through any of the following approved programs which also must be approved by the applicable state office of mental/behavioral health:o Appalachian Consultingo Depression and Bipolar Support Allianceo Recovery Innovationso Mental Health Association of Southeastern Pennsylvaniao NAZCARE of Northern Arizonao The Connecticut Community for Addiction Recovery (CCAR) o Transformation Centero Mountain Stateso NYS Peer Academy

• Any other training program on Peer Support Services must be submitted for review and approval by Optum/UBH prior to credentialing or contracting the organization for peer support services.

• If required by regulation, peer support staff are supervised by an independently licensed mental health professional.


Peer Support Credentialing Process for Organizations

• Once potential organizations who employ Peer Support Specialists are identified, the Network Manager distributes the applicable application and supporting materials to the agency.

• The organization completes the application and supporting materials and submits them back to the Network Manager.

• Once the Network Manager receives the application and materials from the organization they submit a request to have a program audit conducted.

• All Peer Support organizations will need to pass a program audit prior to being credentialed.

• Once the audit of the organization has been completed, the Network Manager confirms the agency passed the audit and forwards the agency application and contract materials to the credentialing team for review and approval by the Credentialing Committee.

• The Credentialing Team Confirms all the Peer Support Specialists of the organization meet the certification, training, and credentialing criteria/requirements applicable to the state requirements, agency licensure type, accreditation, liability insurance, and is in good standing with applicable state and federal agencies

• Credentialing Committee for review and approval


Peer Support Organization – Audit Process• The Peer Support Program audit focuses on general agency policies, the specific

supervision plan, hiring practices, and recordkeeping protocols (contact records) for peer support specialists

• The audit may be completed through a desktop review, or in the case of an unaccredited organization, may be completed on-site (audit team determines)

• The record keeping protocols include a review of:– Initial data gathering

– Coordination of Care

– Recovery Planning

– Case Notes

– Discharge Planning

– General Record Development


Peer Support – Resources

Optum has added the Recovery & Resiliency Toolkit for Providers to the Provider Portal, www.providerexpress.com.

Specific Resources from SAMHSA and the Depression and Bipolar Support Alliance are published in the toolkit.

The Recovery & Resiliency Toolkit can be found at:

www.providerexpress.com/rrtoolkit/

Provider and Network information can be found on :

www.optum.com

www.liveandworkwell.com

http://www.providerexpress.com/

http://www.providerexpress.com/rrtoolkit/

http://www.optum.com/

http://www.liveandworkwell.com/


Optum’s smartphone apps

Behavioral Health Clinician Search is our most popular web tool. The first app we mobilized, it searches our entire clinician network and provides detailed recommendations, clinician background and GPS directions. (Also available in UHC’s Health4Me app.)

Liveandworkwell.com also offers mobile-formatted Parenting/Teen/Child wellness and behavioral information in conjunction with KidsHealth®

Optum Whole Health Tracker is the result of work with Larry Frick, it enables a user to set and track goals in 10 aspects of their life on the way to wellness.

Wellness Recovery Action Plan (WRAP ®) is the result of a collaboration with Dr. Mary Ellen Copeland. It mobilizes her WRAP toolkit that is recognized for supporting people with mental health challenges. It includes, all the WRAP elements, including Trigger Identification, Daily Action Plans, a crisis plan and an Advanced Directive


Resources and Contact Information

Melissa Razzano, Director- Provider Relations for NY, NJ, CT and VT

[email protected]

Phone: (518)-313-4766

Tara Caruso, Senior Network Manager for NYC and Long Island

[email protected]

Phone: (518)-313-4767

Kevin Carknard, Senior Network Manager for Capital Region

[email protected]

Phone: (518) 313-4768

Peggy Elmer , LCSW Clinical Director- Specialty Networks

[email protected]

Phone: 518 362 2231

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mailto:[email protected]




preparing for managed care may 13, 2015 peggy elmer, lcsw senior clinical director- behavioral...

Documents

confidential property

health issue

specialty health solutions

clinical care

systems of care

service system solutions

purpose of care advocacy

express permission