Monitoring Network Adequacy and Most Common Issues …...Toby Strong MCQA Office Auditor Financial...
Transcript of Monitoring Network Adequacy and Most Common Issues …...Toby Strong MCQA Office Auditor Financial...
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Monitoring Network Adequacy and Most Common Issues Found during Examination
Managed Care Quality Assurance Office and Quality of Care Examinations
Texas Department of Insurance
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Monitoring Network Adequacy
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Debra Diaz-Lara and Rita Martinez
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Managed Care Quality Assurance- MCQA
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Debra Diaz-LaraDirector - Managed Care Quality Assurance Office
TBDTeam Lead - Independent Review Organizations (IRO) and Utilization review Agents (URA)
Carolyn PowersTeam Lead - Network Adequacy, Form Review and Workers’ Compensation Health Care Networks (WCNet)
Nikki HoskinsTeam Lead - MCQA Technology and Administrative Support, Prompt Pay Reporting
Toby StrongMCQA Office Auditor
Financial Regulation Division
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TDI Mission and Goals
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TDI is a dynamic leader in state, national and global regulation, consumer protection and promotion of market viability through:
Regulating the insurance industry fairly and diligently
Promoting a stable and competitive market
Providing information that makes a difference
Effective communication with stakeholders to ensure a strong, positive, and legitimate insurance market
Developing regulatory tools/ processes that are adaptable, but permitted within our statutory framework
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Network Adequacy Reviews
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Certificate of Authority- Quality of Care Examinations
Service Area Expansion or Reduction- MCQA Office
Material Change or Network Configuration Change- MCQA Office
Examinations- Quality of Care Examinations, Market Conduct Examinations
Annual Network Adequacy Report- MCQA Office
• Audits
Complaints Received- MCQA Office
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Network Adequacy Review
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Health Maintenance Organizations (HMO)
Applicable Law &Rules
• TIC Chapter 843
• 28 TAC Chapter 11
• 28 TAC 11.1610 Annual Reports due August 15
• 28 TAC §11.1607 Accessibility and Availability Requirements
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Network Adequacy Review
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Network Adequacy for Preferred Provider Benefit Plans (PPBP) and Exclusive Provider Benefit Plans (EPBP)
Applicable Law & Rules
• TIC Chapter 1301
• 28 TAC Subchapter X
• 28 TAC §3.3704 Freedom of Choice Availability of Preferred Providers
• 28 TAC §3.3709 Annual Reports due April 1
• 28 TAC §3.3710 Failure to Provide an Adequate Network
Requests for Access Plans- required by rule, ensures enrollees get care
Narrow Networks- trending up over the last 3 years resulting in cost containment for carriers, however the network MUST be adequate
Network Configurations- material changes to a network
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Network Adequacy Review
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Network Adequacy for Workers’ Compensation Health Care Networks (WCNet)
Applicable Law & Rules
• TIC 1305 Workers’ Compensation Health Care Networks
• 28 TAC §10.26 Modifications to Service Area
• 28 TAC §10.27 Modifications to Network Configuration
• 28 TAC §10.80 Accessibility and Availability Requirements
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Quality of Care Examinations
Financial Regulation Division
Rita Martinez – [email protected]
512-676-6869
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Quality of Care Examinations
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Types of Entities Examined
• Health Maintenance Organizations (HMOs)
• Exclusive Provide Benefit Plans
• Independent Review Organizations
• Worker’s Compensation Networks
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Quality of Care Examinations
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Frequency of Examinations
• Statutorily Required
oQualifying – certificate of authority (COA) application
o Initial – one year after issuance of COA
o Triennial- every three years for HMOs
oQuinquennial – every five years for EPBPs
oReferrals from Other Divisions
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Quality of Care Examinations
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HMO Common Compliance Issues
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HMO Common Compliance Issues
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Complaint System
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HMO Common Compliance Issues
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For an oral complaint, acknowledgement letter did not include a one-page complaint form that prominently and clearly states the form must be returned to the HMO for prompt resolution.
Complaint resolution letter does not contain a complete description of the HMO’s process for appeal as required in TIC Sections 843.254-843.258.
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HMO Common Compliance Issues
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Clean Claims – Prompt Pay
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HMO Common Compliance Issues
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Incorrect received date. Claims submitted electronically, the claim is presumed received on the date of the electronic verification of receipt by the HMO or the HMO's clearinghouse.
HMO used the processed date and not the “actual” paid date to determine if the claim was paid within the applicable statutory timeframe.
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HMO Common Compliance Issues
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HMO did not pay prompt payment penalties to providers or to the Department.
HMO did not submit to the Department quarterly claims payment reports or for the HMO’s delegates.
HMO did not pay a non-contracted provider prompt pay penalties when provider provided emergency care or services that were not reasonably available from a network provider.
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HMO Common Compliance Issues
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Provider Credentialing / Recredentialing
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HMO Common Compliance Issues
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Current list of network providers show recredentialing was not completed within 36 months of the previous credentialing decision.
HMO did not provide a credentialing file for a provider listed on its current list of credentialed an contracted network providers.
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HMO Common Compliance Issues
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For a group contract, a list of the providers contracted with the group and the date the provider joined the group was not provided with the credentialing file.
Recredentialing file did not include documentation of the previous credentialing date.
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HMO Common Compliance Issues
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Network Accessibility and Availability
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HMO Common Compliance Issues
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HMO does not have an adequate network for its approved service area, 30 miles for PCP and general hospital and 75 miles for specialty care and specialty hospitals.
HMO does not contract with hospital-based providers in the HMO’s contracted hospitals within the HMO’s approved service area.
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HMO Common Compliance Issues
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Utilization Review Agent
Adverse Determination (AD)
Initial and Appeal
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HMO Common Compliance Issues
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HMO/URA did not use the adverse determination template letters and forms approved by the Department.
The HMO or URA who issued the AD letters is not a licensed URA.
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HMO Common Compliance Issues
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The URA did not afford the provider of record a reasonable opportunity to discuss the services under review prior to issuing the AD or appeal of an AD.
AD appeal acknowledgment letter did not include a list of relevant documents the appealing party must submit for review.
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HMO Common Compliance Issues
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The AD notice did not include the most current IRO form, LHL009 / 1217.
IRO request for a life-threatening condition was not forwarded to the Department.
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HMO Common Compliance Issues
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QI, Delegated Entities, Form Filings, and CAP
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HMO Common Compliance Issues
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The Quality Improvement Program, did not include the active involvement of one or more enrollees who are not employees of the HMO.
The HMO’s Quality Improvement Committee did not include practicing physicians and individual providers.
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HMO Common Compliance Issues
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The HMO did not file the executed delegation agreement with the Department 30 days after the agreement or amendment was executed.
The HMO did not monitor its delegated entity for compliance with all applicable statute and rules.
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HMO Common Compliance Issues
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The HMO did not implement its corrective action plan (CAP) within 90 days from receipt of its final examination report.
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Quality of Care Examinations
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Examination Tips
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Examination Tips
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Adhere to the due dates and if absolutely necessary request an extension prior to the due date.
Make sure to perform a quality check of the information you are submitting and also the information provided by your delegates.
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Examination Tips
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Begin preparing the CAP as soon as you accept a deficiency. You may implement the CAP prior to the examination closing.
Changes to adverse determination template letters and utilization review policies and procedures must be submitted for approval by using the URA Application Form, LHL005.
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Questions?