MLTSS – A Provider Prospective September 16, 2015 Presented By: Joanne Jones Director, Clinical...

MLTSS – A Provider Prospective

September 16, 2015

Presented By:

Joanne Jones

Director, Clinical Consulting

MLTSS – New Jersey Experience

Goals of MLTSS

Expand Home and Community Based Services

Intensive Care Management Services

Identify Community Resources

Facilitate Discharge from Nursing Facility

Ensuring Quality

Credentialing Facilities

Increasing Efficiency

Capitated payment between the State & MCO

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NJ-MLTSS Implementation Timeframe

July 1, 2014 Full State Implementation

All new Medicaid Approvals for Residents in Nursing Facilities

Any Medicaid approved Resident who transferred from another Facility

Existing Medicaid approved residents in Facilities remain FFS

No target date for change to MLTSS unless a qualifying event

– Transfer from one Nursing Facility to another Facility is qualifying event

– Hospitalization was not a qualifying event



NJ Managed Medicaid Health Plans

Aetna*

Amerigroup NJ*

Horizon NJ Health

United Healthcare Community Plan

Wellcare*

* Health Plan does not serve all Counties



Resident Choice is central to MLTSS

Resident/family chooses plan at time of enrollment

Resident/Family can change Health plans

Within 90 days of enrollment

Annual open enrollment Period

“Good cause”



Key Aspects of the Implementation of the Nursing Homes

No mandate for dual participation in Managed Medicare/Medicaid

Nursing Home residents could maintain their Medicare FFS

“Any Willing Provider” provisions

Plans were required to contract with all interested Nursing Facilities

Plans were required to contract with Facility Physicians

Plans were required to contract with Facility Pharmacy

State established rate structure for 2 years

No need to negotiate a different rate unless Facility/Plan agreed



Reimbursement Structure

State mandated rate structure until July 1, 2016

Plans can negotiate rates with facilities after July 1, 2016

Managed Medicaid Health Plan billed 1st day of the month after MA approval

State FFS is billed for all months that MA was pending


NJ MLTSS – Provider Experience

Contracting with Health Plans

Identifying any Credentialing Requirements

Criminal background Checks

Critical Incident Reporting Requirements

Understanding Other Requirements

Pre-authorization for Services

Notification of Hospital Transfers



Admissions Process

Verification of the Health Plans on Admission

MLTSS or Skilled Services

Education of Residents/Families on Process

Educate Residents/Families on Plans that have contracts with Facility

Transfers from another Nursing facility

Identify where Resident is in MA approval process

Identify if Health Plan already assigned



Business Office/Billing

Establish the Plan Files in the AR system to assure accurate billing

Need specific Billing formats for each Health Plan

Medicaid Health Plan Verification Process

Contingent on enrollment date

Medicaid Tracking process for approvals

FFS for pending period



Case Management

Authorization Process

If no Medicare coverage, authorization for diagnostics and specialty appointments

Facility Point of Contact for Health Plan

Requirement for onsite evaluation by Health Plan Case Manager

Focus on return to the Community

Focus on Discharge Planning – Coordinated by Case Manager



Physician Services

Facility Physicians participation in Network

Potential for denial of payment for services ordered if not in network



Quality Assessment and Improvement

Collection and reporting of data

Hospitalization/Rehospitalization Rates

Discharge Planning Effectiveness

Quality Measures


New York State – MLTC Experience

Implementation of MLTC

Community based implemented in 2012

Nursing Homes implemented in 2015 by County

Started February 1, 2015 – completed by July 1, 2015

October 1, 2015 – Voluntary enrollment for current Nursing Home FFS Residents

26 Plans in the State



Reimbursement Transition

3 years for Benchmark Rate unless negotiated at different rate

After 3 years then fully negotiated rate

Nursing Home Quality Incentive payment still in place

Based on specific Quality Measures and Performance Measures



Provider Challenges

Plans not required to contract with “any willing” Provider

Must pay facility as Out of Network if no available bed in network

Plans are required to contract with Facility Pharmacy

Mandatory dual eligible participation in MLTC in Community

Reduce the volume of participation in the Medicare FFS population

– Community Residents are joining Medicaid Advantage Plus Plans

– Combines both Medicare and Medicaid in same plan


MLTSS Panel Discussion

Cindy Gensamer, LNHA, CCACVice President Absolute Rehabilitation

Dual Eligible Managed Care- “You Are Not Alone”…

Report by AHCA

http://www.ahcancal.org/facility_operations/medicaid/Documents/MLTSS%20Analysis.pdf

Key Findings

Ohio’s Experience

Ohio’s Implementation

1. Five insurance companies were selected to:1. Manage Medicaid in Ohio2. Manage Medicare A & B (January 1, 2015), unless a

patient opted out. (70%-80%)

Lessons From Ohio

• Voice concern about how the rates will be adjusted to reflect true patient needs

• Decide now to accept what you can’t change and develop a relationship with contractors immediately

• Educate physicians as there may be more involvement with contractors’ nurse practitioners

• Plan to spend man hours on obtaining authorizations and pre-authorizations

• Learn early how billing will work, be aggressive by asking detailed questions

• Make preparations for slowed payment– Cash flow concerns

Public to Private, “All I Want To Say Is That …”

Be knowledgeable about MLTSS PA Timelines

Our Goals Remain The Same

• Person Centered Care• Clinical Outcomes• Patient Advocacy• Fiscal Stability

– Our job is to find a way to accomplish our goals under a new payment system.

HeadlineQuestions?

Cindy Gensamer, LNHA, CCAC

Vice President

Absolute Rehabilitation & Consulting

339 East Maple St. North Canton, Ohio 44720

330-498-8204 • [email protected]

The Emerging World of Post-Acute Care (PAC)

Therapy Provision

How Therapies Will Respond to an Ever-Evolving Care Delivery Environment

Patient-Centered Demonstrate Value Collaborate

The times, they are a-changing’…

The traditional payer for our services is shrinking every year as more and more potential patients need those services.


The times, they are a-changing’…

With so many different reimbursement “experiments” out there, are there some over-riding trends that are emerging?

Patient-centric

Value-based

Collaboration



Length of Stay

CATEGORY DIAGNOSISSub acute GOAL - LOS

Sub acute MEDIAN - LOS

Cardiology Heart Failure 9 to 16 days 20 days

Infective Endocarditic 11 to 20 days 22 days

Myocardial Infarction 10 to 17 days 20 days

Syncope 10 to 17 days 20 days

Orthopedics Ankle Dislocation 11 to 20 days 27 days

Ankle Fracture 12 to 20 days 26 days

Back Pain 10 to 17 days 20 days

Cervical Spine Surgery 9 to 15 days 20 days

Femur Fracture 13 to 24 days 30 days

Foot: Transmetatarsal Amputation 10 to 18 days 21 days

Hip Arthroplasty 7 to 12 days 14 days

Hip Fracture, Open Repair 14 to 23 days 28 days

Knee: Amputation Above or Below Knee 13 to 23 days 29 days

Knee Arthroplasty 7 to 10 days 12 days

Knee: Fracture of Tibial Plateau 12 to 20 days 25 days

Lumbar Spine Surgery 7 to 12 days 14 days

Pressure Ulcer Closure 25 to 39 days 39 days

Tibia/Fibula Fracture 11 to 21 days 27 days


Real Patient Experiences

Patient: VioletDRG: Hip & femur procedures w/o complicationsTarget Cost: $30,237.77

Patient: HenryDRG: Hip & femur procedures with complicationsTarget Cost: $33,726.18


Real Patient Experiences

Patient: VioletDRG: Hip & femur procedures w/o complicationsTarget Cost: $30,237.77

Independent in ADLs and driving prior to her surgery. Pt. Goal = Transition home to live with her son, where she will continue w HH Tx.

Patient: HenryDRG: Hip & femur procedures with complicationsTarget Cost: $33,726.18

Independent in ADLs and driving prior to surgery.

Pt. Goal = Transition home to live with his wife, where he will continue w HH Tx.


How Did Violet & Henry Do?Patient: VioletDRG: Hip & femur procedures w/o complicationsTarget Cost: $30,237.77Actual Cost: $15,812.52Cost Variance: $14,425.25

1/17/14 – 2/8/14: SNF (22 days) $11,584.762/10/14 – 4/10/14: HH (16 visits) $3,277.44

Patient: HenryDRG: Hip & femur procedures with complicationsTarget Cost: $33,726.18Actual Cost: $36,709.57Cost Variance: $4,983.39

1/20/14 – 1/25/14: SNF (5 days) $2,400.511/26/14 – 1/29/14: Hospital (3 days) $5,921.081/29/14 – 3/14/14: SNF (44 days) $24,712.703/15/14 – 4/19/14: HH (15 visits) $3,222.06


What am I ACCOUNTABLE for?

CONTROL

INFLUENCE

CONCERN


What am I ACCOUNTABLE for?

SNF

HH

OP


What Does That Mean For Us?

Patient-centric

Value-based

Collaboration

So how do we prepare ourselves to be the best at it, as soon as possible?


Scope of Practice and Goal Setting

What will change? We will … Still provide highly skilled rehab services Determine the transition plan by Day 3 Communicate with previous care setting in order to

begin where they left off Collaborate with the next care setting to know what

the patient will need Assess health literacy of pt./family & provide

training Establish and implement an FMP and train staff


What May Need to Change?

From Day 1, the focus of therapy education is two-fold: on the patient and family

By Day 2 of admission, the interdisciplinary team needs to have the same understanding of LOS and transition environment (home or SNF)

Home visit is completed by Day 3, on-site with the patient or potential for “virtual home visit”/

Establish the FMP and initiated education and

training to caregiver/staff if remaining in the SNF


How Will We Respond?

Therapy Scope of Practice Current: We treat most underlying impairments

and functional deficits identified during the evaluation.

New world: Treat the underlying impairments or functional deficits necessary to get the patient to his/her next transition.

Goal Setting Current: Goals are set at the highest level the

patient seems able to achieve. New world: Goals are set at the level the

patient needs to attain in order to achieve a safe transition point.


How Will We Shift Our Focus?

Frequency and Intensity With these co-morbidities, frequency of

therapy needs to be 7 days per week; all you have is one week with him

Intensity is based on clinical need to prioritize goals for the transition point


Planning Next Steps

o Do we have the clinical skill set on our therapy teams to meet the needs of the resident’s ?

o Do we have adequate communication and collaboration between therapy and nursing to meet

the evolving changes of the resident’s ?

o Have we educate families to the evolving changes

and shorter length of stays ?

o Are we networked with other providers in other settings?


Questions ???????

MLTSS – A Provider Prospective September 16, 2015 Presented By: Joanne Jones Director, Clinical...

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