ValueOptions Provider ForumEast Lansing, MIMay 6, 2005

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Agenda• Welcome and Introductions

– ValueOptions Staff• Kathy Balcom, Service Center Vice President, GLSC• Stan Golec, MD MPH, Medical Director, GLSC• Gary Lalicki, Director Clinical Operations, ESD-GLSC• Jane Trupiano, Director, Claims – GLSC • Marvin Guynes, Interim QM Director - GLSC• Ruth Barry, Manager, Provider Relations – GLSC• Greg Irey, Account Representative• Lynne Tolbert, Team Leader, Clinical Operations-HPD-GLSC • Cathy Gilbert, Director, Corporate Provider Relations

• Guest Speaker– James Keener, Owner- River’s Bend PC, Troy MI

• Provider Relations– BCN and Blue Choice Updates

Agenda (cont)• The New IVR - TeleConnect

– Demonstration• Coming soon to www.ValueOptions.com

– Web Self Service Demonstration – ProviderConnect• Eligibility• Authorizations• Claims

• Clinical Initiatives– ITR– Focus Care Management– EAP

• Claims– Electronic Claims Submission and Scanning– Fraud and Abuse Issues

• Quality – QIAs– Member and Provider Satisfaction Surveys

• Questions and Answers

Partnering with Managed CareJames Keener – Guest Speaker

• Jim Keener has worked in the behavioral medicine field for over 27 years. He has served on the MAADAC board for the past 3 years. He has served as chair of the Ethics Committee, and chair of the Website Committee. Keener has served on the EAPA-GDC board as Ethics Committee chair and served a term as President.

• Keener has worked successfully with labor and management in the Detroit area and nationally to implement and grow EAP programs. Most notably, secured and developed the first external labor/management EAP for the auto industry at Saturn Corporation. He has over twenty years of experience partnering with local labor unions as well as management around EAP/Work Life programs.

• Directed and designed behavioral medicine programs at numerous facilities including:– St. Joseph’s Mercy Hospital Fox Center – St. John’s Hospital Oxford Institute– Comprehensive Psychiatric Services– Square Lake Counseling Center– Kingswood Hospital– Henry Ford Health System– Brighton Hospital

• He currently owns and operates a private for profit outpatient behavioral medicine clinic called River’s Bend, PC in Troy, MI. Keener carries an average active caseload of forty clients.

Partnering with Managed Care - Clinical• Both working toward serving the client/patient• Team approach to arrive at best level of care with

collaboration between Care Managers and Providers• Working together to better serve difficult clients. For

Example:– Manipulative client – i.e. Provider shopping, drug seeking

individual– MBHO Referrals back to original treating organization leads to

better outcomes– Tracking through levels of care – Facilitate coordination of care thru multiple organizations –

Inpatient and Outpatient providers– Clinical Care Managers at an MBHO can be part of the treatment

team by partnering with providers for better outcomes

Partnering with Managed Care - Claims• Old manual process – paper copy and snail mail

– May take as long as 3 weeks for a response – either payment or denial

• Electronic claims submission– Saves time – Rapid notification if claim error – including missing authorization

when using the direct entry of claims through www.valueoptions.com

– Payment often in less than week from time of submission– TAT on payments faster– Less staff time following up on denied claims or claims errors

• Rejections / Denials have decreased from 40% to 0% since starting electronic claims

Corporate Provider Relations

BCN and Blue Choice• Credentialing

– BCN Process• CAQH for MDs and PhDs• Acknowledgement agreements

• Blue Choice De-Implementation– Restructuring and Consolidation– Transition to BCBSM – Effective 9/1/05– Details will be sent to all providers around July 1, 2005

Technology

Technology Enhancements Increased convenience & decreased administrative burden

• TeleConnect (Interactive Voice Response) – May 2005– Voice recognition software that will allow for eligibility

verification, claims status, benefits, form requests and outpatient authorizations*

• ProviderConnect (Provider Online Services) – July 2005– Enhanced online claims submission, claims status, benefits,

eligibility verification, form request and Web-based outpatient authorizations*

* Outpatient Authorizations via TeleConnect & ProviderConnect will be introduced beginning in Q4’05.

TeleConnect (Interactive Voice Response)• Replacing our existing touch

tone telephonic systems.

• Offers easy-to-navigate voice response self-service.

• The new system will give you 24/7 access to conduct authorization approvals, claims inquiries, eligibility and benefit inquiries - that is, the ability to retrieve information at your convenience.

ProviderConnect (Provider Online Service)

• Provides an online alternative to the telephonic services of TeleConnect.

• Gives providers a 24/7 available, easy-to-use tool for completing everyday service requests.

• Will allow users to check eligibility, benefits, outpatient authorizations claims status, claims history, claims payment and view correspondence on-line in Fall 2005.

• Allows single and batch claims submissions• Enable providers to view their demographic

information and submit changes online. • www.valueoptions.com

ValueOptions’ Website

Corporate Website

Corporate Provider Relations Website

Corporate Provider Relations Website• Company News: Read the most recent news about our company.

• Network-Specific Information: Find handbooks, forms, and other details that pertain to program-specific networks.

• Educational Opportunities: View educational articles and 2005 Provider Forums. eLearning under development.

• The Valued Provider: Access articles found in our provider newsletter. Read informative articles and learn about new initiatives underway at ValueOptions.

• Change of Address and W-9 forms: Help us keep the information we have on file for you current by downloading, completing and sending these forms to us.

• Online Services: ProviderConnect - confirm eligibility of our members for service, submit claims directly over the internet, and check the status of a claim you submitted (etc.).

• Forms: Current VO forms posted for your convenience to download and submit.

• Provider Handbook: Available online. Always up-to-date.

Provider Handbook• Prepared as a guide to ValueOptions’ policies and procedures for

individual providers, affiliates, group practices, programs and facilities. • Provides important information regarding the managed care features

incorporated in the ValueOptions’ provider contract; and also reflects the policies that are applicable to our “general” commercial product lines.

• Divided into the following sections: – Administration

Provider Responsibilities, Credentialing and Sanctions, Claims, Online Services, Referral, Quality Management, and Utilization

– Clinical Criteria– EAP Information– Treatment Guidelines– Forms– Glossary of Terms

• We also made each section printer friendly for your convenience.

Corporate Member Website

Corporate Member Website• Resource Center

– Print Members Rights and Responsibilities poster – Post in your office - visible to all members

• Education Center– Offers information on various Mental Health topics

Clinical

Clinical Initiatives 2005• Health Plans

– Clinical Redesign• Care Team• Inpatient Team

– Psychiatry Consults on Medical Unit– Bariatric Assessments – BCN specific– Current IVR – Outpatient authorization process– Aftercare Follow-Up – PCP Coordination

Outpatient Authorizations 2005 - HPD

• ValueOptions is making the following changes to the Outpatient Authorization process for Health Plan Accounts in 2005:

– The 6 visit pass through for Health Plan Accounts was discontinued for 2005 –this is for BCN, OmniCare, Oakwood, M-Care and DMC Care.

– IVR will now be used for the first and second authorizations for Outpatient care.• The first call will register the care and authorize an initial 4 sessions. • The second call to the IVR will authorize up to 6 additional sessions.

– The IVR will back date up to 30 days. – For additional visits after 10 visits, you speak to a care manager to complete a

clinical review.– For members who have been in treatment and utilized their full benefit during

2003 and 2004, providers will be notified to contact VO to review the case.– The toll free number for the IVR for all of the health plans is: 866-206-9316. The

IVR allows you to register care for your clients 24 hours a day, 7 days a week. • Please use IVR to obtain authorization for all outpatient services. This

change will be effective for all claims submitted after 1/1/2005, regardless of date of service.

Clinical Initiatives 2005• Employer Solutions Division

– Inpatient Treatment Record (ITR)– Integrated Case Activity Form (CAF)/Billing Form for EAP

Services– EAP Providers needed in area– Overview of EAP Programs– Focus Care Management

EAP Providers • EAP Providers/Counselors -

– Must be licensed in one of the disciplines recognized by ValueOptions (MD/DO, PSY, SW, RNCS, ARNP, MFT, or LPC) at the highest level of independent practice in the state where the practice is to occur and meet ValueOptions credentialing criteria.

– All provider applicants must have a minimum of three (3) years post licensure experience in a mental health / substance abuse/ EAP setting providing direct patient care.

– Must possess knowledge and work experience of EAP Core Technology by:• Active status as a Certified Employee Assistance Professional (CEAP); or• Two (2) years of verifiable experience as an internal EAP counselor and/or as an external

EAP consultant to other organizations. Examples of verifiable experience include but are not limited to:

– Management and/or union representative consultation on the impact of personal problems on work, performance issues, the appropriate use of constructive confrontation and the role of the EAP.

– Direct care functions of an EAP practice including assessment referral, short-term counseling and linkage to treatment and/or community resources.

– Crisis Intervention including critical incident stress management (CISM) services.– Training and experience in organizational dynamics/development, human resource management or

industrial social work / psychology.– Assessment and identification of drug and alcohol abuse / dependency problems and appropriate

treatment interventions.

EAP Providers (cont)– Must possess knowledge and work experience in the assessment and

treatment of substance abuse by:• Active status as a Certified Employee Assistance Professional

(CEAP) with an acceptable level of experience in the assessment and/or treatment of chemical dependency, or

• Possess one year of experience in a substance abuse treatment facility: or

• Completed a state-level certification acceptable to support eligibility for the National Certified Addiction Counselor (NCAC) credential: or

• Possess International Certified Alcohol and Drug Counselor Certification (ICADC): or

• Possess a minimum of six (6) units of continuing education (CEU’s, PDH’s etc) in chemical dependency assessment/treatment: or

• Completed three (3) graduate level hours of coursework in chemical dependency.

GM CareLine -• CareLine is for all hourly employees, retirees, surviving

spouses and their eligible dependents enrolled in Non HMO Insurance. The CareLine Program has been developed according to the National Agreement between the UAW and the General Motors Corp.

• The purpose of the CareLine Program is to ensure quality mental health and substance abuse care to covered enrollees in the most appropriate setting. This is accomplished though the coordinated efforts of the Central Review Organization (ValueOptions), the Carrier (CIGNA Behavioral Health), the Central Diagnostic and Referral Agency (Helpnet), the Work/Family Program (EAP) at the local plant, and with the cooperation of the enrollees and providers.

GM CareLine (cont)• The Central Review Organization (CRO) ValueOptions

– Confirms eligibility of the patient for mental health/substance abuse coverage

– Authorizes and approve all mental health services, including inpatient, partial hospitalization, intensive outpatient andtraditional outpatient services

– Credentials providers for the CareLine Program and give recommendation to the Carrier (CIGNA Behavioral Health)

– Assures that benefits are authorized based on medical necessity

GM CareLine (cont)• The Carrier-CIGNA Behavioral Health

– Executes Provider Agreements with qualified providers – Processes claims for service and make reimbursement for

authorized services– Maintains provider information such as tax Id’s, addresses, etc– Facilitates the Sanction/Overpayment program

GM CareLine (cont)• The Central Diagnostic and Referral Agency (Helpnet)

– Conducts face to face assessment of patients under substance abuse diagnosis and develop a continuing care treatment program (CCTP)

– Makes determinations regarding whether the patient’s condition requires mental health and/or substance abuse treatment

– Monitors compliance of the Continuing Care Treatment Plan and report to the CareLine Program if the patient does not complete treatment as stated in the CCTP, which will lead to a sanction (for the employee only)

– Coordinates with the CRO the treatment of those enrollees that require both substance abuse and mental health services, and register all substance abuse authorizations with the CRO

GM CareLine (cont)• Benefits

– 45 days of inpatient treatment (covers both mental health and substance abuse) 45 days are renewed after an absence of 60 days of any inpatient care for either medical or behavioral health services

– 90 days of partial hospitalization (covers both mental health and substance abuse)

– 35 outpatient visits for mental health per calendar year (coverage is 100 percent for sessions 1-20 and at 75 percent for sessions 21-35)

– 35 outpatient visits for substance abuse per calendar year (coverage is at 100 percent for all 35 sessions)

• All services for mental health and/or substance abuse must be authorized by either the CRO or the CDR in order for the Carrier to reimburse providers for service rendered

Claims

Scanning Claims – Dos and Don’ts

Critical success factors for scanning – Dos• Original red line claim forms• Black ink machine print• Print within the boxes• Use upper case letters• Use a laser printer• Use white correction tape for corrections• Use 8 digit dates (e.g. 01232004)• Use fixed width fonts like Courier• Use 8 ½” x 11” paper for any additional notes• Complete the patient’s date of birth

Don’ts

Factors that may require manual intervention & delay claims:

• Use black line or copies of claim forms• Hand print or hand write• Use red ink• Use dashes, slashes, or circles• Use type smaller than 10 point• Use proportional fonts like Times New Roman• Use of stamps, highlighters, correction fluid, labels,

stickers• Folding or stapling items to the claim form• Use of handwritten signatures (use signature on file)

EDI• ValueOptions can receive your 837 transaction directly• Access the VO web site at www.valueoptions.com• Access “For Providers” on the left hand side of the

screen• Access Handbooks – Administration- Online Services.• EDI help is available from eSupport Services at

1.888.247.9311

FRAUD AND ABUSE

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Fighting fraud and abuse strengthens and preserves ValueOptions’ services to providers and members and enhances the health care delivery system as a whole.

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Abuse• ValueOptions defines abuse as any practice, direct or indirect, that is

inconsistent with sound or established fiscal, business, insurance, or medical practices and results in an unnecessary cost to a behavioral health benefits program.

• It also consists of reimbursement for services performed that are not medically necessary or that fail to meet professionally recognized standards for health care.

• A provider may or may not have knowingly and/or intentionally misrepresented facts to obtain payment.

• Abuse also includes any practices by a member that results in unnecessary costs to a behavioral health program.

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Fraud• ValueOptions defines fraud as an intentional deception or

misrepresentation made by an entity or person in any managed care setting with the knowledge that the deception could result in some unauthorized benefit to the entity, himself/herself, or some other person.

• In the context of health care claims, purposely billing for services that were never given, for a service that has a higher reimbursement than the service provided, or at the incorrect reimbursement level.

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Common Examples of Fraud and Abuse• Submitting claims for services that were not provided (this

includes no shows or canceled appointments)

• Misrepresenting the diagnosis for the member in order to justify payment

• Utilizing split billing schemes (i.e., billing procedures over a period of days when all treatment occurred during one visit)

• Coding a service at a higher level that what was rendered (i.e. up-coding)

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Common Examples of Fraud and Abuse Continued

• Inappropriate documentation of services rendered

• Billing for all participants of a family therapy session

• Billing for services by a provider for services actually rendered by an affiliated (i.e. employed or associated with same group etc.) provider who is not a contracted or credentialed provider of ValueOptions.

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When Fraud is Committed . . .Automatic Termination Providers will be immediately terminated upon the happening of any of the following events:

– Insolvency or Dissolution

– Loss of License

– Conviction of Fraud

– Limited Ability to Practice

– Death

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Eliminating Fraud and AbuseTo eliminate fraud and abuse successfully, providers, facilities, and members must work together to prevent and identify inappropriate and potentially fraudulent billings. This can only occur by:

– Monitoring claims submitted for compliance with billing guidelines

– Adherence by providers and facilities to Treatment Record Standards

– Education of all staff members responsible for dealing with medical records (including documentation, storage, retrieval, orreview) or who are involved with billing

– Referring cases of suspected fraud and abuse

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For More Information• Contact Us

– FHC Ethics and HIPAA Hotline at 1-888-293-3027.

• Visit our Website– www.valueoptions.com

Quality

Quality Management Department– Evaluates quality of care across the entire range of

services – Fully operational quality structure– NCQA/URAC accreditation status

Quality Improvement ActivitiesOngoing Activity:• Improving Ambulatory Follow-up Care After Discharge

from an Acute Mental Health Level of Care

New Activities for 2005:• Increasing the Identification, Initiation and Engagement

of Treatment for Members in Need of Alcohol or Other Drug Services

• Increasing Time in Community for Members Treated for Major Depression in an Inpatient Setting

• Enhancing the Management of Care for Children and Adolescents

Ambulatory Follow-up Rates

38.6%

58.2%

65.6%

77.7%

69.4%

85.2%

62.2%

81.1%80.5%

91.2%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Within 7 days Within 30 days

Perc

enta

ge o

f Com

plia

nce

Baseline: (1/1/00 - 12/31/00) 2001: (1/1/01 - 12/31/01) 2002: (1/1/02 - 12/31/02) 2003: (1/1/03 - 12/31/03) 2004: (1/1/04 - 12/31/04)

Continuity of Care InitiativesContinuity of Care Initiatives1. Between Behavioral Health Providers:

– An audit was conducted during 2003/2004. Charts were reviewed on members that had been discharged from inpatient to outpatient care in 2003 and had at least three outpatient visits by the time of the audit.

– The percentage of outpatient cases that demonstrated coordination of care was 45%.

– Information on discharge medications was found in 43% of the cases.

– Ongoing onsite education instituted on mechanisms to improve communications between Behavioral Health Providers

2. Between Primary Care Physicians for 2004 the compliance rate was 71% - Performance Standard is 80%

Prevention Programs• Major Depression-Keys to Recovering From Depression• ADHD -Parenting the Child With Attention

Deficit/Hyperactivity Disorder (ADHD)– Workbooks are available on the ValueOptions web site at

www.valueoptions.com or if you have any questions please call 1-(866) 228-8703.

– On-line screening available to health plan members as of September 2003

• Post-Partum Depression Program

Member Satisfaction SurveyQuarterly Surveys completed by FactFinders• 2004 Great Lakes Service Center Results

– Overall Member Satisfaction with Providers – Positive Response

• 90.4% of Health Plan Members • 89.1% of Employer Group/EAP members• 89.2 of Employer Group MH/SA Members

– Quality of Service from Therapist – Positive Response

• 91% of Health Plan Members• 85.8% of EAP Members• 88.9% of Employer Group MH/SA Members

Annual Provider Satisfaction SurveyGreat Lakes Regional Results

• Conducted 3rd – 4th quarter • Telephone interviews by Fact Finders, Inc• Overview of ValueOptions National Results

Provider Collaboration and Feedback

Annual Provider Satisfaction Survey - independent auditorNational Network Results- 91% overall satisfaction- 96% availability across all licensure types

Provider Satisfaction With ValueOptions• Annual Survey completed in December 2004

Overall Satisfaction with ValueOptions

8 5 . 2 %9 0 . 3 % 8 8 . 1 %

9 2 . 3 %

8 0 . 4 %8 6 . 0 %

0 . 0 %

1 0 . 0 %

2 0 . 0 %

3 0 . 0 %

4 0 . 0 %

5 0 . 0 %

6 0 . 0 %

7 0 . 0 %

8 0 . 0 %

9 0 . 0 %

1 0 0 . 0 %

V e r y S a t is f ie d 5 9 . 3 % 3 6 . 6 % 5 0 . 0 % 4 1 . 0 % 3 9 . 1 % 2 4 . 0 %

S o me w h a t S a t is f ie d 2 5 . 9 % 5 3 . 7 % 3 8 . 1 % 5 1 . 3 % 4 1 . 3 % 6 2 . 0 %

N o t S a t is f ie d 1 1 . 1 % 2 . 4 % 1 1 . 9 % 7 . 7 % 1 9 . 6 % 1 4 . 0 %

S a t is f a c t io n 8 5 . 2 % 9 0 . 3 % 8 8 . 1 % 9 2 . 3 % 8 0 . 4 % 8 6 . 0 %

1 9 9 9 2 0 0 0 2 0 0 1 2 0 0 2 2 0 0 3 2 0 0 4

Helpfulness with Certification of Care

SOMEWHAT HELPFUL

55%

NOT HELPFUL

8%

VERY HELPFUL

37%

Provider Satisfaction with Certification of Care

% WHO THINK CERTIFICATION IS EASY

74%

13%OUTPATIENT CARE

INPATIENT CARE

Practice Characteristics by Professional Discipline

22%

22%

18%

38%Psychiatrist

Psychologist

Social Worker

All Other Disciplines

2004 TREATMENT RECORD DOCUMENTATION

• OPPORTUNITIES FOR IMPROVEMENT– Each page in the treatment record contains the enrollees name

or ID number– Special situations-imminent risks of harm to members must be

noted– Documentation of a medical/psychiatric history– Treatment plans are consistent with diagnosis and have

measurable timely goals – The treatment record has evidence of continuity and

coordination of care between Behavioral healthcare practitionersand the member’s Primary care Physician (PCP)

– Treatment record reflects evidence of coordination with EAP/employer if a referral was made

Website www.valueoptions.com has the following documents available:– PCP Communication Form– ValueOptions’ Quality Management Program in the

ValueOptions’ Provider Handbook (Section C).– The ValueOptions’ “After-Care Tip Sheet” for members.– The ValueOptions’ “My Medication Log” for members.– Member Rights and Responsibilities Statement

HIPAA Reminders• Email is not secure unless encrypted

– Do not send member information via email. This includes:• Member name or initials• I.D. numbers• Any identifying information

• New HIPAA Security Rules Effective 4-2005• For details on HIPAA issues – please use the links on

www.valueoptions.com under the Compliance section of the Provider Handbook.

Questions and Answers

Thank you!www.valueoptions.com