Physical Health - NM Human Services...Final Report Main Report June 23, 2014 Purpose The purpose of...

Physical Health Compliance Audit

Audit Period: July 1, 2012-June 30, 2013

Final Report: June 23, 2014

Prepared for the New Mexico Human Services Department under PSC 12-630-8000-0017

By HealthInsight New Mexico External Quality Review staff:

Allen Buice, MA, CPHQ, PMP, Project Manager Gary Logsdon, MHA, CDP, Auditor

Greg Lujan, LISW, Auditor Debi Peterman, RN, MSN, Auditor

Jennifer Salazar, LPN, CBI, Auditor Sabrina Villalobos, BBA, Auditor

Denise Anderson, MAOM, CQPA, Analyst Amber Bennett, Communications Specialist

Margaret White, RN, BSN, MSHA, EQR Director Herb Koffler, MD, MS, EQR Medical Director

Margy Wienbar, MS, Executive Director

5801 Osuna NE, Suite 200 Albuquerque, NM 87109-2587

www.healthinsightnm.org 505-998-9898

http://www.healthinsightnm.org/

of 81

PH Compliance Audit Final Report Main Report

June 23, 2014

Table of Contents Executive Summary .................................................................................................................... 3

Background ................................................................................................................................. 4

Purpose ...................................................................................................................................... 5

Audit Method ............................................................................................................................... 5

Discussion of Regulations Reviewed .......................................................................................... 6

Scoring Method ........................................................................................................................... 8

Evaluation Activities Prior to the Onsite Audit ............................................................................ 11

Evaluation Activities at the Onsite Audit .................................................................................... 11

Audit Findings: Salud! ............................................................................................................... 12

Audit Findings: SCI ................................................................................................................... 16

Recommendations .................................................................................................................... 19

Rebuttal and Reconsideration Review ...................................................................................... 22

Conclusion ................................................................................................................................ 22

Section A: Blue Cross Blue Shield (BCBS) .................................................................... 23

Audit Findings ..................................................................................................... 23

MCO Multi-year Salud! Audit Comparison ........................................................... 28

Recommendations .............................................................................................. 30

Rebuttal and Reconsideration Review ................................................................. 30

Section B: Lovelace Health Plan (LHP) ......................................................................... 34

Audit Findings: Salud! ......................................................................................... 34


Audit Findings: SCI .............................................................................................. 42

MCO Multi-year SCI Audit Comparison ............................................................... 47



Section C: Molina Health Plan (MHP) ............................................................................ 51



Audit Findings: SCI .............................................................................................. 59




Section D: Presbyterian (PHP) ...................................................................................... 67



Audit Findings SCI ............................................................................................... 74

of 81


June 23, 2014




of 81


June 23, 2014

Executive Summary The following report details the annual external quality review (EQR) audit of the Medicaid Salud! and State Coverage Insurance (SCI) Managed Care Organizations (MCOs) in the State of New Mexico. Four MCOs were contracted with Human Services Department Medical Assistance Division (HSD) at the time of this audit: Blue Cross Blue Shield of New Mexico (BCBS), Molina Healthcare of New Mexico (MHP), Lovelace Community Healthcare Plan (LHP), and Presbyterian Health Plan (PHP). HSD requested that the audit for LHP be conducted separately from the other three Physical Health (PH) MCOs and it was completed in the fall of 2013. The other three MCOs were audited 3 months later in early 2014. This report covers the results of both audits. The audit timeframe was July 1, 2012, through June 30, 2013 (State Fiscal Year [SFY] 2013) and included a document review of the MCOs’ policies, procedures, and other documentation. It also included an onsite review of medical records and case files. This audit compared structures and processes against 18 parts and sections of the New Mexico Administrative Code (NMAC). The previous audit (SFY 2012) was the second year of expansion to include the Program Integrity section of the audit. This expansion included the NMAC Fraud and Abuse standards along with selected requirements of the Patient Protection and Affordable Care Act (ACA), 42 CFR1 455. The Letter of Direction (LOD) #44 was issued to the MCOs by HSD on April 4, 2012, to clarify and further define the Program Integrity requirement to be included in this expansion. BCBS was determined to be in Full Compliance with the Salud! program requirements (see Table 1 below). Each individual regulation was also fully compliant. BCBS did not administer an SCI program. LHP was determined to be in Full Compliance with both the Salud! and SCI program requirements (see Table 1 below). Each individual regulation, except for SCI members with Special Healthcare Needs (SCI-SHCN), was also fully compliant. MHP was determined to be in Full Compliance with both the Salud! and SCI program requirements (see Table 1 below). Each individual regulation was also fully compliant. PHP was determined to be in Full Compliance with both the Salud! and SCI program requirements (see Table 1 below). Each individual regulation was also fully compliant.

1 The Code of Federal Regulations (CFR) is the assembled rules and regulations set forth annually by the Federal

Government. Electronic versions of the CFR are available via the Government Printing Office’s website: http://www.gpo.gov/fdsys/browse/collectionCfr.action?collectionCode=CFR (Accessed October 8, 2013)

http://www.gpo.gov/fdsys/browse/collectionCfr.action?collectionCode=CFR

of 81


June 23, 2014

Table 1: Overall Compliance

MCO Overall Score Demonstrated

Compliance Level

BCBS Salud! 98.81% Full Compliance

LHP Salud! 97.08% Full Compliance

LHP SCI 95.84% Full Compliance

MHP Salud! 97.54% Full Compliance

MHP SCI 97.68% Full Compliance

PHP Salud! 99.73% Full Compliance

PHP SCI 98.92% Full Compliance

Background The Centers for Medicare & Medicaid Services (CMS) and the Balanced Budget Act (BBA) require each state to provide quality services for its enrollees and to subject all MCOs rendering services to Medicaid consumers to an EQR. HealthInsight New Mexico is contracted with HSD to serve as its External Quality Review Organization (EQRO) to audit contracted MCOs for adherence to federal and state regulations and contractual obligations based on CMS published protocols. HSD developed a quality strategy to address the needs for quality health care services in New Mexico. HSD published the State of New Mexico Quality Assessment and Performance Improvement Strategy for Medicaid Services in May 2009. In the report, HSD outlines the strategy for MCOs in New Mexico to exceed nationally recognized standards for access to care, clinical quality of care, and quality of service. At the time of this writing, the state of New Mexico has drafted a new Quality Strategy for Medicaid Services that is in public review. After years of traditional fee-for-service Medicaid, the state legislature mandated the creation of managed care programs to provide comprehensive medical and social services to the Medicaid population. The Salud! program was developed to implement this mandate and was launched on July 1, 1997. The program was designed to improve the quality of health care, improve access to care, and make cost-effective use of state and federal funds. In 2005, New Mexico launched the SCI Program, which combined some features of Medicaid with a basic commercial plan. New Mexico has focused on fostering cooperation among federal, state, and private organizations to increase funding for, and access to, care for SCI participants. Elements of this program include health insurance for small businesses, nonprofit organizations, the self-employed, and families, children, and pregnant women who are not eligible for Medicaid.2 The State of New Mexico initiated a waiting list for SCI benefits in November 2009. HSD directed HealthInsight New Mexico to conduct a compliance audit of the four physical health MCOs programs for the period of SFY 2013. The Salud! and SCI programs concluded on December 31, 2013, in preparation for the new Medicaid managed care program, Centennial Care, to begin January 1, 2014.

2 State of NM Quality Assessment and Performance Improvement Strategy for Medicaid Services, May 2009, pg. 4.

of 81


June 23, 2014

Purpose The purpose of this audit was to measure the MCOs’ levels of compliance with NMAC 8.305 and 8.306 pertaining to Medicaid managed care, and with LOD #44 pertaining to Program Integrity as found in 42 CFR 455. HealthInsight New Mexico reviewed the MCOs’ processes, policies, and procedures, and conducted interviews and assessments at the MCOs’ physical locations. MCO and provider files were reviewed to measure compliance with applicable regulations.

Audit Method The audit method was designed to align the audit process with:

Specifications of the HSD LOD issued to HealthInsight New Mexico

MCOs’ state contractual obligations

CMS EQR protocols

Industry standards The specific NMAC regulations under review are:

Salud!

8.305.8.12 Standards for Quality Management and Improvement

8.305.8.17 Standards for Medical Records

8.305.8.19 Delegation

8.305.9 Coordination of Services

8.305.12 MCO Member Grievance System

8.305.13 & 42 CFR 455 Fraud and Abuse & Program Integrity

8.305.14 Reporting Requirements

8.305.15 Services for Individuals with Special Health Care Needs

8.305.16 Client Transition of Care

SCI

8.306.8.9 Quality Management

8.306.8.9 Standards for Medical Records

8.306.8.10 Delegation

8.306.9 Coordination of Benefits

8.306.12 Member Grievance Resolution

8.306.13 & 42 CFR 455 Fraud and Abuse & Program Integrity

8.306.14 Reporting Requirements

8.306.15 Services for SCI Members with Special Health Care Needs

8.306.16 Member Transition of Care The rules that regulate SCI are mirrored after the Salud! regulations with two noticeable differences, namely:

SCI Coordination of Benefits (COB) regulations have fewer requirements than the corresponding Salud! Coordination of Services (COS) regulations

SCI-SHCN regulations have fewer requirements than the corresponding Salud! Individuals with Special Health Care Needs (ISHCN) regulations

of 81


June 23, 2014

Discussion of Regulations Reviewed In the section below, there is a description of each regulation reviewed and the process that was used to evaluate it. Some sections are only a document review where policies, procedures, processes and data submissions for compliance and evidence of implementation were analyzed. Other sections include a document review plus a file review. A file review takes place at the MCO’s physical location. Auditors review files provided by the MCO for adherence to HSD regulations and to the MCO’s policies and procedures. LODs issued by HSD to HealthInsight New Mexico specified the regulations to be included in this audit. For ease of understanding, only the Salud! regulations will be discussed in detail. Where there is overlap, the requirements for the SCI program are identical to the corresponding Salud! regulations.

Quality Management 8.305.8 Several sections of NMAC 8.305.8 were evaluated individually as follows:

Standards for Quality Management and Improvement 8.305.8.12 (with a focus on Disease Management)

This portion of the review evaluated the quality management/quality improvement (QM/QI) plan including policies, procedures, and other implementation documents. Particular focus was given to program structure and operation, mechanisms for continuous QI, member satisfaction, health management systems, clinical practice guidelines, and program effectiveness.

Standards for Medical Records 8.305.8.17 Policies and procedures for medical records were reviewed for evidence of medical record confidentiality processes and compliance with the Health Insurance Portability and Accountability Act (HIPAA) in the transfer of information between the MCO and providers. The review also included policies and procedures designed to allow MCO and HSD/designees, such as HealthInsight New Mexico, access to records. The MCO’s process for review of medical records to guarantee proper documentation was also assessed.

Delegation 8.305.8.19 This section was a document review of policies, procedures, and delegate contracts with the MCOs. These items were examined for completeness and evidence of monitoring (audits of the delegated entities; records by the MCO).

Coordination of Services 8.305.9 (with a joint focus on coordination with Behavioral Health and services for ISHCN) The document review analyzed the policies, procedures, and structures regarding coordination of services between the MCO and the behavioral health (BH) Statewide Entity (SE); Aging and Long Term Services Department (ALTSD); schools; New Mexico Children, Youth, and Families Department (CYFD); and waiver programs. The evaluation also included mechanisms for appropriate reporting from primary care providers (PCPs), identification, and stratification of Individuals with Special Health Care Needs (ISHCN), member assessment, development of care coordination plans, and appropriate follow-up as determined by the service coordinator and the member. A random sample of case files were reviewed for compliance with relevant NMAC regulations.

MCO Member Grievance System 8.305.12 Policies and procedures were reviewed for compliance with NMAC standards, including mandated timeframes, appropriateness of assigned staff, and dissemination of information to

of 81


June 23, 2014

consumers and providers. Policies and procedures were also reviewed for inclusion of appropriate timeframes for expedited appeals and for grievance and appeals for both consumers and providers. This section included a random sample file review of grievances, appeals, and expedited appeals, with particular focus on adherence to timeliness, policies, and procedures.

Fraud and Abuse 8.305.13 & Program Integrity 42 CFR 455 This section was a document review of policies and procedures developed to comply with the NMAC Fraud and Abuse regulations, ACA Sections 6401 and 6402, 42 CFR 455, and LOD #44. This review focused on specifications within the CFR that require the MCO to detect and report suspected instances of fraud or abuse; and to gather, record, and report relevant ownership, controlling interest, adverse action, and payment suspension information.

Reporting Requirements 8.305.14 A review of the basic elements of reporting requirements, including accuracy, timeliness, conformity to HSD standards, content, and pre-submission analysis by the MCO was completed.

Services for Individuals with Special Health Care Needs (ISHCN) 8.305.15 The policies and procedures were reviewed to determine if members with multiple and complex physical and BH care needs were proactively identified by the MCO according to at least the minimum criteria defined in the NMAC. The process of applying stratification criteria to identified ISHCN and policies and procedures governing care coordination for ISHCN were examined. A random sample file review was conducted to evaluate compliance with NMAC regulations, including assessment and education of ISHCNs regarding care coordination.

Client Transition of Care 8.305.16 Policies and procedures were reviewed to determine if the MCO was proactively identifying members who might be in need of transition of care (TOC) services and to determine if those services were offered at the time of enrollment in the MCO or transfer out of the MCO. Policies and procedures were also reviewed to determine if TOC services were provided during transition out of an inpatient facility, and if pre-authorizations were honored for the first 30 days of enrollment.

Data Collection Audit Tools The data collection audit tools, interpretive guidelines, and scoring methods were developed using the NMAC with the exception of Program Integrity. Program Integrity was developed using LOD #44, the CFR, and the ACA. The interpretive guidelines contained detailed criteria regarding each regulation. The audit tools and guides were approved by HSD prior to the onsite audits. The compliance audit consisted of document reviews, file reviews, and onsite interviews with MCO staff.

Defining and Measuring Compliance The data collected from the MCO, either prior to the onsite audits or during the onsite audits, were considered in determining the extent to which the MCO was in compliance with NMAC, CFR, ACA, and CMS regulations. Audit tools were completed as part of the evaluation.

of 81


June 23, 2014

Table 2 shows the definitions and scoring ranges for each compliance level available.

Table 2: Compliance Level Definitions

Full Compliance 90%-100% MCO met or exceeded standard

Moderate Compliance

80%-89% MCO met most requirements of the standard but has deficiencies in certain areas

Minimal Compliance 50%-79% MCO met some of the requirements of the standard but has significant deficiencies requiring corrective action

Non-compliance <50% MCO did not meet standard and requires corrective action

Scoring Method This section presents the numerical system used to determine the score for each subject and an overall score for compliance.

of 81


June 23, 2014

Allocation of Points Each regulatory element is allocated a specific number of points, based on document and file review, as applicable. These points are distributed within each category as summarized below in Table 3. The maximum number of points an MCO could achieve is 100.

Table 3: Allocation of Points

Regulation Number Salud! Regulation Description Available

Points

8.305.8 Quality Management

8.305.8.12 Standards for Quality Management and Improvement

10.00

8.305.8.17 Standards for Medical Records3 3.00

8.305.8.19 Delegation 6.00

8.305.9 Coordination of Services 17.00

8.305.12 MCO Member Grievance System 17.00

8.305.13 & 42 CFR 455 Fraud and Abuse & Program Integrity 3.00

8.305.14 Reporting Requirements 10.00

8.305.15 Services for Individuals with Special Health Care Needs

17.00

8.305.16 Client Transition of Care 10.00

Overall Total 93.00

Regulation Number SCI Regulation Description Available

Points

8.306.8 Quality Management

8.306.8.9 Quality Management 10.00

8.306.8.9 Standards for Medical Records 3.00

8.306.8.10 Delegation 6.00

8.306.9 Coordination of Benefits 17.00

8.306.12 Member Grievance Resolution 17.00

8.306.13 & 42 CFR 455 Fraud and Abuse & Program Integrity 3.00

8.306.14 Reporting Requirements 10.00

8.306.15 Services for SCI Members with Special Health Care Needs

17.00

8.306.16 Member Transition of Care 10.00

Overall Total 93.00

3 After MCO rebuttals, HSD directed the Medical Record file review to no be included as a scored item.

The points for this regulation moved from 10 to 3. The overall points moved from 100 to 93.

of 81


June 23, 2014

Auditor Inter-rater Reliability The HealthInsight New Mexico auditors completed an inter-rater reliability (IRR) assessment for each audit section that had a file review element. A peer review of each section was conducted to provide an accurate and reliable score.

Data Validation Multiple reviewers validated all completed instruments to guarantee the data is precise, inclusive, and meets the criteria for the particular regulations under review. Discrepancies and missing data elements were discussed with HealthInsight New Mexico EQRO staff, including the medical director, as needed. All HealthInsight New Mexico file review data entry was reviewed for both accuracy and completeness prior to analyzing results. During the onsite audit, hard-copy records were used to validate the data, which the MCO provided with the universe submission4. Reviewers discussed discrepancies with MCO staff to facilitate accurate collection and reporting of information.

Potential Point Deductions from Overall Score The scoring method included criteria to reduce the overall score of the MCO program for late submission or inaccurate identification of the documentation requested by HealthInsight New Mexico. One point may be deducted from the overall score for each identified violation. As enumerated in Table 4, the potential existed for up to a 7-point deduction from the overall score due to timeliness and accuracy issues with the submission.

Table 4: Timeliness and Accuracy Penalties

Identified Deficiency Timeliness Accuracy

Document Review Documents -1

Universe Submission -1 -1

Chart Preparation -1 -1

Clarification Documents -1

Closing – deadline for submission of additional documents -1

Calculation of Final Score Final score was calculated using the following method:

1. The points earned within each subject were divided by the points available to determine a percentage.

2. Each subject was reported individually as a percentage with a corresponding compliance level.

3. The total points earned for all subjects were divided by the total points available for all subjects to determine an overall percentage.

4. The final overall score was reported as a percentage and determined the overall compliance level.

4 A universe is the entire population of events occurring within a set time period for a particular regulation

element being audited.

of 81


June 23, 2014

Evaluation Activities Prior to the Onsite Audit Below is a detailed description of audit activities that took place prior to the onsite audit.

Pre-evaluation Overview Meeting A meeting between the auditors, LHP representatives, and HSD staff was held on August 5, 2013, prior to the onsite audit. The meeting included a detailed overview of the regulations and documentation requirements, as well as a review of the audit process and the overall timeline of the audit. At the meeting, the MCO was presented with a list of data sources to submit for the document review prior to the onsite portion of the audit. The MCO was encouraged to ask clarification questions regarding requested documentation and regulations during this time. In response to issues identified at the meeting, the project manager made minor revisions to the audit tools, interpretive guidelines, and scoring methods which were reapproved by HSD. The meeting for the other three MCOs was scheduled separately but that meeting was cancelled because there were no questions presented by the MCOs to address.

Document Review In preparation for the onsite audit, the auditors reviewed all documentation submitted by the MCOs. This documentation consisted of the required policies and procedures, the member handbook, the provider handbook, provider directory, the QM/QI plan, and other documents as needed to demonstrate compliance with specific regulations. The MCOs were required to submit file universes in an electronic workbook. Five weeks prior to the onsite audit, a random selection of files from the universe submissions was sent to the MCO for compilation of hard-copy files, including oversample files, to be reviewed onsite.

Evaluation Activities at the Onsite Audit A three- or four-day audit was conducted by five HealthInsight New Mexico auditors at each MCO’s physical location. The onsite audit consisted of demonstrations by MCO staff of systems changes from the previous audit, file reviews, and interviews with key staff. On the first day of each onsite audit, an opening session was held to discuss the onsite audit process. At the conclusion of the onsite audit, the HealthInsight New Mexico auditors conducted a closing conference attended by MCO staff. Auditors presented their preliminary findings, provided feedback, and answered MCO staff questions.

of 81


June 23, 2014

Audit Findings: Salud! The overall scores for the Salud! Compliance Audits for each MCO by year are presented below in Table 5. Table 6 displays the scores in the current audit for each individual Salud! regulation. These tables are followed by discussion of each Salud! regulation followed by the SCI results.

Table 5: MCO Overall Scores and Historical Comparison

Salud! MCO SFY 2010

Score SFY 2011

Score SFY 2012

Score SFY 2013

Score SFY 2013

Compliance Level

BCBS 98.52% 99.19% 98.47% 98.81% Full Compliance

LHP 98.87% 97.70% 94.04% 97.08% Full Compliance

MHP 98.22% 99.04% 99.97% 97.54% Full Compliance

PHP 99.44% 99.74% 99.90% 99.73% Full Compliance

Individually Scored Subjects Each individually scored NMAC part and section is detailed in Table 6 for Salud!. MCO-specific findings are included in the appropriate MCO sections.

Table 6: Scores for Individual Salud! Regulations, by MCO

Regulation BCBS LHP MHP PHP

Standards for Quality Management and Improvement

100.00% 100.00% 100.00% 100.00%

Standards for Medical Records 100.00% 100.00% 100.00% 100.00%

Delegation 100.00% 100.00% 100.00% 100.00%

Coordination of Services 96.35% 95.53% 98.65% 100.00%

MCO Member Grievance System 97.65% 99.24% 98.82% 100.00%

Fraud and Abuse & Program Integrity 100.00% 94.00% 100.00% 100.00%

Reporting Requirements 100.00% 100.00% 100.00% 100.00%

Services for Individuals with Special Health Care Needs

100.00% 95.76% 94.53% 99.24%

Client Transition of Care 99.10% 100.00% 100.00% 98.90%

Table 7 shows the Overall Score for each MCO after points were removed for timeliness and accuracy issues.

Table 7: Overall Score After Timeliness and Accuracy Penalty Assessments

Timeliness and Accuracy Point Deductions 0 -1 -1 0

Overall Score 98.81% 97.08% 97.54% 99.73%

of 81


June 23, 2014

Salud! Discussion As discussed in the Scoring Method section of this report, there was a potential for up to a 7-point deduction due to various timeliness and accuracy reasons. BCBS did not have any points deducted for timeliness or accuracy. LHP had 1 point deducted from the overall score for Universe Accuracy for the Salud! program. The member’s Medicaid ID number was requested for all universes but was not provided. All universes except Medical Records used the member’s Social Security Number and the Medical Records used an internal “LH alphanumeric identifier.” This caused a delay with data analytics to make the stratified random sample with no duplicate members pulled. MHP had 1 point deducted from the overall score for Universe Accuracy for the Salud! program. There were no dates of service provided for the Medical Records Universe. The date of service is an integral part of the sampling process. PHP did not have any points deducted for timeliness or accuracy. The following section details the current status of any changes from the SFY 2012 audit. Additional detail is available in the MCO-specific sections.

Standards for Quality Management and Improvement 8.305.8.12 (with a focus on Disease Management) Findings: All four MCOs demonstrated Full Compliance with the standards related to this regulation. QM policies and procedures and supporting documentation of the Disease Management Programs were explicit and completely referenced all aspects of the regulation.

No adverse findings in this audit Previous Audit Follow-up: All four MCOs earned Full Compliance last year.

Standards for Medical Records 8.305.8.17 Findings: All four MCOs demonstrated Full Compliance for this regulation. Medical records policies and procedures and supporting documentation were explicit and completely referenced all aspects of the NMAC regulation. Following MCO rebuttal process and discussion with HSD staff, it was decided that the Medical Record file review would not be a scored item for this audit year. However, the recommendations stemming from the Medical Record file review will stand. Previous Audit Follow-up: All four MCOs earned Full Compliance last year.

Delegation 8.305.8.19 Findings: All four MCOs demonstrated Full Compliance with the standards related to this regulation. Delegation agreements and oversight processes were explicit and completely referenced all aspects of the HSD regulation. Documents were reviewed for oversight activities.

No adverse findings in this audit

of 81


June 23, 2014

Previous Audit Follow-up: All four MCOs earned Full Compliance last year.

Coordination of Services 8.305.9 (with a joint focus on coordination with Behavioral Health and services to ISHCN) Findings: All four MCOs demonstrated Full Compliance with the standards related to coordination of services. Coordination of services policies and procedures and supporting documentation were explicit and completely referenced all aspects of the regulation. A random sample of case files were reviewed for care coordination of PH and behavioral health (BH) services and indicated the following:

No adverse findings in the document review PHP scored 100 percent while the other three MCOs scored in the mid to upper 90s

(95.53 percent or greater) The deficiencies were sporadic and no systemic issues were identified


MCO Member Grievance System 8.305.12 Findings: All four MCOs demonstrated Full Compliance with the standards related to the member grievance regulations. Member grievance policies and procedures and supporting documentation were explicit and completely referenced all aspects of the regulation. A random sample of case files were reviewed for timeliness of MCO response and dissemination of information for grievances, appeals, and expedited appeals. Case files were reviewed for each element of the Member Grievance System and the following was noted:

No adverse findings in the document review PHP scored 100 percent while the other three MCOs scored in the high 90s (97.65

percent or greater) The deficiencies were sporadic and no systemic issues were identified


Fraud and Abuse 8.305.13 & Program Integrity 42 CFR 455 Findings: All four MCOs demonstrated Full Compliance with reviewed regulations, including the NMAC Fraud and Abuse regulations as well as the requirements set forth in LOD #44 from HSD to the physical health MCOs. These requirements included regulations from the CFR and referenced the Affordable Care Act (ACA).

BCBS, MHP and PHP scored 100 percent and LHP scored 94.00 percent LHP’s policies did not explicitly state that it will comply with some of the specifics of the ownership and control interest disclosure.

Previous Audit Follow-up: This is the second year of scoring for this regulation; the

additional ownership and control interest disclosure was not a scored item previously. All four MCOs earned Full Compliance last year

Reporting Requirements 8.305.14 Findings: All four MCOs demonstrated Full Compliance with the standards related to reporting requirements. Reporting requirements, policies and procedures, and supporting documentation were explicit and completely referenced all aspects of the regulation.

of 81


June 23, 2014

No adverse findings in this audit Previous Audit Follow-up: All four MCOs earned Full Compliance last year.

Services for Individuals with Special Health Care Needs (ISHCN) 8.305.15 Findings: All four MCOs demonstrated Full Compliance with the identified standards for this regulation. Each of the MCOs had sufficient policies and procedures in place to identify ISHCNs. A random sample of case files were reviewed for each MCO. BCBS scored 100 percent and PHP scored 99.20 percent. Between LHP and MHP, the following elements had the lowest compliance scores:

Documentation of members’ education regarding ER care and clinical history to provide when ER or inpatient admission is needed

Documentation of access to clinical history by ER physician Documentation that member received a list of key MCO resource people and phone

numbers, with designated single POC Previous Audit Follow-up: BCBS, MHP and PHP earned Full Compliance last year. LHP was minimally compliant.

LHP’s score significantly improved from last year’s 76.47 percent to this year’s 95.78 MHP had a 5.47 percentage point drop from 100 percent last year to 94.53 percent this

year BCBS’ and PHP’s scores remained stable this year at 100 percent and 99.20 percent

respectively

Client Transition of Care 8.305.16 Findings: All four MCOs demonstrated Full Compliance with the standards related to client transition of care. The MCOs appropriately identified the transition of care cases. The MCOs performed well in this regulation, each scoring greater than 98.80 percent. BCBS and MHP scored 100 percent for this regulation. The few deficiencies noted were sporadic and no systemic issues were revealed. Previous Audit Follow-up: All four MCOs earned Full Compliance in the previous audit.

of 81


June 23, 2014

Audit Findings: SCI The overall scores for the SCI Compliance Audits for each MCO by year are presented below in Table 8. Table 9 displays the scores in the current audit for each individual SCI regulation. These tables are followed by discussion of each SCI regulation.

Table 8: MCO Overall Scores and Historical Comparison

SCI SFY 2010

Score SFY 2011

Score SFY 2012

Score SFY 2013

Score SFY 2013

Compliance Level

LHP 96.45% 98.14% 94.55% 95.84% Full Compliance

MHP 98.81% 98.29% 99.46% 97.68% Full Compliance

PHP 98.80% 99.66% 99.70% 98.92% Full Compliance

Each individually scored NMAC part and section is detailed in Table 9 for SCI. MCO-specific findings are included in the appropriate MCO sections.

Table 9: Scores for Individual SCI Regulations, by MCO

Regulation LHP MHP PHP

Standards for Quality Management and Improvement 100.00% 100.00% 100.00%

Standards for Medical Records 100.00% 100.00% 100.00%

Delegation 100.00% 100.00% 100.00%

Coordination of Benefits 100.00% 100.00% 94.12%

Member Grievance Resolution 99.82% 100.00% 100.00%

Fraud and Abuse & Program Integrity 94.00% 100.00% 100.00%

Reporting Requirements 100.00% 100.00% 100.00%

Services for SCI Members with Special Health Care Needs 86.16% 93.88% 100.00%

Member Transition of Care 100.00% 100.00% 100.00%

Table 10 shows the Overall Score for each MCO after points were removed for timeliness and accuracy issues.


Timeliness and Accuracy Point Deductions -1 -1 0

Overall Score 95.84% 97.68% 98.92%

State Coverage Insurance Discussion LHP had 1 point deducted from the overall score for Universe Accuracy for the SCI program. There were two issues with the universe submission:

1. The member’s Medicaid ID number was requested for all universes but was not provided. All universes except Medical Records used the member’s Social Security

of 81


June 23, 2014

Number and the Medical Records used an internal “LH alphanumeric identifier.” This caused a delay with data analytics to make the stratified, random sample to ensure no duplicate members were pulled.

2. During the onsite audit, several files were found to be outside of the audit timeframe. Since there were over 100,000 records available for selection, the probability is very low that there were not additional files in the universe that were outside of the audit timeframe.

MHP had 1 point deducted from the overall score for Universe Accuracy for the SCI program. There were three issues with the universe submission:

1. There were no dates of service for medical records 2. There were 17 files that were outside of the audit timeframe 3. SCI Provider Appeals did not contain provider or facility names

PHP did not have any points deducted for timeliness or accuracy.

Standards for Quality Management and Improvement 8.306.8.9 (with a focus on Disease Management) Findings: All three MCOs demonstrated Full Compliance with the standards related to this regulation. QM policies and procedures and supporting documentation of the Disease Management Programs were explicit and completely referenced all aspects of the regulation.

No adverse findings in this audit; all three MCOs achieved 100 percent Previous Audit Follow-up

All three MCOs earned Full Compliance last year

Standards for Medical Records 8.306.8.9 Findings: All of the MCOs demonstrated Full Compliance for this regulation. Medical records policies and procedures and supporting documentation were explicit and completely referenced all aspects of the HSD regulation. Following MCO rebuttal process and discussion with HSD staff, it was decided that the Medical Record file review would not be a scored item for this audit year. However, the recommendations stemming from the Medical Record file review will stand. Previous Audit Follow-up: The composite scores for last year included the file review, so comparisons cannot be made.

Delegation 8.306.8.10 Findings: All three MCOs demonstrated Full Compliance with the standards related to this regulation. Delegation agreements and oversight processes were explicit and completely referenced all aspects of the HSD regulation.

No adverse findings for this regulation Previous Audit Follow-up: All three MCOs earned Full Compliance last year.

of 81


June 23, 2014

Coordination of Benefits 8.306.9 (with a joint focus on coordination with Behavioral Health and services to SCI-SHCN) Findings: All three MCOs demonstrated Full Compliance with the standards related to coordination of benefits. LHP and MHP scored 100 percent. Coordination of Benefits policies and procedures and supporting documentation were explicit and completely referenced all aspects of the regulation. Case files were reviewed for coordination of benefits between PH and BH services and indicated the following:

There were no adverse findings in the document review. The one MCO that did not achieve 100 percent only had one deficiency identified. There were only three files in the universe submission; therefore the one deficiency had a large impact.

Previous Audit Follow-up: All MCOs earned Full Compliance last year with 100 percent scores.

Member Grievance Resolution 8.306.12 Findings: All three MCOs demonstrated Full Compliance with the standards related to the member grievance regulations. MHP and PHP scored 100 percent and LHP scored 99.82 percent. Member grievance policies and procedures and supporting documentation were explicit and completely referenced all aspects of the regulation. A random sample of case files were reviewed for timeliness of MCO response and dissemination of information for grievance, appeals, and expedited appeals. Case files were reviewed for each element of the Member Grievance Resolution and the following was noted:

No adverse findings in the document review Previous Audit Follow-up: All three MCOs earned Full Compliance last year.

Fraud and Abuse 8.305.13 & Program Integrity 42 CFR 455 Findings: All three MCOs demonstrated Full Compliance with reviewed regulations. The review included the NMAC Fraud and Abuse regulations as well as the requirements set forth in LOD #44 from the HSD to the physical health MCOs. These requirements included regulations from the CFR and referenced the ACA.

MHP and PHP scored 100 percent LHP did not have policy language explicitly stating its compliance with some areas of the

ownership and control interest disclosure Previous Audit Follow-up: All three MCOs Full Compliance last year. The elements of ownership and control interest disclosure were not scored in the previous audit.

Reporting Requirements 8.306.14 Findings: All three of the MCOs demonstrated Full Compliance with all standards related to reporting requirements. Reporting requirement policies and procedures and supporting documentation were explicit and completely referenced all aspects of the regulation.

No adverse findings in this audit Previous Audit Follow-up: All three MCOs earned Full Compliance last year.

of 81


June 23, 2014

Services for SCI Members with Special Health Care Needs (SCI-SHCN) 8.306.15 Findings: MHP and PHP demonstrated Full Compliance and LHP demonstrated Moderate Compliance with the standards for this regulation. All three of the MCOs had sufficient policies and procedures in place to identify SCI-SHCN members. A random sample of case files were reviewed for each MCO and the following elements had the lowest compliance scores:

Documentation of the assessment for care coordination Provision of access to clinical history by ER physician Documentation of having provided education regarding access to ER care and clinical

history to provide when ER or inpatient admission is needed Previous Audit Follow-up: There were a range of changes. LHP was minimally compliant in the previous audit is now moderately compliant. For the remaining two, PHP had an increase in this score but MHP had a decrease.

Member Transition of Care 8.306.16 Findings: The three MCOs demonstrated Full Compliance with the standards related to member transition of care. A random review of the case files for each MCO indicated the following:

No adverse findings in this audit All three MCOs scored 100 percent

Previous Audit Follow-up: All three MCOs earned Full Compliance designations last year with scores of 100 percent.

Recommendations This audit was conducted to discover the extent to which the MCOs were compliant with federal and state regulations in the provision of Salud! and SCI services. Recommendations for improvement are listed separately for each regulation and each program. Specific recommendations for each MCO are listed in the MCO sections.

Salud! Recommendations


There are no general recommendations for improvement.

Medical Records 8.305.8.17 It is recommended that the MCOs develop and implement a way that providers can easily document medication effectiveness, medication reactions, medications prescribed, and advanced directives, and then have an efficient way of providing that documentation for audit purposes. As electronic health records (EHRs) become more prevalent, these would be useful enterprise-wide enhancements to have in place. It is recommended that the MCOs work with their providers to get their EHR system to print the patient’s name and a secondary identifier on each page. If the patient identification is only on the first page, then there is a risk that the pages could get separated and mixed in with another member’s data.

of 81


June 23, 2014

Delegation 8.305.8.19 There are no general recommendations for improvement.

Coordination of Services 8.305.9 (with a joint focus on coordination with Behavioral Health and services to ISHCN) It is recommended that the MCOs consistently document that members were informed of their Single Point of Contact (SPOC) and how to contact the SPOC. One actionable option would be to work with the software vendor to add a check box in the care management software saying that such education has been provided. That data point could then be queried. The results could then be presented to auditors either internally or externally and could show the date and name of the service coordinator who made the contact or contact attempt. It could also be used to flag the member’s file if such education had not yet been provided by a predetermined day of the month. Further, it would be beneficial to communicate to other care team members whether the contact had been made so that any follow-up activity could be conducted.

MCO Member Grievance Resolution 8.305.12 There are no general recommendations for improvement.

Fraud and Abuse 8.305.13 & Program Integrity 42 CFR 455 There are no general recommendations for improvement.

Reporting Requirements 8.305.14 There are no general recommendations for improvement.

Services for Individuals with Special Health Care Needs (ISHCN) 8.305.15 It is recommended that the MCOs develop a way to document in an auditable format that all required education and resources are provided to members, including education regarding access to the ER and clinical history to provide when ER or inpatient admission is needed and access to clinical history by the ER physician. Two actionable recommendations are:

1) Work with the vendor to add a check box to the care management software 2) Add these items to a job aid for training purposes, then make checking for these items a

standard part of internal audits and performance checks for care managers or others who are responsible for this documentation

Client Transition of Care 8.305.16 There are no general recommendations for improvement.

SCI Recommendations



Standards for Medical Records 8.306.8.9 It is recommended that MCOs develop and implement a way that providers can easily document medication effectiveness, medication reactions, advanced directives, and drugs prescribed including strength, amount, directions, and refills, and then have an efficient way of providing that documentation for audit purposes. As EHRs become more prevalent, these would be useful enterprise-wide enhancements to have in place.

of 81


June 23, 2014

It is recommended that MCOs work with their providers to get their EHR system to print the patient’s name and a secondary identifier on each page. If the patient identification is only on the first page, then there is a risk that the pages could get separated and mixed in with another member’s data and create a potential HIPAA violation.

Delegation 8.306.8.10 There are no general recommendations for improvement.

Coordination of Benefits 8.306.9 (with a joint focus on coordination with Behavioral Health and services to SCI-SHCN)


Member Grievance Resolution 8.306.12 There are no general recommendations for improvement.

Fraud and Abuse 8.306.13 & Program Integrity 42 CFR 455 There are no general recommendations for improvement.

Reporting Requirements 8.306.14 There are no general recommendations for improvement.

Services for SCI Members with Special Health Care Needs (SCI-SHCN) 8.306.15 It is recommended that MCOs develop a way to document in an auditable format that all required education and resources are provided to members including the list of key resources, education regarding access to the ER, and clinical history to provide when ER/Inpatient admission is needed. The two recommendations from Salud! ISHCN are also applicable here. It is recommended that MCOs develop a way to document that the assessments for care coordination are completed and that there is a consistent, auditable way to provide that documentation.

Member Transition of Care 8.306.16 There are no general recommendations for improvement.

Previous Audit Follow-up

Medical Records 8.306.8.9 In the previous audit, HealthInsight New Mexico recommended that provider education continue and some form of reminder be built in to prompt providers to consistently accomplish and document the following:

History of smoking, alcohol use, and/or substance abuse for members 12 years of age and older is noted in each medical chart.

Discussion of advance directives with members 18 years of age and older is noted in each medical chart.

The evidence in the current review suggests that the MCOs did not sufficiently address the issues found in the Medical Record Reviews. The MCOs had policies in place that, if followed, would have addressed many of the issues identified in the file review.

of 81


June 23, 2014

Services for Individuals with Special Health Care Needs (ISHCN) 8.305.15 In the previous audit, HealthInsight New Mexico recommended to HSD to implement a Corrective Action Plan (CAP) with LHP to bring the ISHCN and SCI-SHCN regulations into compliance. It was undetermined whether or not a CAP was implemented, but both scores increased considerably since the previous audit. The ISHCN program went from 76.47% (Minimal Compliance) to 95.78% (Full Compliance). The SCI-SHCN program went from 76.61% (Minimal Compliance) to 86.16% (Moderate Compliance).

Rebuttal and Reconsideration Review Each MCO was given the opportunity to offer rebuttals or requests for reconsideration of any findings in this report. Each MCO’s rebuttals, in addition to HealthInsight New Mexico’s reply, are outlined in the MCO-specific section.

Conclusion The MCOs continue to meet contractual requirements in both the Salud! and SCI programs based on this audit. MCO policies and procedures appear to be effective and, for the most part, are being followed at both the organizational and provider levels. With the exception of Medical Records, continuous improvements to services and system changes are demonstrating positive results in compliance levels. LHP earned Full Compliance with all but two regulations: Salud! ISHCN and SCI-SHCN. The remainder of programs earned Full Compliance for each regulation.

of 81

PH Compliance Audit Final Report Section A: BCBS

June 23, 2014

Section A: Blue Cross Blue Shield (BCBS)

Audit Findings This section gives detailed scoring information, findings, and recommendations for the BCBS Salud! program for SFY 2013 (July 1, 2012-June 30, 2013). Table 1 presents the Salud! composite score for each individual regulation. The composite score is determined by calculating the total points earned for audit-related documentation and chart reviews, where applicable. The “N/A’s” in Table 1 indicate that a chart or document review audit was not required. The overall score, shown on Table 2, is determined by adding the total assigned points for each individual regulation which is then converted to a percentage for reporting.

Table 1: Regulatory Element Scores for BCBS Salud!

Regulation

Documentation Review

Chart Review

Tota

l A

vailable

Tota

l A

ssig

ned

Com

posi

te S

core

Available

Poin

ts

Actu

al

Poin

ts

Available

Poin

ts

Actu

al

Poin

ts

Quality Management


10.00 10.00 N/A N/A 10.00 10.00 100.00%

Standards for Medical Records

3.00 3.00 N/A N/A 3.00 3.00 100.00%

Delegation 6.00 6.00 N/A N/A 6.00 6.00 100.00%

Coordination of Services 5.00 5.00 12.00 11.38 17.00 16.38 96.35%

MCO Member Grievance System

5.00 5.00 12.00 11.60 17.00 16.60 97.65%

Fraud and Abuse & Program Integrity

3.00 3.00 N/A N/A 3.00 3.00 100.00%

Reporting Requirements 10.00 10.00 N/A N/A 10.00 10.00 100.00%

Individuals with Special Health Care Needs (ISHCN)

5.00 5.00 12.00 12.00 17.00 17.00 100.00%

Client Transition of Care 3.00 3.00 7.00 6.91 10.00 9.91 99.10%

of 81


June 23, 2014

Table 2 shows the Overall Score after points were removed for timeliness and accuracy issues.


Timeliness and Accuracy Point Deductions 0

Overall Score 98.81%

As discussed in the Scoring Method section of this report, there was a potential for up to a 7-point deduction due to various timeliness and accuracy reasons. BCBS did not have any points deducted for timeliness or accuracy. The purpose of this audit was to measure the MCO’s level of compliance with NMAC 8.305 pertaining to Medicaid managed care, and with LOD #44 pertaining to Program Integrity as found in 42 CFR 455. HealthInsight New Mexico reviewed the MCO’s processes, policies, and procedures, and conducted interviews and assessments at the MCO’s physical locations. MCO and provider files were reviewed to measure compliance with applicable regulations. In the following section, HealthInsight New Mexico provides findings for the audit including document review and file review, including any noted improvements for each regulation and recommendations/opportunities for improvement. Table 3 shows the score and compliance level for the Quality Management and Improvement document review.

Table 3: 8.305.8.12 Salud! Standards for Quality Management and Improvement

Composite Score 100% Compliance Level Full Compliance

Findings: As Table 3 shows, there were no adverse findings for this regulation. This regulation only includes a document review. Previous Audit Follow-up: BCBS received 100 percent of points in the previous audit. There were no recommendations on which to follow up. BCBS continues to perform well in this regulation, having received 100 percent of points from SFY 2010 through the current audit. Table 4 shows the score and compliance level for the Medical Records document review.

Table 4: 8.305.8.17 Salud! Standards for Medical Records


Findings: For the document review portion of the audit, there were no adverse findings Following MCO rebuttal process and discussion with HSD staff, it was decided that the Medical Record file review would not be a scored item for this audit year. However, the recommendations stemming from the Medical Record file review will stand. Previous Audit Follow-up: The composite score was 98.61. The record review was not a scored item in the current audit year.

of 81


June 23, 2014

Table 5 shows the score and compliance level for the Delegation document review.

Table 5: 8.305.19 Salud! Delegation


Findings: As Table 5 shows, there were no adverse findings for this regulation. This regulation only includes a document review. Previous Audit Follow-up: BCBS received 100 percent of points in the previous audit. BCBS continues to perform well in this regulation, having received 100 percent of points from SFY 2010 onwards. Table 6a shows the score and compliance level for the Coordination of Services document and file review.

Table 6a: 8.305.9 Salud! Coordination of Services

Composite Score 96.35% Compliance Level Full Compliance

Findings: For the document review portion of the audit, there were no adverse findings. For the file review, BCBS received 94.83 percent of points with only two deficiencies identified. There were only four files available for review, of which two were missing sufficient documentation that the single point of contact was communicated to the member. No other systemic issues were revealed. The composite score includes the document and file review. The score is weighted so that the file review counts more heavily than the document review. Previous Audit Follow-up: BCBS continues to perform well for this regulation, having received a composite score of greater than 97.00 percent each year since SFY 2010. The errors were sporadic and non-systemic in the previous audit. Table 6b shows the number of deficiencies found for each regulatory element in the files for the Coordination of Services file review. Regulatory elements without any deficiencies are not noted in Table 6b.

Table 6b: Salud! Deficiencies Noted in Coordination of Services

Regulation Number of Files

Deficient

Single Point of Contact 2

Table 7a shows the score and compliance level for the Member Grievance System document and file review.

Table 7a: 8.305.12 Salud! MCO Member Grievance System


of 81


June 23, 2014

Findings: For the document review portion of the audit, there were no adverse findings. Sporadic, non-systemic issues were identified in the file review, yielding a 96.67 percent file review-only score. Full samples of 30 records were reviewed for all but two sub-sections. Member Grievance, Member Appeals, and Provider Appeals all had full samples while Provider Grievances had three files and Member Expedited Appeals had six files available for review. The composite score includes the document and file review. The score is weighted so that the file review counts more heavily than the document review. Previous Audit Follow-up: BCBS continues to process and resolve appeals and grievances in a timely manner. Table 7b shows the number of deficiencies found for each regulatory element in the files for the Member Grievances file review. Regulatory elements without any deficiencies are not noted in Table 7b.

Table 7b: Salud! Deficiencies Noted in Member Grievances


Deficient

Notification letter notes expected date of resolution (30 calendar days) 6

Table 7c shows the number of deficiencies found for each regulatory element in the files for the Member Appeals file review. Regulatory elements without any deficiencies are not noted in Table 7c.

Table 7c: Salud! Deficiencies Noted in Member Expedited Appeals


Deficient

Timeliness of follow-up with written notice (2 calendar days) 2

Table 8 shows the score and compliance level for the Program Integrity document review.

Table 8: 8.305.13 Salud! Fraud and Abuse & 42 CFR 455 Program Integrity


Findings: As Table 8 shows, there were no adverse findings for this regulation. This regulation only includes a document review. BCBS continues to work to implement quality processes for their Program Integrity initiative. Previous Audit Follow-up: BCBS also received 100 percent compliance in the previous audit. This is the second year that Program Integrity has been a scored item.

of 81


June 23, 2014

Table 9 shows the score and compliance level for the Reporting Requirements document review.

Table 9: 8.305.14 Salud! Reporting Requirements


Findings: As Table 9 shows, there were no adverse findings for this regulation. This regulation only includes a document review. Previous Audit Follow-up: BCBS received 100 percent of points in the previous audit. BCBS continues to perform well in this regulation, having received 100 percent of points from SFY 2010 onwards. Table 10 shows the score and compliance level for the Individuals with Special Health Care Needs (ISHCN) document and file review.

Table 10: 8.305.15 Salud! Services for ISHCN


Findings: There were no adverse findings in either the document review or the file review. Only 13 files were available for review. The composite score includes the document and file review. The score is weighted so that the file review counts more heavily than the document review. Previous Audit Follow-up: BCBS also received 100 percent of available points in the previous audit. Table 11a shows the score and compliance level for the Client Transition of Care document and file review.

Table 11a: 8.305.16 Salud! Client Transition of Care


Findings: For the document review, there were no adverse findings. A full sample of 30 files was reviewed and only one deficiency was identified. The composite score includes the document and file review. The score is weighted so that the file review counts more heavily than the document review. Previous Audit Follow-up: BCBS received 100 percent of available points in the previous audit. There were no recommendations on which to follow-up. BCBS continues to perform well in this regulation, having received 99.00 percent or greater of available points each year since SFY 2010.

of 81


June 23, 2014

Table 11b shows the number of deficiencies found for each regulatory element in the files for the Client Transition of Care file review. Regulatory elements without any deficiencies are not noted in Table 11b.

Table11b: Deficiencies Noted in Salud! Client Transition of Care


Deficient

Care coordinated during transition out of MCO 1

MCO Multi-year Salud! Audit Comparison The following graphs provide historical score comparison for the overall score and for each regulatory element by fiscal year (FY).

80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

Overall Score

of 81


June 23, 2014

80%85%90%95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

Standards for Quality Measurement/Quality

Improvement

80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

Delegation

80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

Coordination of Services

80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013


80%

90%

100%

FY 2012 FY 2013


80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

Reporting Requirements

80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

Client Transition of Care

80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

ISHCN

of 81


June 23, 2014

Recommendations This audit was conducted to discover the extent to which BCBS was compliant with federal and state regulations in the provision of Salud! services. Recommendations for improvement are listed separately for each regulation. It is recognized that the Salud! contract and program concluded at the end of calendar year 2013. The following recommendations are for process improvement and can be extrapolated and transferred to other of BCBS’s lines of business beyond the current Medicaid contract. Further, this information can benefit BCBS staff that may be continuing similar quality improvement efforts at both BCBS and at other organizations.


Standards for Medical Records 8.305.8.17 It is recommended that BCBS develop and implement a way that providers can easily document medication effectiveness, medication reactions, and advanced directives and then have an efficient way of providing that documentation for audit purposes. As electronic health records (EHRs) become more prevalent, these would be useful enterprise-wide enhancements to have in place. It is recommended that BCBS work with their providers to get their EHR system to print the patient’s name and a secondary identifier on each page. If the patient identification is only on the first page, then there is a risk that the pages could get separated and mixed in with another member’s data.

Coordination of Services 8.305.9 It is recommended that BCBS consistently document that members were informed of their Single Point of Contact (SPOC) and how to contact the SPOC. One actionable option would be to work with the software vendor to add a check box in the care management software saying that such education has been provided. That data point could then be queried. The results could then be presented to auditors either internally or externally that would show the date and name of the service coordinator who made the contact or contact attempt. It could also be used to flag the member’s file if such education had not yet been provided by a predetermined day of the month. Further, it would be beneficial to communicate to other care team members whether the contact had been made so that any follow-up activity could be conducted.

MCO Member Grievance System 8.305.12 It is recommended that BCBS consistently follow up with written notice to members for the results of expedited appeals. A letter should be sent either to inform the member that the appeal was resolved and the outcome or that the appeal did not meet the criteria for expedited appeal.

Rebuttal and Reconsideration Review BCBS was allotted time to offer any rebuttals or requests for reconsideration for any of the findings in this report. The rebuttals offered by BCBS and the HealthInsight New Mexico responses are below. The first rebuttal is a general summarization of what HealthInsight New Mexico understands to be the primary concern. The subsequent rebuttals below address the individual concerns expressed by BCBS in the rebuttal documentation.

of 81


June 23, 2014

BCBS Rebuttal: BCBS expressed concern that there were several process changes that resulted in a lowered score for the Medical Record Review. These process changes included conducting the audits separately, the cancellation of the Overview Meeting, and a departure from a customary understanding of how some of the medical record standards would be scored. HealthInsight New Mexico Response: We wish to acknowledge the concerns expressed by BCBS regarding process changes resulting in lowered scores, specifically in the medical records reviews. There were two audit process changes, both of which were communicated with the MCOs. The first process change was by having the LHP audited 3 months prior to the others. The rationale for this change was twofold. The first is that LHP’s contract would conclude on December 31, 2013, after which the contract was at an end and staff may not be available to conduct the onsite audit and rebut the findings. The second is that BCBS, MHP, and PHP were in readiness review for Centennial Care go-live on January 1, 2014 and staff would be less available to conduct onsite audits in fall 2013 during the same timeframe as the LHP audit. The differences in time frame were sensitive to contracting issues across the MCOs and were approved by HSD. The second process change was that an Overview Meeting for the Spring 2014 audits was not conducted. In an effort to be respectful of MCO staff time, HealthInsight New Mexico suggested the Overview Meeting be cancelled unless any of the MCOs felt they needed the Overview Meeting to ask additional questions. The MCOs were all queried regarding additional questions. None were presented, so the meeting was cancelled. There were questions raised by the MCOs after the meeting time had passed and those questions were addressed individually. Concurrent with the spring audit schedule was an internal quality improvement effort in which HealthInsight updated policies and procedures that included a revision of internal interpretive guidance documents to make them clearer and more user-friendly. There was never any expectation or intent that these internal improvement efforts would impact the scoring or would necessitate communication with MCOs. It cannot be determined definitively whether or not this impacted the scoring. Following MCO rebuttal process and discussion with HSD staff, it was decided that the Medical Record file review would not be a scored item for this audit year. The score has been adjusted accordingly. However, the recommendations stemming from the Medical Record file review will stand. BCBS Rebuttal: BCBS expressed concern that “Medication history and effectiveness,” was their top deficiency in 2013 but the MCO scored 100% for years 2010, 2011 and 2012. BCBS states that this regulation was included in 2009 HealthInsight New Mexico guidance and documented internally by the MCO as, "medication history acceptable even if effectiveness is not listed, per HealthInsight 05/2009". HealthInsight New Mexico Response: No documentation of this guidance could be provided by HealthInsight New Mexico, BCBS, or HSD. HealthInsight New Mexico auditors reviewed the sample medical records based on BCBS policies, procedures, and NMAC regulations. The BCBS policies, procedures, and NMAC

of 81


June 23, 2014

regulations state that effectiveness is part of the documentation of medication history. HealthInsight New Mexico followed-up with HSD officials and was told that this process is appropriate. Further, BCBS has submitted a “Medicaid Medical Record Content Review Report” each year since at least 2009 which clearly states that medication effectiveness is an element reviewed in internal record reviews. The auditors conducted the audit based upon each MCO’s policies and procedures and the NMAC regulations published and effective for the audit timeframe. Each negative finding is reviewed by MCO staff during the onsite audit and before the exit meeting. An IRR is conducted for each regulation. Following MCO rebuttal process and discussion with HSD staff, it was decided that the Medical Record file review would not be a scored item for this audit year. The score has been adjusted accordingly. However, the recommendations stemming from the Medical Record file review will stand. BCBS Rebuttal: BCBS expressed concern that documentation of drugs prescribed, strength, amount, and directions also scored 100% in 2010, 2011, and 2012. BCBS stated that HealthInsight New Mexico guidance documented internally by the MCO was, "Number of refills not required for antibiotics but is required for medications used for chronic conditions such as asthma. Per HealthInsight 05/2009". HealthInsight New Mexico Response: No documentation of this guidance could be found by HealthInsight New Mexico, BCBS, or HSD. HealthInsight New Mexico auditors reviewed the sample medical records based on BCBS policies, procedures, and NMAC regulations. The BCBS policies, procedures, and NMAC regulations state that documentation of refills is part of the documentation of this regulatory element. HealthInsight New Mexico followed-up with HSD officials and was instructed that this process is appropriate. At the onsite audit, BCBS staff was given the opportunity to find the required information in the medical records and were unable to locate it. Following MCO rebuttal process and discussion with HSD staff, it was decided that the Medical Record file review would not be a scored item for this audit year. The score has been adjusted accordingly. However, the recommendations stemming from the Medical Record file review will stand. BCBS Rebuttal: BCBS expressed concern that the LHP audit was conducted 3 months prior to the other MCOs and scored higher for Medical Records. HealthInsight New Mexico Response: The LHP audit was conducted 3 months prior to the other 3 MCOs at the request of HSD because LHP was not selected as a Centennial Care MCO. HSD wanted the audit complete before the conclusion of the LHP Salud! and SCI contracts at the end of calendar year 2013.

of 81


June 23, 2014

The LHP audit was conducted using the same processes and resources as the other three audits. Three of the four nurses that conducted the BCBS, MHP, and PHP Medical Record audits also conducted the LHP Medical Record audit. The Inter Rater Reliability (IRR) score for the four audits averaged 99.61%. The IRR for Medical Records averaged 98.56% among the four Salud! MCOs. At the onsite audits, each MCO’s staff was given the same opportunity to locate any missing information and provide appropriate documentation to HealthInsight New Mexico auditors. Following MCO rebuttal process and discussion with HSD staff, it was decided that the Medical Record file review would not be a scored item for this audit year. The score has been adjusted accordingly. However, the recommendations stemming from the Medical Record file review will stand. BCBS Rebuttal: BCBS expressed concern regarding a report statement reading “The types of things found in the file review were similar to the previous audit, but more pronounced in the current audit." In the previous audit (SFY 2012) BCBS scored 100% on every regulation standard for medical record except Advance Directive and Smoking, Alcohol Use and Substance Abuse. In 2012, the Smoking, Alcohol Use and Substance Abuse had 1 noncompliant record out of 22 applicable records. In 2013, BCBS actually scored a 100% on the Smoking, Alcohol Use and Substance Abuse standard--it was definitely not "more pronounced." BCBS also states “I am unable to tell if our Advance Directive rate was better/worse/same; the total applicable charts that were reviewed for the standard is not mentioned in the draft reports.” HealthInsight New Mexico Response: Following MCO rebuttal process and discussion with HSD staff, it was decided that the Medical Record file review would not be a scored item for this audit year. Therefore, the text addressed in the rebuttal is no longer relevant.

of 81

PH Compliance Audit Final Report Section B: LHP June 23, 2014

Section B: Lovelace Health Plan (LHP)

Audit Findings: Salud! This section gives detailed scoring information, findings, and recommendations for the LHP Salud! program for SFY 2013 (July 1, 2012-June 30, 2013). At the request of HSD, the LHP audit was conducted 3 months prior to the other 3 Physical Health (PH) Managed Care Organizations (MCOs). Table 1 presents the Salud! composite score for each individual regulation. The composite score is determined by calculating the total points earned for audit-related documentation and chart reviews, where applicable. The “N/A’s” in Table 1 indicate that a chart or document review audit was not required. The overall score, shown on Table 2, is determined by adding the total assigned points for each individual regulation which is then converted to a percentage for reporting.

Table 1: Regulatory Element Scores for LHP Salud!

Regulation


Chart Review

Tota

l A

vailable

Tota

l A

ssig

ned

Com

posi

te S

core

Available

Poin

ts

Actu

al

Poin

ts

Available

Poin

ts

Actu

al

Poin

ts

Quality Management


10.00 10.00 N/A N/A 10.00 10.00 100.00%


3.00 3.00 N/A N/A 3.00 3.00 100.00%

Delegation 6.00 6.00 N/A N/A 6.00 6.00 100.00%


Member Grievance System 5.00 5.00 12.00 11.87 17.00 16.87 99.24%


3.00 2.82 N/A N/A 3.00 2.82 94.00%


ISHCN 5.00 5.00 12.00 11.28 17.00 16.28 95.76%


of 81




Timeliness and Accuracy Point Deductions -1


As discussed in the Scoring Method section of this report, there was a potential for up to a 7-point deduction due to various timeliness and accuracy reasons. LHP had 1 point deducted from their overall score for Universe Accuracy for the Salud! program. The consumer’s Medicaid ID number was requested for all universes but was not provided. All universes except Medical Records used the member’s Social Security Number and the Medical Records used an internal “LH alphanumeric identifier.” This caused a delay with data analytics to make the stratified random sample with no duplicate members pulled. The purpose of this audit was to measure the MCO’s level of compliance with NMAC 8.305 pertaining to Medicaid managed care, and with LOD #44 pertaining to Program Integrity as found in 42 CFR 455. HealthInsight New Mexico reviewed the MCO’s processes, policies, and procedures, and conducted interviews and assessments at the MCO’s physical locations. MCO and provider files were reviewed to measure compliance with applicable regulations. In the following section, HealthInsight New Mexico provides findings for the audit, including document review and file review, and any noted improvements for each regulation and recommendations/opportunities for improvement. The Salud! program is discussed first, followed by the SCI program. Table 3 shows the score and compliance level for the Quality Management and Improvement document review.



Findings: As Table 3 shows, there were no adverse findings for this regulation. This regulation only includes a document review. Previous Audit Follow-up: LHP received 100 percent of points in the previous audit. There were no recommendations on which to follow up. LHP continues to perform well in this regulation, having received 100 percent of points from SFY 2011 through the current audit. Table 4 shows the score and compliance level for the Medical Records document review.



Findings: For the document review portion of the audit, there were no adverse findings.

of 81


Following MCO rebuttal process and discussion with HSD staff, it was decided that the Medical Record file review would not be a scored item for this audit year. The score has been adjusted accordingly. However, the recommendations stemming from the Medical Record file review will stand. Previous Audit Follow-up: The composite score was 98.70. The record review was not a scored item in the current audit year. Table 5 shows the score and compliance level for the Delegation document review.



Findings: As Table 5 shows, there were no adverse findings for this regulation. This regulation only includes a document review. Previous Audit Follow-up: LHP received 100 percent of points in the previous audit. LHP continues to perform well in this regulation, having received 100 percent of points from SFY 2010 onwards. Table 6a shows the score and compliance level for the Coordination of Services document and file review.



Findings: For the document review portion of the audit, there were no adverse findings. For the file review, LHP received 93.63 percent of points with sporadic deficiencies observed as detailed in Table 6b. There were only 27 non-duplicate files in the universe so a full sample of 30 was not available. No systemic issues were revealed. The composite score includes the document and file review. The score is weighted so that the file review counts more heavily than the document review. Previous Audit Follow-up: LHP continues to perform well for this regulation, having received a composite score of greater than 95.00 percent each year since SFY 2010. The errors were sporadic and non-systemic in the previous audit.

of 81


Table 6b shows the number of deficiencies found for each regulatory element in the files for the Coordination of Services file review. Regulatory elements without any deficiencies are not noted in Table 6b.



Deficient

Single Point of Contact 4

Plan of Care 3

Plan of Care involving member and/or family 2

PCP keeps SE and BH provider informed (drug therapy, tests sentinel events, discharges)

2

Co-managed cases 1

PCP consistently receives communication 1


Table 7a: 8.305.12 Salud! Member Grievance System


Findings: For the document review portion of the audit, there were no adverse findings. Sporadic, non-systemic issues were identified in the file review, yielding a 99.24 percent compliance rate as shown in Table 7a. Full samples of 30 records were reviewed for all but one sub-section. Member Grievance, Provider Grievance, Member Appeals and Provider Appeals all had full samples while Member Expedited Appeals only had one file available for review. The composite score includes the document and file review. The score is weighted so that the file review counts more heavily than the document review. Previous Audit Follow-up: LHP continues to process and resolve appeals and grievances in a timely manner. Table 7b shows the number of deficiencies found for each regulatory element in the files for the Member Grievances file review. Regulatory elements without any deficiencies are not noted in Table 7b.

Table 7b: Salud! Deficiencies Noted in Member Grievances


Deficient

Information considered during investigation 2

Findings and conclusions 2

Disposition 2

of 81


Table 7c shows the number of deficiencies found for each regulatory element in the files for the Member Appeals file review. Regulatory elements without any deficiencies are not noted in Table 7c.

Table 7c: Salud! Deficiencies Noted in Member Appeals


Deficient

Timeliness of written notification of receipt of appeal (5 working days) 2

Review of case file 2




Findings: LHP continues to work to implement quality processes for their Program Integrity initiative. This regulation only includes a document review. Subsequent to clarifications and an onsite audit interview, only one section of the review was found to be deficient. The regulation involved was 42 CFR § 455.104, which states:

(a) Information that must be disclosed. The Medicaid agency must require each disclosing entity to disclose the following information... (3) The name of any other disclosing entity in which a person with an ownership or control interest in the disclosing entity also has an ownership or control interest. This requirement applies to the extent that the disclosing entity can obtain this information by requesting it in writing from the person. The disclosing entity must: (i) Keep copies of all these requests and the responses to them; (ii) Make them available to the Secretary or the Medicaid agency upon request; and (iii) Advise the Medicaid agency when there is no response to a request.

The statements labeled “(i),” “(ii)” and “(iii)” were the three found to be deficient. The rest of the paragraph is included for context. Previous Audit Follow-up: LHP received 100 percent of available points in the previous audit. These three data elements were not assigned a scoring value in the previous audit. This is the second year that Program Integrity has been a scored item. As Program Integrity gains more legislative and regulatory support on the national and state level, it continues to grow in importance. Table 9 shows the score and compliance level for the Reporting Requirements document review.



Findings: As Table 9 shows, there were no adverse findings for this regulation. This regulation only includes a document review.

of 81


Previous Audit Follow-up: LHP received 100 percent of points in the previous audit. LHP continues to perform well in this regulation, having received 100 percent of points from SFY 2010 onwards. Table 10a shows the score and compliance level for the medical record document and file review.

Table 10a: 8.305.15 Salud! Services for Individuals with Special Health Care Needs


Findings: For the document review, there were no adverse findings. For the file review, there were several elements missing from six of a full sample of 30 files, or 25 percent of the files reviewed. These deficiencies are listed in Table 10b. The composite score includes the document and file review. The score is weighted so that the file review counts more heavily than the document review. Previous Audit Follow-up: LHP has had considerable improvement over the last audit. In the SFY 2012 audit, LHP received a composite score of 76.47 percent versus 95.76 percent in the current audit. For the current audit, LHP was able to provide documentation of education being provided to members. Table 10b shows the number of deficiencies found for each regulatory element in the files for the Individuals with Special Health Care Needs file review. Regulatory elements without any deficiencies are not noted in Table 10b.

Table 10b: Salud! Deficiencies Noted in Services for ISHCN


Deficient

List of key MCO resource people, phone numbers, with designated single POC

6

Education regarding access to ER care and clinical history to provide when ER or Inpatient admission is needed

6

Access to clinical history by ER physician 6

Table 11 shows the score and compliance level for the Client Transition of Care document and file review.

Table 11: 8.305.16 Salud! Client Transition of Care


Findings: There were no adverse findings. A full sample of 30 files was reviewed. The composite score includes the document and file review. The score is weighted so that the file review counts more heavily than the document review.

of 81


Previous Audit Follow-up: LHP received 100 percent of points in the previous audit. There were no recommendations on which to follow up. LHP continues to perform well in this regulation, having received 100 percent of points each year since SFY 2010, except for SFY 2011 when the score dipped slightly to 98.85 percent.


80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

Overall Score

80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

Quality Measurement/Quality Improvement

80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

Delegation

of 81


80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013


80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

Member Grievance

80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013


75%

80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

ISHCN

80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

Transition of Care

80%

85%

90%

95%

100%

FY 2012 FY 2013

Program Integrity

of 81


Audit Findings: SCI Table 12 presents the SCI composite score for each individual regulation. The composite score is determined by calculating the total points earned for audit-related documentation and chart reviews, where applicable. The “N/A’s” in Table 1 indicate that a chart or document review audit was not required. The overall score, shown on Table 13, is determined by adding the total assigned points for each individual regulation which is then converted to a percentage for reporting.

Table 12: Regulatory Element Scores for LHP SCI

Regulation


Chart Review

Tota

l A

vailable

Tota

l A

ssig

ned

Com

posi

te

Score

Available

Poin

ts

Actu

al

Poin

ts

Available

Poin

ts

Actu

al

Poin

ts

Quality Management


10.00 10.00 N/A N/A 10.00 10.00 100.00%


3.00 3.00 N/A N/A 3.00 3.00 100.00%

Delegation 6.00 6.00 N/A N/A 6.00 6.00 100.00%

Coordination of Benefits 5.00 5.00 N/A N/A 5.00 5.00 100.00%

Member Grievance Resolution

5.00 5.00 12.00 11.97 17.00 16.97 99.82%


3.00 2.82 N/A N/A 3.00 2.82 94.00%


SCI-SHCN 5.00 5.00 12.00 9.65 17.00 14.65 86.18%

Member Transition of Care 3.00 3.00 7.00 7.00 10.00 10.00 100.00%





As discussed in the Scoring Method section of this report, there was a potential for up to a 7-point deduction due to various timeliness and accuracy reasons. LHP had 1 point deducted from the overall score for Universe Accuracy for the SCI program. The member’s Medicaid ID number was requested for all universes but was not provided. All universes except Medical

of 81


Records used the member’s Social Security Number and the Medical Records used an internal “LH alphanumeric identifier.” This caused a delay with data analytics to make the stratified, random sample to ensure no duplicate members were pulled. Further, during the onsite audit, several files were found to be outside of the audit timeframe. Since there were over 100,000 records available for selection, the probability is very low that there were not additional files in the universe that were outside of the audit timeframe. Table 14 shows the score and compliance level for the Quality Management document review.

Table 14: 8.306.8.9 SCI Quality Management


Findings: As Table 14 shows, there were no adverse findings for this regulation. This regulation only includes a document review. Previous Audit Follow-up: LHP has performed well on this regulation, having achieved 100 percent of points each year since SFY 2010. Table 15 shows the score and compliance level for the Medical Record document review.

Table 15: 8.306.8.9 SCI Standards for Medical Records


Findings: For the document review, there were no adverse findings. Following MCO rebuttal process and discussion with HSD staff, it was decided that the Medical Record file review would not be a scored item for this audit year. The score has been adjusted accordingly. However, the recommendations stemming from the Medical Record file review will stand. Previous Audit Follow-up: The composite score was 96.76. The record review was not a scored item in the current audit year. Table 16 shows the score and compliance level for the Delegation document review.

Table 16: 8.306.8.10 SCI Delegation


Findings: As Table 16 shows, there were no adverse findings for this regulation. This regulation only includes a document review. Previous Audit Follow-up: LHP continues to perform well on this regulation, having received 100 percent of points each year since SFY 2010.

of 81


Table 17 shows the score and compliance level for the Coordination of Benefits document and file review.

Table 17: 8.306.9 SCI Coordination of Benefits


Findings: There were no records in this universe; however, LHP received 100 percent of points for the document review. Previous Audit Follow-up: LHP continues to perform well on this regulation, having received 100 percent of points each year since SFY 2011. Table 18a shows the score and compliance level for the Member Grievance Resolution document and file review.

Table 18a: 8.306.12 SCI Member Grievance Resolution


Findings: For the document review, there were no adverse findings. For the onsite chart review, full samples of 30 files were available for review for all sections except Provider Grievances and Member Expedited Appeals. Of all those, only two files were found to be deficient. The deficiencies are detailed in Table 18b below. The composite score includes the document and file review. The score is weighted so that the file review counts more heavily than the document review. Previous Audit Follow-up: LHP continues to perform well on this regulation with only one file being found deficient in the previous audit. LHP has trended upwards since scoring 97.13 percent in SFY 2010. Table 18b shows the number of deficiencies found for each regulatory element in the files for the SCI Member Appeals file review. Regulatory elements without any deficiencies are not noted in Table 18b.

Table 18b: SCI Deficiencies Noted in Member Appeals


Deficient

Opportunity to present evidence (before, during, and after the process) 2


Table 19: 8.306.13 SCI Fraud and Abuse & 42 CFR 455 Program Integrity


Findings: LHP continues to work to implement quality processes for their Program Integrity initiative. This regulation only includes a document review. Subsequent to clarifications and an

of 81


onsite audit interview, only one section of the review was found to be deficient. The regulation involved was 42 CFR § 455.104 which states:

(a) Information that must be disclosed. The Medicaid agency must require each disclosing entity to disclose the following information... (3) The name of any other disclosing entity in which a person with an ownership or control interest in the disclosing entity also has an ownership or control interest. This requirement applies to the extent that the disclosing entity can obtain this information by requesting it in writing from the person. The disclosing entity must: (i) Keep copies of all these requests and the responses to them; (ii) Make them available to the Secretary or the Medicaid agency upon request; and (iii) Advise the Medicaid agency when there is no response to a request.

The statements labeled “(i),” “(ii)” and “(iii)” were the three found to be deficient. The rest of the paragraph is included for context. Previous Audit Follow-up: LHP received 100 percent of available points in the previous audit. These three data elements were not assigned a scoring value in the previous audit. This is the second year that Program Integrity has been a scored item. As Program Integrity gains more legislative and regulatory support on the national and state level, it continues to grow in importance for regulatory compliance. Table 20 shows the score and compliance level for the Reporting Requirements document review.

Table 20: 8.306.14 SCI Reporting Requirements


Findings: As Table 20 shows, there were no adverse findings for this regulation. This regulation only includes a document review. Previous Audit Follow-up: LHP continues to perform well in this audit, having received 100 percent of points each year since SFY 2010. Table 21a shows the score and compliance level for the SCI Members with Special Health Care Needs document and file review.

Table 21a: 8.306.15 Services for SCI Members with Special Health Care Needs

Composite Score 86.16% Compliance Level Moderate

Compliance

Findings: For the document review, LHP received 100 percent of available points. There were six files available for review, far short of a full sample of 30. The two deficiencies had a large impact on the score due to the small sample size. The deficiencies are detailed in Table 21b below. The file review only score was 80.39 percent. The composite score includes the document and file review. The score is weighted so that the file review counts more heavily than the document review.

of 81


Previous Audit Follow-up: LHP has improved the score over the previous audit. In that audit, LHP received a file review score of 66.86 percent, which falls within the “Minimal Compliance” level. LHP received a composite score of 76.61 percent, which remains on the same level. There were 22 files available for review in that sample. The regulatory elements “Information and Education Provided to Consumer and/or Family Related to Specific Needs,” “Education Regarding Access to ER Care and Clinical History to Provide when ER or Inpatient Admission Is Needed,” and “Access to Clinical History by ER Physician” were each deficient in 19 files. The regulatory element “Coordination with the PCP & hospitalist while Inpatient” was deficient in one file, while in 15 files it was deemed N/A. Table 21b shows the number of deficiencies found for each regulatory element in the files for the SCI Member with Special Health Care Needs file review. Regulatory elements without any deficiencies are not noted in Table 21b.

Table 21b: Deficiencies Noted in Services for SCI Members with Special Health Care Needs


Deficient


5

Access to clinical history by ER physician 5

Table 22 shows the score and compliance level for the Transition of Care document and file review.

Table 22: 8.306.16 SCI Member Transition of Care


Findings: There were no adverse findings in either the file or the document review. Previous Audit Follow-up: LHP continues to perform well in this regulation, having received 100 percent of points each year since SFY 2010

of 81


MCO Multi-year SCI Audit Comparison The following graphs provide historical score comparison for the overall score and for each regulatory element by fiscal year (FY).

80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

Overall Score

80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

Quality Measurement/Quality Improvement

80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

Delegation

of 81


Recommendations This audit was conducted to discover the extent to which LHP was compliant with federal and state regulations in the provision of Salud! and SCI services. Recommendations for improvement are listed separately for each regulation and each program. It is recognized that the Salud! and SCI contract and programs concluded at the end of calendar year 2013. The following recommendations are for process improvement and can be extrapolated and transferred to other of LHP’s Lines of Business, including the Centennial Care contract.


Standards for Medical Records 8.305.8.17 It is recommended that LHP develop and implement a way that providers can easily track that they have asked members about advance directives and then have an efficient way of providing that documentation for audit purposes. As advance directives and electronic health records become more prevalent, this would be a useful enterprise-wide enhancement to have in place.

80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

Member Grievance

80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

Coordination of Benefits

80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013


70%75%80%85%90%95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

SCI-SHCN

80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

Transition of Care

80%

85%

90%

95%

100%

FY 2012 FY 2013

Program Integrity

of 81


Coordination of Services 8.305.7 It is recommended that LHP consistently document that members were informed of their Single Point of Contact (SPOC) and how to contact the SPOC. One actionable option would be to work with the software vendor to add a check box in the care management software saying that such education has been provided. That data point could then be queried. The results could then be presented to auditors either internally or externally that would show the date and name of the service coordinator who made the contact or contact attempt. It could also be used to flag the member’s file if such education had not yet been provided by a predetermined day of the month. Further, it would be beneficial to communicate to other care team members whether the contact had been made so that any follow-up activity could be conducted. It is recommended that Service Coordinators consistently document Care Plans and clearly state how those plans involve the member’s caregivers. Otherwise, consistent documentation should be provided in an auditable format that the member declined to participate in the process and thus no care plans could be developed.

Fraud and Abuse 8.305.13 & Program Integrity 42 CFR 455 It is recommended that LHP add language to their Disclosure of Ownership Form to include requiring the disclosing entity to: keep copies of all these requests and the responses to them; make them available to the HSD Secretary or the Medicaid agency upon request; and advise the Medicaid agency when there is no response to a request.

Services for Individuals with Special Health Care Needs 8.305.15 It is recommended that LHP develop a way to document in an auditable format that all required education and resources are provided to members, including the list of key resources, education regarding access to the ER and clinical history to provide when ER/Inpatient admission is needed, and access to clinical history by ER physician. Two actionable recommendations are:

1) As with Coordination of Services above, work with the vendor to add a check box to the care management software.

2) Add these items to a job aid for training purposes, then make checking for these items a standard part of internal audits and performance checks for care managers or others who are responsible for this documentation.

SCI Recommendations

Standards for Medical Records 8.306.8.9 It is recommended that LHP develop and implement a way that providers can easily track that they have asked members about advance directives and then have an efficient way of providing that documentation for audit purposes. As advance directives and electronic health records become more prevalent, this would be a useful enterprise-wide enhancement to have in place.

Fraud and Abuse 8.306.1342 & Program Integrity CFR 455 It is recommended that LHP add language to their Disclosure of Ownership Form to include requiring the disclosing entity to: keep copies of all these requests and the responses to them; make them available to the Secretary or the Medicaid agency upon request; and advise the Medicaid agency when there is no response to a request.

of 81


Services for SCI Members with Special Health Care Needs 8.306.15 It is recommended that LHP develop a way to document in an auditable format that all required education and resources are provided to members, including the list of key resources, education regarding access to the ER, and clinical history to provide when ER/Inpatient admission is needed. The two recommendations from Salud! ISHCN are also applicable here. It is recommended that LHP develop and implement a method to make sure that the Emergency Department physician has a way of obtaining a member’s medical history, either from the member providing the clinical history or some other means. It is also important for compliance purposes that this activity be documented in a consistent, auditable way.

Rebuttal and Reconsideration Review LHP was offered the opportunity to comment on this report and to rebut any findings. LHP accepted the findings in this report without any rebuttals or requests for reconsideration.

of 81

PH Compliance Audit Final Report Section C: MHP June 23, 2014

Section C: Molina Health Plan (MHP)

Audit Findings: Salud! This section gives detailed scoring information, findings, and recommendations for the MHP Salud! program for SFY 2013 (July 1, 2012-June 30, 2013). Table 1 presents the Salud! composite score for each individual regulation. The composite score is determined by calculating the total points earned for audit-related documentation and chart reviews, where applicable. The “N/A’s” in Table 1 indicate that a chart or document review audit was not required. The overall score, shown on Table 2, is determined by adding the total assigned points for each individual regulation which is then converted to a percentage for reporting.

Table 1: Regulatory Element Scores for MHP Salud!

Regulation


Chart Review

Tota

l A

vailable

Tota

l A

ssig

ned

Com

posi

te S

core

Available

Poin

ts

Actu

al

Poin

ts

Available

Poin

ts

Actu

al

Poin

ts

Quality Management


10.00 10.00 N/A N/A 10.00 10.00 100.00%


3.00 3.00 N/A N/A 3.00 3.00 100.00%

Delegation 6.00 6.00 N/A N/A 6.00 6.00 100.00%



5.00 5.00 12.00 11.80 17.00 16.80 98.82%


3.00 3.00 N/A N/A 3.00 3.00 100.00%



5.00 5.00 12.00 11.07 17.00 16.07 94.53%


of 81






As discussed in the Scoring Method section of this report, there was a potential for up to a 7-point deduction due to various timeliness and accuracy reasons. MHP had 1 point deducted from their overall score for Universe Accuracy for the Salud! program. There were no dates of service provided for the Medical Records Universe. The date of service is an integral part of the sampling process. The purpose of this audit was to measure the MCO’s level of compliance with NMAC 8.305 pertaining to Medicaid managed care, and with LOD #44 pertaining to Program Integrity as found in 42 CFR 455. HealthInsight New Mexico reviewed the MCO’s processes, policies, and procedures, and conducted interviews and assessments at the MCO’s physical locations. MCO and provider files were reviewed to measure compliance with applicable regulations. In the following section, HealthInsight New Mexico provides findings for the audit, including document review and file review, with any noted improvements for each regulation and recommendations/opportunities for improvement. The Salud! program is discussed first, followed by the SCI program. Table 3 shows the score and compliance level for the Standards for Quality Management and Improvement document review.



Findings: As Table 3 shows, there were no adverse findings for this regulation. This regulation only includes a document review. Previous Audit Follow-up: MHP received 100 percent of points in the previous audit. There were no recommendations on which to follow up. MHP continues to perform well in this regulation, having received 100 percent of available points from SFY 2010 through the current audit. Table 4 shows the score and compliance level for the Standards for Medical Records document review.



Findings: For the document review portion of the audit, there were no adverse findings.

of 81


Following MCO rebuttal process and discussion with HSD staff, it was decided that the Medical Record file review would not be a scored item for this audit year. The score has been adjusted accordingly. However, the recommendations stemming from the Medical Record file review will stand. Previous Audit Follow-up: The composite score was 99.73. The record review was not a scored item in the current audit year. Table 5 shows the score and compliance level for the Delegation document review.



Findings: As Table 5 shows, there were no adverse findings for this regulation. This regulation only includes a document review. Previous Audit Follow-up: MHP received 100 percent of available points in the previous audit. MHP continues to perform well in this regulation, having received 100 percent of available points from SFY 2010 onwards. Table 6a shows the score and compliance level for the Coordination of Services document and file review.



Findings: For the document review portion of the audit, there were no adverse findings. For the file review, MHP received 98.08 percent of points with only two deficiencies observed as detailed in Table 6b. There were only 13 files in the universe, so a full sample of 30 files was not available. No systemic issues were revealed. The composite score includes the document and file review. The score is weighted so that the file review counts more heavily than the document review. Previous Audit Follow-up: MHP continues to perform well for this regulation, having received a composite score of greater than 97 percent each year since SFY 2010. In the previous audit, MHP received 100 percent composite score.

of 81


Table 6b shows the number of deficiencies found for each regulatory element in the files for the Coordination of Services file review. Regulatory elements without any deficiencies are not noted in Table 6b.



Deficient

Plan of Care involving member and/or family 1

Information Sharing between Physical Health and Behavioral Health Providers

1


Table 7a: 8.305.12 Salud! MCO Member Grievance System


Findings: For the document review portion of the audit, there were no adverse findings. For the file review, there was only one deficiency noted. The composite score may seem low because that deficiency was noted in Member Expedited Appeals, which only had three files. In the file review of the Member Grievance System, there are five subsections worth the same value each. That deficiency caused that section to have a low score, bringing down the overall average more than it would have in a section with a full sample of 30. The composite score includes the document and file review. The score is weighted so that the file review counts more heavily than the document review. Previous Audit Follow-up: MHP continues to process and resolve appeals and grievances in a timely manner. The current score is the lowest MHP has had in the last four audits. MHP achieved 100 percent in SFY 2010 and SFY 2012, and 99.67 percent in SFY 2011. Table 7b shows the number of deficiencies found for each regulatory element in the files for the Member Expedited Appeals file review. Regulatory elements without any deficiencies are not noted in Table 7b.

Table 7b: Salud! Deficiencies Noted in Member Expedited Appeals


Deficient

Documentation of reasonable effort to give oral notice 2




of 81


Findings: As Table 8 shows, there were no adverse findings for this regulation. This regulation only includes a document review. MHP has the policies and procedures in place to follow both the CFR and NMAC requirements for this program. Previous Audit Follow-up: MHP received 100 percent of available points in the previous audit. This is the second year that Program Integrity has been a scored item Table 9 shows the score and compliance level for the Reporting Requirements document review.



Findings: As Table 9 shows, there were no adverse findings for this regulation. This regulation only includes a document review. Previous Audit Follow-up: MHP received 100 percent of points in the previous audit. MHP continues to perform well in this regulation, having received 100 percent of points from SFY 2010 onwards. Table 10a shows the score and compliance level for the Individuals with Special Health Care Needs (ISHCN) document and file review.

Table 10a: 8.305.15 Salud! ISHCN


Findings: For the document review, there were no adverse findings. For the file review, there were several elements missing from a full sample of 30 files reviewed. The issues were sporadic and no systemic issues were identified. These deficiencies are listed in Table 10b. The composite score includes the document and file review. The score is weighted so that the file review counts more heavily than the document review. Previous Audit Follow-up: MHP’s score declined from the previous year, in which they received a composite score of 100 percent.

of 81


Table 10b shows the number of deficiencies found for each regulatory element in the files for the Individuals with Special Health Care Needs file review. Regulatory elements without any deficiencies are not noted in Table 10b.



Deficient


5

Access to clinical history by the ER physician 5

Coordination with the PCP & hospitalist while inpatient 3

List of key MCO resource people, phone numbers, with designated single point of contact

2

Assess for care coordination 2

Identification of ISHCN based on criteria 1

Education that care coordination is available and when it may be appropriate for needs

1

Table 11 shows the score and compliance level for the Client Transition of Care document and file review.

Table 11: 8.305.16 Salud! Client Transition of Care


Findings: There were no adverse findings. A full sample of 30 files was reviewed. The composite score includes the document and file review. The score is weighted so that the file review counts more heavily than the document review. Previous Audit Follow-up: MHP received 100 percent of points in the previous audit. There were no recommendations on which to follow up. MHP has performed well in this regulation, having received 100 percent of points each year since SFY 2010, except for SFY 2011 when the score dipped slightly to 96.56 percent.

of 81



80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

Overall Score

80%85%90%95%

100%

FY 2010 FY 2011 FY 2012 FY 2013


Improvement

80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

Delegation

of 81


80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013


80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013


80%

90%

100%

FY 2012 FY 2013


80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013


80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

ISHCN

80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013


of 81


Audit Findings: SCI Table 12 presents the SCI composite score for each individual regulation. The composite score is determined by calculating the total points earned for audit-related documentation and chart reviews, where applicable. The “N/A’s” in Table 12 indicate that a chart or document review audit was not required. The overall score, shown on Table 13, is determined by adding the total assigned points for each individual regulation which is then converted to a percentage for reporting.

Table 12: Regulatory Element Scores for MHP SCI

Regulation


Chart Review

Tota

l A

vailable

Tota

l A

ssig

ned

Com

posi

te

Score

Available

Poin

ts

Actu

al

Poin

ts

Available

Poin

ts

Actu

al

Poin

ts

Quality Management


10.00 10.00 N/A N/A 10.00 10.00 100.00%


3.00 3.00 N/A N/A 3.00 3.00 100.00%

Delegation 6.00 6.00 N/A N/A 6.00 6.00 100.00%

Coordination of Benefits 5.00 5.00 N/A N/A 5.00 5.00 100.00%


5.00 5.00 9.605 9.60 14.60 14.60 100.00%


3.00 3.00 N/A N/A 3.00 3.00 100.00%


SCI-SHCN 5.00 5.00 12.00 10.96 17.00 15.96 93.88%






5 In Member Grievance Resolution, there are five subsections worth 2.4 points each that are summed up

for a total of 12 points available for the file review. There were no files available for the Provider Grievance section, so those 2.4 points were removed leaving 9.6 points available for the file review.

of 81


As discussed in the Scoring Method section of this report, there was a potential for up to a 7-point deduction due to various timeliness and accuracy reasons. MHP had 1 point deducted from the overall score for Universe Accuracy for the SCI program. There were three issues with the universe submission:

1. There were no dates of service for medical records 2. There were 17 files that were outside of the audit timeframe 3. SCI Provider Appeals did not contain provider or facility names

Table 14 shows the score and compliance level for the Standards for Quality Management and Improvement document review.

Table 14: 8.306.8.9 SCI Quality Management and Improvement


Findings: There were no adverse findings. There is no file review portion for this regulation. Previous Audit Follow-up: MHP has performed well on this regulation, having achieved 100 percent of points each year since SFY 2010. Table 15 shows the score and compliance level for the Standards for Medical Records document review.



Findings: For the document review portion of the audit, there were no adverse findings. Following MCO rebuttal process and discussion with HSD staff, it was decided that the Medical Record file review would not be a scored item for this audit year. The score has been adjusted accordingly. However, the recommendations stemming from the Medical Record file review will stand. Previous Audit Follow-up: The composite score was 96.22. The record review was not a scored item in the current audit year. Table 16 shows the score and compliance level for the Delegation document review.



Findings: There were no adverse findings. There is no file review portion for this regulation. Previous Audit Follow-up: MHP continues to perform well on this regulation, having received 100 percent of points each year since SFY 2010.

of 81


Table 17 shows the score and compliance level for the Coordination of Benefits document and file review.

Table 17: 8.306.9 SCI Coordination of Benefits


Findings: There were no adverse findings in either the document or file reviews. Previous Audit Follow-up: MHP continues to do well on this regulation, having received 100 percent of points in SFY 2012, 93.58 percent in SFY 2011, and 98.00 percent in SFY 2010. Table 18 shows the score and compliance level for the Member Grievance Resolution document and file review.

Table 18: 8.306.12 SCI Member Grievance Resolution


Findings: There were no adverse findings in either the document or file reviews. The composite score includes the document and file review. The score is weighted so that the file review counts more heavily than the document review. Previous Audit Follow-up: MHP continues to perform well on this regulation, having achieved a composite score of 100 percent every year since SFY 2010. Table 19 shows the score and compliance level for the Program Integrity document review.



Findings: There were no adverse findings. Previous Audit Follow-up: MHP received 100 percent of available points in the previous audit. This is the second year that Program Integrity has been a scored item. As Program Integrity gains more legislative and regulatory support on the national and state level, it continues to grow in importance. Table 20 shows the score and compliance level for the Reporting Requirements document review.

Table 20 8.306.14 SCI Reporting Requirements


Findings: There were no adverse findings. Previous Audit Follow-up: MHP continues to perform well in this audit, having received 100 percent of points each year since SFY 2010.

of 81


Table 21a shows the score and compliance level for the SCI Members with Special Health Care Needs document and file review.

Table 21a: 8.306.15 Services for SCI Members with Special Health Care Needs


Findings: For the document review, MHP received 100 percent of available points. There was a full sample of 30 records available for review. The largest deficiency was documentation of assessment for care coordination. This element was deficient in 11 of the 30 files. The other deficiencies were more sporadic and are detailed in Table 21b. The composite score includes the document and file review. The score is weighted so that the file review counts more heavily than the document review. Previous Audit Follow-up: MHP’s score declined over the previous audit where the score was 99.07 percent. While still in full compliance, the score is lower than it has been historically. MHP scored 98.92 percent in SFY 2011 and 99.00 percent in SFY 2010. Table 21b shows the number of deficiencies found for each regulatory element in the files for the SCI Member with Special Health Care Needs file review. Regulatory elements without any deficiencies are not noted in Table 21b.

Table 21b: Deficiencies Noted in Services for SCI Members with Special Health Care Needs


Deficient

Assess for care coordination 11


4

Involves ISHCN family, caregivers, physicians, and therapy providers in Plan Of Care

2

Information and education provided to consumer and/or family related to specific needs

1

Table 22 shows the score and compliance level for the Member Transition of Care document and file review.



Findings: There were no adverse findings in either the file or the document review. The composite score includes the document and file review. The score is weighted so that the file review counts more heavily than the document review. Previous Audit Follow-up: MHP continues to perform well in this regulation, having received 100 percent of points each year since SFY 2011.

of 81


MCO Multi-year SCI Audit Comparison The following graphs provide historical score comparisons for the overall score and for each regulatory element by fiscal year (FY).

80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

Overall Score

80%85%90%95%

100%

FY 2010 FY 2011 FY 2012 FY 2013


Improvement

80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

Delegation

of 81


Recommendations This audit was conducted to discover the extent to which MHP was compliant with federal and state regulations in the provision of Salud! and SCI services. Recommendations for improvement are listed separately for each regulation and each program. It is recognized that the Salud! and SCI contract and programs concluded at the end of calendar year 2013. The following recommendations are for process improvement and can be extrapolated and transferred to other of MHP’s lines of business beyond the current Medicaid contract. Further, this information can benefit MHP staff that may be continuing similar quality improvement efforts both at MHP and at other organizations.


Standards for Medical Records 8.305.8.17 It is recommended that MHP develop and implement a way that providers can easily document medication effectiveness, medication reactions, drugs prescribed, and advanced directives and

80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013


80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013


80%

85%

90%

95%

100%

FY 2012 FY 2013


80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013


80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

SCI-SHCN

80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

Member Transition of Care

of 81


then have an efficient way of providing that documentation for audit purposes. As electronic health records (EHRs) become more prevalent, these would be useful enterprise-wide enhancements to have in place. It is recommended that MHP work with their providers to get their EHR system to print the patient’s name and a secondary identifier on each page. If the patient identification is only on the first page, then there is a risk that the pages could get separated and mixed in with another member’s data and create a potential violation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Services for Individuals with Special Health Care Needs 8.305.15 It is recommended that MHP develop a way to document in an auditable format that all required education and resources are provided to members including education regarding access to the ER and clinical history to provide when ER or inpatient admission is needed and access to clinical history by the ER physician. Two actionable recommendations are:

1) Work with the vendor to add a check box to the care management software 2) Add these items to a job aid for training purposes, then make checking for these items a

standard part of internal audits and performance checks for care managers or others who are responsible for this documentation

SCI Recommendations

Standards for Medical Records 8.306.8.9 It is recommended that MHP develop and implement a way that providers can easily document medication effectiveness, medication reactions, drugs prescribed, and advanced directives and then have an efficient way of providing that documentation for audit purposes. As EHRs become more prevalent, these would be useful enterprise-wide enhancements to have in place. It is recommended that MHP work with their providers to get their EHR system to print the patient’s name and a secondary identifier on each page. If the patient identification is only on the first page, then there is a risk that the pages could get separated and mixed in with another member’s data.

Services for SCI Members with Special Health Care Needs 8.306.15 It is recommended that MHP develop a way to document that the assessments for care coordination are completed and that there is a consistent, auditable way to provide that documentation.

Rebuttal and Reconsideration Review MHP was allotted time to offer any rebuttals or requests for reconsideration for any of the findings in this report. The rebuttals offered by MHP and the HealthInsight New Mexico responses are below. MHP Rebuttal: Molina Healthcare of New Mexico challenged the Medical Records review of the HealthInsight Physical Health Compliance Audit for State Fiscal Year 2013. Three of the MCOs (Blue Cross Blue Shield, Presbyterian, and Molina) audit scores dropped significantly from previous year’s audits. One MCO (Lovelace) was audited 3 months prior to the other MCOs and their Medical

of 81


Records score stands as an outlier as their score did not drop significantly from previous year’s audits. There appears to be a considerable difference in the interpretation and application of the NMAC 8.305.817 Standards for Medical Records between the new audit team and previous year’s audit teams. The outlier score and LHP’s audit being conducted 3 months prior also suggests that there may have been different auditors scoring the Lovelace records than the other three MCOs. Molina Healthcare of New Mexico recommends that HealthInsight eliminate the Medical Records section from the State Fiscal Year 2013 Compliance Audit score. Molina Healthcare of New Mexico appreciates this opportunity for rebuttal and reconsideration. HealthInsight Rebuttal: We wish to acknowledge the concerns expressed by MHP regarding process changes resulting in lowered scores, specifically in the medical records reviews. There were two audit process changes, both of which were communicated with the MCOs. The first process change was by having the LHP 3 months prior to the others. The rationale for this change was twofold. The first is that LHP’s contract would conclude on December 31, 2013, after which the contract was at an end and staff may not be available to conduct the onsite audit and rebut the findings. The second is that BCBS, MHP, and PHP were in readiness review for Centennial Care go-live on January 1, 2014 and staff would be less available to conduct onsite audits in fall 2013 during the same timeframe as the LHP audit. The second process change was that an Overview Meeting for the Spring 2014 audits was not conducted. In an effort to be respectful of MCO staff time, HealthInsight New Mexico suggested the Overview Meeting be cancelled unless any of the MCOs felt they needed the Overview Meeting to ask additional questions. The MCOs were all queried regarding additional questions. None were presented, so the meeting was cancelled. There were questions raised after the meeting time had passed and those questions were addressed individually. Concurrent with the spring audit schedule was an internal quality improvement effort in which HealthInsight New Mexico updated policies and procedures that included a revision of internal interpretive guidance documents to make them clearer and more user-friendly. There was never any expectation or intent that these internal improvement efforts would impact the scoring or would necessitate communication with MCOs. It cannot be determined definitively whether or not this impacted the scoring. However, the auditors conducted the audit based upon each MCO’s policies and procedures and the NMAC regulations published and effective for the audit timeframe. Each negative finding is reviewed by MCO staff during the onsite audit and before the exit meeting. An IRR is conducted for each regulation. Following MCO rebuttal process and discussion with HSD staff, it was decided that the Medical Record file review would not be a scored item for this audit year. The score has been adjusted accordingly. However, the recommendations stemming from the Medical Record file review will stand.

of 81

PH Compliance Audit Final Report Section D: PHP June 23, 2014

Section D: Presbyterian (PHP)

Audit Findings: Salud! This section gives detailed scoring information, findings, and recommendations for the PHP Salud! program for SFY 2013 (July 1, 2012-June 30, 2013). Table 1 presents the Salud! composite score for each individual regulation. The composite score is determined by calculating the total points earned for audit-related documentation and chart reviews, where applicable. The “N/A’s” in Table 1 indicate that a chart or document review audit was not required. The overall score, shown on Table 2, is determined by adding the total assigned points for each individual regulation which is then converted to a percentage for reporting.

Table 1: Regulatory Element Scores for PHP Salud!

Regulation


Chart Review

Tota

l A

vailable

Tota

l A

ssig

ned

Com

posi

te S

core

Available

Poin

ts

Actu

al

Poin

ts

Available

Poin

ts

Actu

al

Poin

ts

Quality Management


10.00 10.00 N/A N/A 10.00 10.00 100.00%


3.00 3.00 N/A N/A 3.00 3.00 100.00%

Delegation 6.00 6.00 N/A N/A 6.00 6.00 100.00%



5.00 5.00 12.00 12.00 17.00 17.00 100.00%


3.00 3.00 N/A N/A 3.00 3.00 100.00%



5.00 5.00 12.00 11.87 17.00 16.87 99.24%


of 81






PHP has no point deductions for timeliness or accuracy.

The purpose of this audit was to measure the MCO’s level of compliance with NMAC 8.305 pertaining to Medicaid managed care, and with LOD #44 pertaining to Program Integrity as found in 42 CFR 455. HealthInsight New Mexico reviewed the MCO’s processes, policies, and procedures, and conducted interviews and assessments at the MCO’s physical locations. MCO and provider files were reviewed to measure compliance with applicable regulations. In the following section, HealthInsight New Mexico provides findings for the audit including document review and file review, along with any noted improvements for each regulation and recommendations/opportunities for improvement. The Salud! program is discussed first, followed by the SCI program. Table 3 shows the score and compliance level for the Standards for Quality Management and Improvement document review.



Findings: As Table 3 shows, there were no adverse findings for this regulation. This regulation only includes a document review. Previous Audit Follow-up: PHP received 100 percent of points in the previous audit. There were no recommendations on which to follow up. PHP continues to perform well in this regulation, having received 100 percent of available points from SFY 2010 through the current audit. Table 4 shows the score and compliance level for the Standards for Medical Records document review.



Findings: For the document review portion of the audit, there were no adverse findings. Following MCO rebuttal process and discussion with HSD staff, it was decided that the Medical Record file review would not be a scored item for this audit year. The score has been adjusted accordingly. However, the recommendations stemming from the Medical Record file review will stand.

of 81


Previous Audit Follow-up: The composite score was 98.95 percent. The record review was not a scored item in the current audit year. Table 5 shows the score and compliance level for the Delegation document review.



Findings: As Table 5 shows, there were no adverse findings for this regulation. This regulation only includes a document review. Previous Audit Follow-up: PHP received 100 percent of available points in the previous audit. PHP continues to perform well in this regulation, having received 100 percent of available points from SFY 2010 onwards. Table 6 shows the score and compliance level for the Coordination of Services document and file review.

Table 6: 8.305.9 Salud! Coordination of Services


Findings: There were no adverse findings in either the document or the file review. The composite score includes the document and file review. The score is weighted so that the file review counts more heavily than the document review. Previous Audit Follow-up: PHP continues to perform well for this regulation, having received a composite score of 99 percent or greater each year since SFY 2010. PHP also received 100 percent for this regulation in the previous audit (SFY 2012). Table 7 shows the score and compliance level for the MCO Member Grievance System document and file review.

Table 7: 8.305.12 Salud! MCO Member Grievance System


Findings: There were no adverse findings in either the document or the file review. A full sample of 30 files was reviewed for Member Grievances, Member Appeals, Provider Appeals, and Member Expedited Appeals. Only nine files were available for review in the Provider Grievances. The composite score includes the document and file review. The score is weighted so that the file review counts more heavily than the document review. Previous Audit Follow-up: PHP continues to process and resolve appeals and grievances in a timely manner. PHP continues to do well in this regulation, having received 100 percent every year since at least SFY 2010.

of 81





Findings: As Table 8 shows, there were no adverse findings for this regulation. This regulation only includes a document review. Previous Audit Follow-up: PHP received 100 percent of available points in the previous audit. This is the second year that Program Integrity has been a scored item. Table 9 shows the score and compliance level for the Reporting Requirements document review.



Findings: As Table 9 shows, there were no adverse findings for this regulation. This regulation only includes a document review. Previous Audit Follow-up: PHP received 100 percent of points in the previous audit. PHP continues to perform well in this regulation, having received 100.00 percent of points from SFY 2010 onwards. Table 10a shows the score and compliance level for the Individuals with Special Health Care Needs (ISHCN) document and file review.

Table 10a: 8.305.15 Salud! Services for Individuals with Special Health Care Needs


Findings: For the document review, there were no adverse findings. For the file review, there were only three deficiencies noted of a full sample of 30 files. These deficiencies are listed in Table 10b. The bottom two deficiencies in Table 10b occurred in the same file. The composite score includes the document and file review. The score is weighted so that the file review counts more heavily than the document review. Previous Audit Follow-up: The scored declined slightly, as PHP received 100.00 percent of points in the previous three audits.

of 81


Table 10b shows the number of deficiencies found for each regulatory element in the files for the Individuals with Special Health Care Needs file review. Regulatory elements without any deficiencies are not noted in Table 10b.



Deficient

List of key MCO resource people, phone numbers, with designated single Point Of Contact

1

Education regarding access to the ER care and clinical history to provide when ER or Inpatient admission is needed

1

Access to clinical history by the ER physician 1

Table 11a shows the score and compliance level for the Client Transition of Care document and file review.

Table 11a: 8.305.16 Salud! Client Transition of Care


Findings: There were no adverse findings in the document review. Only one deficiency was noted in the file review. That deficiency is recorded in Table 11b below. The composite score includes the document and file review. The score is weighted so that the file review counts more heavily than the document review. Previous Audit Follow-up: PHP received 100 percent of points in the previous audit. There were no recommendations on which to follow-up. PHP continues to perform well in this regulation, having received 99 percent or greater for SFY 2010, 2011, and 2012.

Table 11b: Deficiencies Notes in Salud! Client Transition of Care

Care coordinated during transition from an inpatient facility 1

of 81



80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

Overall Score

80%85%90%95%

100%

FY 2010 FY 2011 FY 2012 FY 2013


Improvement

80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

Delegation

of 81


80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013


80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

Member Grievance

80%

90%

100%

FY 2012 FY 2013


80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013


80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

ISHCN

80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013


of 81


Audit Findings SCI Table 12 presents the Salud! composite score for each individual regulation. The composite score is determined by calculating the total points earned for audit-related documentation and chart reviews, where applicable. The “N/A’s” in Table 12 indicate that a chart or document review audit was not required. The overall score, shown on Table 13, is determined by adding the total assigned points for each individual regulation which is then converted to a percentage for reporting.

Table 12: Regulatory Element Scores for PHP SCI

Regulation


Chart Review

Tota

l A

vailable

Tota

l A

ssig

ned

Com

posi

te

Score

Available

Poin

ts

Actu

al

Poin

ts

Available

Poin

ts

Actu

al

Poin

ts

Quality Management


10.00 10.00 N/A N/A 10.00 10.00 100.00%


3.00 3.00 N/A N/A 3.00 3.00 100.00%

Delegation 6.00 6.00 N/A N/A 6.00 6.00 100.00%

Coordination of Benefits 5.00 5.00 12.00 11.00 17.00 16.00 94.12%


5.00 5.00 12.00 12.00 17.00 17.00 100.00%


3.00 3.00 N/A N/A 3.00 3.00 100.00%


SCI-SHCN 5.00 5.00 12.00 12.00 17.00 17.00 100.00%






PHP has no point deductions for timeliness or accuracy.

of 81


Table 14 shows the score and compliance level for the Standards for Quality Management and Improvement document review.

Table 14: 8.306.8.9 SCI Standards for Quality Management and Improvement


Findings: As Table 14 shows, there were no adverse findings for this regulation. This regulation only includes a document review. Previous Audit Follow-up: PHP has performed well on this regulation, having achieved 100.00 percent of points each year since SFY 2010. Table 15 shows the score and compliance level for the Standards for Medical Records document and file review.



Findings: For the document review, there were no adverse findings. Following MCO rebuttal process and discussion with HSD staff, it was decided that the Medical Record file review would not be a scored item for this audit year. The score has been adjusted accordingly. However, the recommendations stemming from the Medical Record file review will stand. Previous Audit Follow-up: The composite score was 98.02 percent. The record review was not a scored item in the current audit year. Table 16 shows the score and compliance level for the Delegation document review.



Findings: As Table 16 shows, there were no adverse findings for this regulation. This regulation only includes a document review. Previous Audit Follow-up: PHP continues to perform well on this regulation, having received 100 percent of points each year since SFY 2010. Table 17a shows the score and compliance level for the Coordination of Benefits document and file review.

Table 17a: 8.306.9 SCI Coordination of Benefits


Findings: There were no adverse findings for the document review. There were only three files available for review with one deficiency identified.

of 81


The small number of available files caused the deficiency to have a large impact on the composite score. The deficiency is listed on Table 17b. The composite score includes the document and file review. The score is weighted so that the file review counts more heavily than the document review. Previous Audit Follow-up: PHP continues to perform well on this regulation, having received 100 percent of points in the previous two audits and a 96.00 percent in SFY 2010.

Table 17b: Deficiencies Noted in SCI Coordination of Benefits


Deficient

Documented Permission for Information Sharing 1

Table 18 shows the score and compliance level for the Member Grievance Resolution document and file review.

Table 18: 8.306.12 SCI Member Grievance Resolution


Findings: There were no adverse findings in either the document or file reviews. The composite score includes the document and file review. The score is weighted so that the file review counts more heavily than the document review. Previous Audit Follow-up: PHP continues to perform well on this regulation, having achieved 100 percent every year since SFY 2010. Table 19 shows the score and compliance level for the Program Integrity document review.



Findings: As Table 19 shows, there were no adverse findings for this regulation. This regulation only includes a document review. Previous Audit Follow-up: PHP received 100 percent of available points in the previous audit. This is the second year that Program Integrity has been a scored item.

of 81


Table 20 shows the score and compliance level for the Reporting Requirements document review.

Table 20: 8.306.14 SCI Reporting Requirements


Findings: As Table 20 shows, there were no adverse findings for this regulation. This regulation only includes a document review. Previous Audit Follow-up: PHP continues to perform well in this audit, having received 100 percent of points each year since SFY 2010. Table 21 shows the score and compliance level for the SCI Members with Special Health Care Needs document and file review.

Table 21: 8.306.15 Services for SCI Members with Special Health Care Needs


Findings: There was no adverse findings for either the document or file review. The composite score includes the document and file review. The score is weighted so that the file review counts more heavily than the document review. Previous Audit Follow-up: PHP continues to do well in this regulation, having achieved 99.44 percent or greater each year since SFY 2010. Table 22 shows the score and compliance level for the Member Transition of Care document and file review.



Findings: There were no adverse findings in either the file or the document review. The composite score includes the document and file review. The score is weighted so that the file review counts more heavily than the document review. Previous Audit Follow-up: PHP continues to perform well in this regulation, having achieved 98.00 percent or greater since SFY 2010.

of 81


MCO Multi-year SCI Audit Comparison The following graphs provide historical score comparison for the overall score and for each regulatory element by fiscal year (FY).

80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

Overall Score

80%85%90%95%

100%

FY 2010 FY 2011 FY 2012 FY 2013


Improvement

80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

Delegation

of 81


Recommendations This audit was conducted to discover the extent to which PHP was compliant with federal and state regulations in the provision of Salud! and SCI services. Recommendations for improvement are listed separately for each regulation and each program. It is recognized that the Salud! and SCI contract and programs concluded at the end of calendar year 2013. The following recommendations are for process improvement and can be extrapolated and transferred to other of PHP’s lines of business beyond the current Medicaid contract. Further, this information can benefit PHP staff that may be continuing similar quality improvement efforts both at PHP and at other organizations.

80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013


80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013


80%

85%

90%

95%

100%

FY 2012 FY 2013


80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013


80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

SCI-SHCN

80%

85%

90%

95%

100%

FY 2010 FY 2011 FY 2012 FY 2013

Member Transition of Care

of 81



Standards for Medical Records 8.305.8.17 It is recommended that PHP develop and implement a way that providers can easily document medication effectiveness, medication reactions, drugs prescribed, advanced directives, discussion of smoking, alcohol use, and drug abuse, and then have an efficient way of providing that documentation for audit purposes. As electronic health records (EHRs) become more prevalent, these would be useful enterprise-wide enhancements to have in place. It is recommended that PHP work with their providers to get their EHR system to print the patient’s name and a secondary identifier on each page. If the patient identification is only on the first page, then there is a risk that the pages could get separated and mixed in with another member’s data.

SCI Recommendations

Standards for Medical Records 8.306.8.9 It is recommended that PHP develop and implement a way that providers can easily document medication effectiveness, medication reactions, advanced directives, drugs prescribed including strength, amount, directions, and refills, and then have an efficient way of providing that documentation for audit purposes. As EHRs become more prevalent, these would be useful enterprise-wide enhancements to have in place. It is recommended that PHP work with their providers to get their EHR system to print the patient’s name and a secondary identifier on each page. If the patient identification is only on the first page, then there is a risk that the pages could get separated and mixed in with another member’s data.

Rebuttal and Reconsideration Review PHP was allotted time to offer any rebuttals or requests for reconsideration for any of the findings in this report. The rebuttals offered by PHP and the HealthInsight New Mexico responses are below. PHP Rebuttal: PHP expressed concern that the Universe Specifications document was not clear on what information was required from Report 22 for several appeals and grievance sections. A point was deducted from the overall score due to universe errors stemming from this issue. HealthInsight New Mexico Response: HealthInsight New Mexico recognizes this issue and agrees with PHP. The point that was removed for universe accuracy for the Salud! and SCI programs has been credited back to the score. PHP Rebuttal: This year more and more providers have begun to implement electronic medical record systems (EMRs). The materials and medical records submitted are reflective of these new systems. It is PHP’s belief and understanding that this may have been one of the first audits post implementation of the EMR systems. Many of the issues identified in the medical record could

of 81


be attributed to this fact. Technical difficulties, including printing formats, and other issues beyond PHP’s control attributed to the negative audit findings. PHP asks that HSD and the HealthInsight auditors take this into consideration at least as a margin of error as there is always a bell curve when there is a transition of process especially when it impacts the entire state of providers. Similarly CMS has used a process for large transitions that help to accommodate these large changes in the past such as with transition of DRG, APC’S , EMR and now ICD-10. HealthInsight Response: HealthInsight New Mexico realizes that there are still technical issues to be resolved with EHRs including when it comes to presenting documentation for audit purposes. The PHP staff was allowed to present additional documentation to HealthInsight at the onsite audit for any elements that were missing. Following MCO rebuttal process and discussion with HSD staff, it was decided that the Medical Record file review would not be a scored item for this audit year. The score has been adjusted accordingly. However, the recommendations stemming from the Medical Record file review will stand. HealthInsight New Mexico is open to discussion about viewing the EHRs electronically in future audits. An exact process would need to be developed, but the potential is there. One concern is how to develop an audit trail for future verification of our findings, should the need arise.

Physical Health - NM Human Services...Final Report Main Report June 23, 2014 Purpose The purpose of...

Documents

Transcript of Physical Health - NM Human Services...Final Report Main Report June 23, 2014 Purpose The purpose of...