Provider Meet & Greet - Family Care...Provider Contracting Team Hannah Harris, Provider Relations &...
Transcript of Provider Meet & Greet - Family Care...Provider Contracting Team Hannah Harris, Provider Relations &...
Provider Meet & GreetDANE COUNTY – OCTOBER 24-26, 2017
Partnering for Success
My Choice Family Care
WHO ARE WE?
AN OVERVIEW OF MY CHOICE FAMILY CARE
My Choice Family CareDEDICATED TO QUALITY, COST EFFECTIVE SERVICES
Experience MattersMy Choice Family Care has been
a Managed Care Organization
since 2000 in Milwaukee County,
one of the State’s pilot Family
Care counties.
Dedicated to Vulnerable Citizens
• Frail Elders
• Adults with Physical Disabilities
• Adults with Intellectual and
Developmental Disabilities
My Choice Family CareGREAT PARTNERSHIPS TO IMPROVE QUALITY OF LIFE
Our recent expansion efforts include:
• Rock County – effective July 1, 2016, Wisconsin Department of Health Services introduced Family Care into this former waiver county.
• Geographic Service Region 2 – My Choice Family Care will be a new MCO within this region effective January 1, 2018.
• Geographic Service Region 3 – My Choice Family Care will be a new MCO within this region effective January 1, 2018.
• Dane County – effective February 1, 2018, the Family Care program will also be expanding into Dane County.
For the past 17 years,
My Choice Family Care
has been administering
the Family Care benefit
package and has served
over 27,300 Members.
MCFC looks forward to
creating new provider
partnerships with those
of you who stand beside
us in our mission of
participation, honoring
choice and providing
quality, cost-effective
supports and services.
My Choice Family CareService regions
My Choice Family Care
Waiver Program
and
Family Care
Similarities
and
Differences
Provider Contracting
HANNAH HARRISPROVIDER RELATIONS & NETWORK MANAGER
Provider Contracting TeamHannah Harris, Provider Relations & Network Manager
Provider Relations & Network Specialists
Diane Baumbach Mary Swanson
Jessica Cullen Randy Westley
Kelli Macon Sheri Wojtowicz
Debora Rieder
**PLEASE SEE THE HANDOUT PROVIDED FOR YOUR ASSIGNED
CONTRACTING REPERSENTATIVE.
Some of the provider services needed include:
CONSULTING SERVICES COUNSELING/THERAPEUTIC SERVICES
*Financial Management
*Housing Counseling EMPLOYMENT/ACTIVITY SERVICES
*Relocation Services *Adult Day Care
*Support Broker *Employment Services
*Prevocational Services
EQUIPMENT & SUPPLIES *Supported Employment
*Adaptive Aids *Vocational Planning and Support
*Comminication Aids
*Personal Emergency Response System MISCELLANEOUS HOME BASED SERVICES
*Specialized Medical Equipment *Home Delivered Meals
*Home Modifications
RESIDENTIAL
*Adult Family Home TRAINING BASED SERVICES
*Community Based Residential Facility *Consumer Education & Training
*Residential Care Apartment Complex *Daily Living Skills Training
*Self Directed Support
TRANSPORTATION *Supportive Independent Living Services
Provider Network Needs
• Contracting is actively calling providers to
introduce MCFC and our mission.
• We are currently accepting applications from
providers for all covered services of the
Family Care program.
• Those interested please contact us or
complete the online application.
• Provider trainings/orientations are tentatively
scheduled for mid November, December and
January. Additional dates and times can be
added if interest exists.
Provider Network EffortsPROVIDER OUTREACH HAS BEGUN
Care Planning and Coordination
KAREN ENGLANDCARE MANAGEMENT ADMINISTRATOR
• The Member is the center of their Interdisciplinary Team (IDT), along with their RN and CM.
• Collaborate to assess, coordinate, and monitor the options available to meet a Member’s health and safety needs and long-term care outcomes.
• IDT staff are responsible to provide on-going care management through regular face-to-face and phone contact.
Care ManagementSUPPORTING MEMBERS TO ACHIEVE THEIR
OUTCOMES
• Providers play a very important role in
Members’ lives and supporting them in
achieving their goals and outcomes.
• It is essential to Member care that the
IDT Staff develop good working
relationships with the staff that provide
care to our Members.
Providers’ Role in Care PlanningCOLLABORATION FOR MEMBER OUTCOMES
• This relationship can only be
successful if there is ongoing
communication between the IDT Staff
and the Member’s supports.
– Ongoing assessment process
– Problem solving
– Monitor quality and contractual adherence
– Evaluate progress on Member outcomes
and continued need for service.
– Assure member satisfaction
IDT and Provider Communication
• The IDT Staff may visit members at
their homes, residential facilities
and/or day and work programs.
• The IDT Staff may review Member’s
records containing:– Individual Service Plan (ISP)
– Progress Notes
– Behavior Support/Intervention Plans and tracking
• Participation in Care Conferences and
Care Planning
• Incident reporting
Coordination with Providers
• Participation in Care Conferences and
Care Planning– Helps ensure an accurate understanding of
Member’s functioning and abilities within the
home and the care and services provided.
• The facility is required to inform the
IDT of all critical incidents, changes in
condition, medical appointments, and
any Member absences from the
facility, including hospitalizations.
Coordination with Providers
(Residential)
Provider Quality
WES ALBINGER
PROVIDER QUALITY MANAGER
• Develop, communicate, and monitor
contract requirements to ensure MCO
compliance with State and to promote
provider quality
• Contract requirements are principally
derived from MCFC’s contract with
State DHS and should be largely
consistent with those you may already
be following for other FC payors
Provider QualityCOMPLIANCE WITH CONTRACT REQUIREMENTS
• Provide technical assistance to network
providers on contract requirements
• Collaboration-Liaison between provider
community and MCO
• Identify areas for growth and expansion
of network to ensure access and
choice to members
• Identify areas for training and other
support to providers
Provider Quality, continued
• Informal resolution process
• Background checks
• Provider Survey
• Training: provider onboarding training
• Provider Advisory Groups
• Member satisfaction surveys
• Provider Newsletter
Provider Quality RECENT AND ONGOING PROVIDER QUALITY INITIATIVES
Provider Portal
MARY JO SAGGIOCLAIMS SPECIALIST
Payment and/
or Provider
Remittance
Advice Sent
Authorization and Payment Process
WPS Process
Claim
According to
Authorization
Provider
Submits Claim
to WPS Via the
Midas Portal
Provider
Submits Claim
to Other
Insurance or
Medicare
Provider
Performs
Authorized
Service
Provider
Receives
Authorization
from MCO
WPS Receives
Authorization
from MCO
Managed Care
Organization
(MCO)
Authorizes the
Approved
Service
Member Needs
Family Care
Approved
Service
Authorizations
1. System:
Provider Portal
2. Login ID and
Password
3. Environment:
Production
4. Login
www.mcfc-midas.com
5 Steps To A Clean Claim
Please visit MyChoiceFamilyCare.org
• Providers Tab
• Become a Provider
• Choose the “Request for Application” link
Quick Link to Request for Application:
https://www.mcfc-midas.com/providerapplication/
Next StepsI’D LIKE TO BECOME A PROVIDER.
WHAT DO I DO NEXT?
Session I – Employment and
Day Services
• My Choice Family Care has a strong
commitment to ensuring all members
have access to community employment
My Choice Family Care
PRE-VOCATIONAL, SUPPORTED
EMPLOYMENT AND DAY
SERVICES
Prevocational Services
PREVOCATIONAL SERVICES ARE THE
PROVISION OF SERVICES INTENDED TO
PREPARE AN INDIVIDUAL FOR PAID
EMPLOYMENT BUT WHICH ARE NON-JOB
SPECIFIC.
• National trend is towards community based services.
• Community Based prevocational services.
• Facility-based prevocational services.
• Members age 18 thru 25 years must have a integrated employment goal to receive facility based services.
• For this age group MCFC will be utilizing prevocational services through DVR.
My Choice Family CarePREVOCATIONAL SERVICES
Supported Employment
SUPPORTED EMPLOYMENT IS THE
PROVISION OF SUPPORT TO MAINTAIN
PAID, COMPETITIVE EMPLOYMENT IN AN
INTEGRATED WORK SETTING TO
INDIVIDUALS WHO, BECAUSE OF THEIR
DISABILITIES, NEED ON GOING SUPPORT
TO PERFORM IN A WORK SETTING.
• Job Development is completed using DVR funding.
• Job Coaching is initially funded by DVR and is transitioned to Long Term Care when member is stable.
• DVR/MCO Transportation funding roles.
• Work Incentive Benefits Counseling
• Post- employment services with DVR
• MCFC CM’s will play an integral role through out the DVR process.
Supported Employment IN COLLABORATION WITH DEPARTMENT OF VOCATIONAL REHABILITATION (DVR)
• Provider to work with MCFC CM.
• JD & JC reports submitted to CM.
• Prevocational services 6-month
progress report & service plan.
• Employment Outcome Data Collection
through PPS System.
• End of the year report.
Provider Expectations REPORTING
• Day center service- provided
traditionally to members with
developmental, intellectual, or cognitive
disabilities geared to help them learn
activities of daily living, community
living skills, and socialization skills in a
controlled environment with their peers.
Day Programming ServicesDEFINED
• Written program statement, or model,
outlining the services, days and hours
of operation, and the goals of their
program.
• Staff shall be trained in the needs and
intervention strategies involved with
members, which include but are not
limited, to developmental, cognitive,
and intellectual disabilities.
Day Programming Services EXPECTATIONS
• Standard Day Service Program
• Medical Assistance Day Program -
• Medical staff required on-site due to Members’ medical needs
- Nursing staff required for medication administration, tube feedings, etc
- Medication management - ordered by primary care provider and not duplicated in-home/residential setting
- Daily Injections
- Bed or chair bound – requires two person assist for re-positioning
- Hoyer transitions
Day Programming ServicesSTRUCTURE
• Behavioral Assistance Day Program
- Elopement risk
- Physical or verbal threats to themselves or others
- Requires physical redirection
- Impulsive behavior – acting out, high volume speaking, etc.
• One to One Assist Day Program
- Behavioral Support Plan and tracking provided by the provider to support need for 1:1
- Persistent self-injurious behavior
- Significant elopement risk
- PICA diagnoses
Day Programming Services Cont.STRUCTURE
Session II - Transportation
• A common carrier, specialized medical
vehicle or other provider who directly
conveys a member and their attendant,
if any, to destinations
• These services enable a member to
gain access to community services,
activities and resources, as specified in
the member’s care plan
• Excludes emergency medical
transportation
Transportation ServicesDEFINED
• Drivers should be easily identified with
company name badges. Company logo
and/or signage on vehicles clearly
visible.
• Vehicles kept clean and in good repair.
• MCFC embraces the Medicaid
requirement of door-to-door service
expected for all rides, SMV and
ambulatory.
• Passenger logs
Transportation ServicesPROVIDER EXPECTATIONS
• Driver background checks, licensed
and insured drivers
• Safe driver and defensive driving
training
• Red Cross or equivalent training in first
aid CPR
• Instruction for the use of lifts, ramps,
and restraint devices
• Comply with DHS Weekly Driver’s
Vehicle Inspection
Transportation ServicesPROVIDER QUALITY
Session III –
Supported Independent living
Scope of Services
Supported Independent Living Service (SIL) is a combination of services to provide assistance to eligible persons in non-regulated settings in order to meet their daily living needs and to insure adequate functioning at home and in the community.
SIL is flexible and member centered, and can be effective across a wide range of support needs.
Members are assessed, and a service plan is developed,
by the member’s IDT, who will consult with the member
and others who have knowledge of the member’s needs
and preferences, such as guardians, family, friends, and
providers).
The SIL Assessment captures many domains of need,
including: Bathing, Dressing, Eating, Mobility, Toileting,
Transferring, Grooming, Meal Preparation, Laundry,
Chores, Budgeting, Medically Oriented tasks, and Mental
and Behavioral Support.
A level of overall assistance is generated which reflects
the type and frequency of assistance the member needs.
Scope of Services
SIL providers play an important, defined
role as described in the member’s care plan. In most cases, SIL providers are one of multiple service providers, including informal/natural supports.
Some activities, although related to independent living, are organized as separate services and are therefore outside the scope of responsibility for the SIL provider.
Scope of Services
Examples include, but are not limited to: transportation, daily living skills training, vocational services, rep payee.
SIL services bear some similarity in scope with Supportive Home Care and Personal Care services.
The selection of specific services is determined by the IDT based on member needs.
Scope of Services
Session IV – Residential Providers
and Services
• Role of Residential Provider
• Compensation
• Payment for Member Absence from
Residential Setting
• Residential Placement of Members
• Residential Scope of Services
Residential Services Overview
A contract with My Choice Family Care
for community residential services
incorporates the services and supports
listed below. This list is not all
encompassing, but a listing of general
categories and examples of costs
typically incurred in each category.
Rates for community residential services
include the following items and supports:
Scope of ServicesIN COMMUNITY RESIDENTIAL SETTINGS ADULT FAMILY
HOME AND COMMUNITY BASED RESIDENTIAL FACILITY
• Physical Space
• Furnishings
• Equipment
• Housekeeping Services
• Building Maintenance
• Grounds Maintenance
• Building Protective Equipment
• Building Support Systems
• Fire and Safety Systems
• Food
• Telephone and Media Access
Physical EnvironmentROOM AND BOARD RATE
• Support and Supervision
• Personal Care, Assistance with Activities of Daily Living
and Daily Living Skills Training
• Activities, Socialization and Access to Community
• Health Monitoring
• Medication Management
• Behavior Management
• Facility Supplies First Aid Supplies - including gauze pads,
blood pressure cuffs, stethoscopes, thermometers, cotton
balls, medication, specimen cups
• Facility Equipment
• Personal Protective Equipment for Staff Use –
including gloves, gowns, masks
• OSHA and Infection Control Systems
• Resident Funds Management
• Transportation
Program ServicesCARE AND SUPERVISION RATE
Go to: www.ewala.org
Affordable Liability Insurance Coverage for
Residential Providers Available Through Wisconsin
Assisted Living Association and M3 Solutions, Inc.
Session V – Behavioral
Health, Personal Care and
Supportive Home Care
• COVERED SHC BENEFITS
• SERVICE REQUIRMENTS
• PRE AUTHORIZATION
• REIMBURSEMENT
SUPPORTIVE HOME CARE SERVICESoverview
BEHAVIORAL HEALTH SERVICEOVERVIEW
• COVERED BH BENEFITSMENTAL HEALTH, AODA (ALCOHOL AND OTHER
DRUG ABUSE), CSP (COMMUNITY SUPPORT
PROGRAMS), IN-HOME THERAPY
• SERVICE REQUIREMENTS
• PRE AUTHORIZATION
• MEDICAID REIMBURSEMENT
• COVERED PC BENEFITS
• SERVICE REQUIRMENTS
• PRE AUTHORIZATION
• MEDICAID REIMBURSEMENT
PERSONAL CARE SERVICESoverview
Session VI – All Other
Services (DME/DMS, Home
Modifications and Other
Therapies)
• COVERED DME/DMS BENEFITS
• SERVICE REQUIRMENTS
• PRE AUTHORIZATION
• MEDICAID REIMBURSEMENT
DURABLE MEDICAL EQUIPMENT & SUPPLIES
overview
• Supervision
• Personal Care, Assistance with Activities of Daily Living
and Daily Living Skills Training
• Activities, Socialization and Access to Community
• Health Monitoring
• Medication Management
• Behavior Management
• Facility Supplies First Aid Supplies - including gauze pads,
blood pressure cuffs, stethoscopes, thermometers, cotton
balls, medication, specimen cups
• Facility Equipment
• Personal Protective Equipment for Staff Use –
including gloves, gowns, masks
• OSHA and Infection Control Systems
• Resident Funds Management
• Transportation
Program ServicesCARE AND SUPERVISION RATE
My Choice Family CareRATE SETTING METHODOLOGY
How are provider rates determined?
What is care under management?
How do costs in Dane County
compare to other Wisconsin Counties?
Partnering with
You to Serve our
Community
THANK YOU FOR
JOINING US TODAY!
We look forward to partnering with you!