Document Title - Finance and Administration Cabinet · Web viewDMS exchanges information with SSA via electronic interfaces based on HIPAA standards. The process requires fewer than

KENTUCKY CABINET FOR HEALTH AND FAMILY SERVICES

DIVISION FOR MEDICAID SERVICES

KENTUCKY MMIS PROCUREMENT 2012Medicaid Information Technology Architecture State Self-

Assessment

MITA As-Is Documentation

Deliverable 6

July 6, 2012Version 1.81

Prepared by:

7926 Jones Branch Drive, Suite 330McLean, VA 22102

(480) 423-8184www.cognosante.com

http://www.cognosante.com/

Kentucky MMIS Procurement 2012MITA SS-A As-Is Assessment

REVISION HISTORYVersion Number Date Reviewer CommentsVersion 1.0 6/15/2012 Fred HindsVersion 1.01 6/19/2012 John Hoffman DMS feedbackVersion 1.02 6/19/2012 Fred Hinds Changes to address

DMS feedbackVersion 1.03 6/20/2012 Fred Hinds Changes acceptedVersion 1.04 7/02/2012 Fred Hinds Comments from OATSVersion 1.8 7/05/2012 Nancy Ferguson QA ReviewVersion 1.81 7/06/2012 Fred Hinds Accepted changes

Kentucky MITA SS-A As Is Update v1.81Page i


TABLE OF CONTENTS1 INTRODUCTION..................................................................................................................11.1 Project Summary and Methodology...................................................................................11.1.1 Project Phases................................................................................................................11.1.2 Project Deliverables........................................................................................................21.2 Terminology Clarification...................................................................................................21.3 MITA Framework 2.01.......................................................................................................61.4 Project Stakeholders..........................................................................................................61.4.1 Internal Stakeholders......................................................................................................61.4.2 External Stakeholders.....................................................................................................6

2 EXECUTIVE SUMMARY......................................................................................................72.1 MITA SS-A Summary Findings – Business Processes......................................................72.2 Results of Kentucky’s As Is Assessment – Primary Factors..............................................8

3 KENTUCKY OVERVIEW....................................................................................................103.1 Kentucky Medicaid Mission..............................................................................................103.2 Kentucky Medicaid Vision................................................................................................103.3 Kentucky Medicaid Values...............................................................................................103.4 Kentucky Medicaid Guiding Principles.............................................................................103.5 Kentucky Goals and Objectives.......................................................................................10

4 KEY FINDINGS AS IS BUSINESS ASSESSMENT...........................................................124.1 Summary..........................................................................................................................124.2 Business Relationship Management................................................................................124.2.1 Overview.......................................................................................................................124.2.2 Impact of Managed Care on Business Relationship Management...............................134.2.3 Business Capabilities Matrix.........................................................................................134.3 Care Management...........................................................................................................144.3.1 Overview.......................................................................................................................144.3.2 Impact of Managed Care on Care Management...........................................................154.3.3 Business Capabilities Matrix.........................................................................................154.4 Contractor Management..................................................................................................164.4.1 Overview.......................................................................................................................164.4.2 Impact of Managed Care on Contractor Management..................................................174.4.3 Business Capabilities Matrix.........................................................................................184.5 Member Management......................................................................................................204.5.1 Overview.......................................................................................................................204.5.2 Impact of Managed Care on Member Management.....................................................21

Kentucky MITA SS-A As Is Update v1.81Page ii


4.5.3 Business Capabilities Matrix.........................................................................................224.6 Operations Management.................................................................................................244.6.1 Overview.......................................................................................................................244.6.2 Impact of Managed Care on Operations Management.................................................264.6.3 Business Capabilities Matrix.........................................................................................264.7 Program Integrity Management.......................................................................................314.7.1 Overview.......................................................................................................................314.7.2 Impact of Managed Care on Program Integrity Management.......................................324.7.3 Business Capabilities Matrix.........................................................................................324.8 Program Management.....................................................................................................334.8.1 Overview.......................................................................................................................334.8.2 Impact of Managed Care on Program Management.....................................................354.8.3 Business Capabilities Matrix.........................................................................................354.9 Provider Management......................................................................................................394.9.1 Overview.......................................................................................................................394.9.2 Impact of Managed Care on Provider Management.....................................................404.9.3 Business Capabilities Matrix.........................................................................................40

5 CONCLUSION....................................................................................................................43

LIST OF FIGURES AND TABLESFigure 1: Medicaid Enterprise As Is MITA Maturity Levels............................................................8Figure 2: Business Relationship Management Summary............................................................12Figure 3: Care Management Summary.......................................................................................15Figure 4: Contractor Management Summary..............................................................................17Figure 5: Member Management Summary..................................................................................21Figure 6: Operations Management Summary.............................................................................25Figure 7: Program Integrity Management Summary...................................................................32Figure 8: Program Management Summary.................................................................................34Figure 9: Provider Management Summary..................................................................................40

Table 1: MITA 2.01 – SS-A Update Phases..................................................................................2Table 2: Project Deliverables.........................................................................................................2Table 3: MITA 2.01 Maturity Model...............................................................................................5Table 4: Business Relationship Process Summaries..................................................................13Table 5: Care Management Process Summaries........................................................................16Table 6: Contractor Management Process Summaries...............................................................18Table 7: Member Management Process Summaries..................................................................22Table 8: Operations Management Process Summaries..............................................................26

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Table 9: Program Integrity Process Summaries..........................................................................33Table 10: Program Management Process Summaries................................................................35Table 11: Provider Management Process Summaries................................................................41

LIST OF ACRONYMSThe following acronyms are used throughout this document:

Acronym DefinitionACH Automated Clearing HouseAVRS Automated Voice Response SystemBCCTP Breast and Cervical Cancer Treatment ProgramBCM Business Capability MatrixBP Business ProcessBPM Business Process ModelBR Business Relationship ManagementCHFS Cabinet for Health and Family ServicesCM Care ManagementCMS Centers for Medicare & Medicaid ServicesCO Contractor ManagementCOB Coordination of BenefitsCOTS Commercial Off-The-ShelfDCBS Department of Community Based ServicesDSS Decision Support SystemEDI Electronic Data InterchangeEFT Electronic Funds TransfereMARS Electronic Management and Administrative Reporting

System EOB Explanation of BenefitsEPSDT Early and Periodic Screening, Diagnosis, and TreatmentFA Fiscal AgentFFP Federal Financial Participation FMAP Federal Medical Assistance PercentageGOEHI Governor’s Office of electronic Health InformationHCBS Home and Community Based ServicesHIE Health Information ExchangeHIPAA Health Insurance Portability and Accountability Act

Kentucky MITA SS-A As Is Update v1.81Page iv


Acronym DefinitionHIX Health Insurance ExchangeHMS Health Management SystemHPES Hewlett Packard Enterprise SolutionsIAPD Implementation Advanced Planning DocumentICD-10 International Classification of Diseases and Related Health

Problems, Tenth RevisionID IdentificationIT Information TechnologyKAMES Kentucky Automated Management & Eligibility SystemKenPAC Kentucky Patient Access and CareKHIE Kentucky Health Information ExchangeKY KentuckyKYME Kentucky Medicaid EnterpriseMCO Managed Care Organization ME Member ManagementMITA Medicaid Information Technology ArchitectureMITS Medicaid IT SupplementMMA Magellan Medicaid AdministrationMMIS Medicaid Management Information SystemMMM MITA Maturity ModelMOU Memoranda of UnderstandingOM Operations ManagementPE Presumptive EligibilityPG Program ManagementPI Program IntegrityPM Provider ManagementRA Remittance AdviceREC Regional Extension CenterRFP Request for ProposalSCHIP State Children’s Health Insurance ProgramSDX State Data ExchangeSNAP Supplemental Nutrition Assistance ProgramSOA Service Oriented ArchitectureSSA Social Security AdministrationSS-A State Self-AssessmentSUR Surveillance and Utilization ReviewTANF Temporary Assistance to Needy Families

Kentucky MITA SS-A As Is Update v1.81Page v


Acronym Definition

TPL Third Party LiabilityUSPS United States Postal Service

Kentucky MITA SS-A As Is Update v1.81Page vi


1 INTRODUCTIONThe Centers for Medicare & Medicaid Services (CMS) requires that each state Medicaid Enterprise complete a Medicaid Information Technology Architecture (MITA) State Self-Assessment (SS-A). The Kentucky (KY) Cabinet for Health and Family Services (CHFS) Division for Medicaid Services (DMS) selected Cognosante for professional consulting services and technical assistance to update and revise the State’s previous MITA SS-A As Is assessment completed in 2008 and the To Be assessment completed in 2010. The MITA SS-A update is part of the Medicaid Enterprise Takeover and Replacement Planning Project.

The Commonwealth’s previous MITA SS-A assessments utilized the MITA 2.0 framework and were completed when the program was a wholly fee-for-service (FFS) based program. Since the previous assessments, the Commonwealth has shifted to a dual-model (FFS and Managed Care) with Managed Care Organizations (MCOs).

This document is the MITA As Is Assessment that provides a comprehensive description of the current business and technical environment of the Kentucky Medicaid Enterprise (KYME). This documentation includes the Commonwealth’s goals and objectives, current business processes, legal framework, and information technology tools now supporting the Commonwealth’s Medicaid mission.

1.1 Project Summary and Methodology

The project tasks involve a review and update of the existing MITA SS-A and the compilation of MMIS requirements analysis. Based upon the existing KY MITA SS-A, the project will review the As Is status of the KYME and existing maturity levels along with the To Be status of business processes (BPs) and aspired maturity levels. Activities to be completed in support of this effort include the following:

Identify those business processes affected by the CMS published guidance in its Seven Conditions and Standards1

Identify impacts to business, information, and technical state that are different from what is otherwise specified in the existing KY MITA SS-A

Develop a Gap Analysis that identifies the differences between the KYME As Is state and goal of the To Be direction

Develop a Transition Plan that outlines the path to close the gaps

1.1.1 Project Phases1 Enhanced Funding Requirements: Seven Conditions and Standards, Medicaid IT Supplement (MITS-11-01-v1.0, Version 1.0, April 2011

Kentucky MITA SS-A As Is Update v1.81Page 1


The MITA SS-A Update task is divided into the four phases listed in Table 1: MITA 2.01 – SS-A Update Phases below.



Table 1: MITA 2.01 – SS-A Update Phases

Phase Item Description1 Update Existing As Is Documentation2 Update Existing To Be Documentation3 Analyze the Gap between the As Is and To Be Maturity Levels4 Develop a Transition Plan to progress to the desired maturity

levels

1.1.2 Project DeliverablesThe MITA SS-A project has been organized into a series of four deliverables. These deliverables are logically arranged to determine the future needs of the program to meet the Commonwealth’s Executive Vision for the program, stakeholder needs, and federal requirements.

Table 2: Project Deliverables

Deliverable Number Deliverable Name

Amendment 1.6 Commonwealth As Is Documentation Current business process documentation As Is detailed Report

Amendment 1.7 MITA To Be Documentation Amendment 1.8 Gap Analysis ReportAmendment 1.9 Transition Plan

1.2 Terminology Clarification

Several concepts and entities are used in specific sense throughout this document, and the following definitions serve to clarify the in-depth discussions they precede.

1. Enterprise

The term enterprise is used throughout this document. It is preceded by an adjective to describe the processes and systems that make up the Medicaid solution. In this document, the term enterprise means:

A group of organizations (e.g., CHFS operating agencies)

Staff, systems, and interfaces that have a common purpose (e.g., Medicaid)



The following enterprise definitions are used to help the reader understand the context of terms used throughout this document.

CHFS Enterprise – The staff, systems, and interfaces that make up the Kentucky CHFS organization

o Program Agencies

Department for Aging and Independent Living

Commission for Children with Special Health Care Needs

Department for Community Based Services

Department for Family Resource Centers and Volunteer Services

Office of Health Policy

Department for Income Support

Department for Medicaid Services (DMS)

Department for Behavioral Health, Developmental and Intellectual Disabilities

Department for Public Health

o Program Support Agencies

Governor’s Office for Electronic Health Information

Office of Administrative and Technology Services (OATS)

Office of Health Policy

Office of Communication and Administrative Review

Office of Human Resource Management

Office of the Inspector General

Office of Legal Services

Office of Ombudsman

Office of Policy and Budget

o Divisions

Administrative Hearings

Child Care

Child Support



Disability Determination Services

Family Resource and Youth Services Centers

Family Support

Prevention Violence Resources

Protection and Permanency

Women’s Physical and Mental Health

o Advisory Commissions, Councils and Boards

Institutional Review Board

Kentucky Commission on Community Volunteerism and Service

Commonwealth Council on Developmental Disabilities

Kentucky e-Health Network Board

Kentucky Health Information Exchange Coordinating Council (KY-HIECC)

Medicaid Enterprise – The staff, systems, and interfaces that are used to process, hold, or distribute Kentucky Medicaid information across the operating agencies

2. Silo

Silo is another term used throughout this document. Along with the term “compartmentalized,” silo is used to describe the lack of system interoperability, communication, and common goals across two or more business areas. For most of the CHFS enterprise management systems, the focus is inward and information communication is vertical. In general, staff members serve as information gatekeepers, making timely coordination and communication among departments difficult to achieve. Information gatekeepers also make seamless interoperability with external parties impractical. In general, silos tend to limit productivity in practically all organizations and provide greater risk for security lapses and privacy breaches.

3. MITA Maturity Model, Maturity Level, and Capability

The MITA Framework is grounded in several significant terms. Among the most significant terms are MITA Maturity Model (MMM), Maturity Level, and Capability.

MMM – A maturity model serves to measure and guide the performance of a specific business area (e.g., a long-term care waiver program) or business function (e.g., enrolling members) across time. The MMM provides each state’s Medicaid Enterprise with a structured timeline for realizing certain performance standards (e.g., within five years, enrolling members occurs online and information is automatically transferred from the application to systems for enrollment).



Maturity Level – Within the MMM there are five maturity levels for the each business process. These maturity levels are the summation of a set of performance standards and represent steps along the MMM. The maturity levels for individual processes are described in the tables beginning with Section 4. Each business process is assessed at one of its five maturity levels. This will be described as a certain business process having been assessed at a “MITA Maturity Level.”



Table 3: MITA 2.01 Maturity Model

Definition of State Medicaid Levels of MaturityLevel 1 Level 2 Level 3 Level 4 Level 5

Agency focuses on meeting compliance thresholds for State and Federal regulations, primarily targeting accurate enrollment of program eligibles and timely and accurate payment of claims for appropriate services.

Agency focuses on cost management and improving quality of and access to care within structures designed to manage costs (e.g., managed care, catastrophic care management, and disease management). Focus on managing costs leads to program innovations.

Agency focuses on adopting national standards, collaborating with other agencies in developing reusable business processes, and promoting one-stop-shop solutions for providers and consumers. Agency encourages intrastate data exchange.

Agency benefits from widespread and secure access to clinical data and focuses on improvement of healthcare outcomes, empowering beneficiaries and provider stakeholders, measuring objectives quantitatively, and ensuring overall program improvement.

Agency focuses on fine tuning and optimizing program management, planning and evaluation since it has benefited from national (and international) interoperability and previously noted improvements that maximize automation of routine operations.

Capability – The “performance standards” referred to in the two definitions above, are commonly referred to in the MITA Framework as capabilities. Each of the 79 business processes discussed in these deliverables has a set of capabilities associated with them. For each business process, the sum of capabilities is known as a Business Capability Matrix (BCM). The KY MITA SS-A Update was completed using the BCM from MITA Framework 2.01. As noted by CMS, below are the main types of capabilities:2

Timeliness of Business Process – Time lapse between the agency’s initiation of a business process and attaining the desired result (e.g., length of time to enroll a provider, assign a member, pay for a service, respond to an inquiry, make a change, or report on outcomes)

Data Accuracy and Accessibility – Ease of access to data that the business process requires and the timeliness and accuracy of data used by the business process

Efficiency; Ease of Performance – Level of effort necessary to perform the business process given current resources

2 CMS. MITA Framework 2.0. Part 1, Chapter 3, p. 5. www.cms.hhs.gov/MedicaidInfoTechArch/Downloads/part1.zip (Accessed 4 June 2009).


http://www.cms.hhs.gov/MedicaidInfoTechArch/Downloads/part1.zip


Cost Effectiveness – Ratio of the amount of effort and cost to outcome

Quality of Process Results – Demonstrable benefits from using the business process

Utility or Value to Stakeholders – Impact of the business process on individual beneficiaries, providers, and Medicaid staff

1.3 MITA Framework 2.01

The goal of this assessment is to bring the previous SS-A materials up to MITA 2.01 in conjunction with the development of an RFP as part of the MMIS Procurement Project. Cognosante is performing the following activities building upon the existing KY MITA SS-A:

Identifying business processes affected by the CMS published guidance in its Seven Conditions and Standards

Identifying impacts to business, information, and technical state that are different than otherwise specified in the existing KY MITA SS-A

Developing a Gap Analysis of the differences in where the current KYME is and goal of the “To Be” direction

Developing a Transition Plan that outlines the path to satisfy the gaps

The intent of the SS-A update is to identify MITA capabilities that will need to be improved in order to meet CMS requirements and the future needs of the Kentucky Medicaid. These requirements will be reviewed for possible inclusion into the MMIS Procurement Project RFP.

The Office of Administrative and Technology Services (OATS) will be leading the effort on the State Self-Assessment (SS-A) update to MITA v3.0.

1.4 Project Stakeholders

The Commonwealth has both internal and external stakeholders that are involved in the KY Medicaid Enterprise. The internal stakeholders are typically part of the administrative organizations that operate or support the Medicaid program. The external stakeholders are those that fund, provide, or receive services from the program.

1.4.1 Internal Stakeholders CHFS

Governor’s Office of Electronic Health Information (GOEHI)

Kentucky Health Information Exchange (KHIE)

1.4.2 External Stakeholders



CMS

Medicaid Providers serving Kentucky citizens

Provider professional organizations

Members/consumers

Regional Extension Centers (RECs)

Managed Care Organizations (MCOs)

Fiscal Agent



2 EXECUTIVE SUMMARYCMS requires that each state Medicaid Enterprise complete a MITA SS-A. CHFS completed its initial MITA SS-A in 2008. DMS has selected Cognosante to review and update the 2008 SS-A for KY Medicaid.

The four key deliverables for the KY MITA SS-A update are as follows:

1. Updated KY As Is Assessment – This deliverable outlines the current Medicaid Enterprise business process As Is state and the corresponding maturity levels for the various MITA business processes and technical environment.

2. Updated KY To Be Assessment – This deliverable outlines the future Medicaid Enterprise business process To Be state and the corresponding maturity level goals for the various MITA business processes and technical environment. It also includes an analysis of the impact of the CMS Seven Conditions and Standards on the MITA Maturity needs.

3. Gap Analysis – This deliverable provides a gap analysis that identifies the gaps between the As Is and the To Be, encompassing the KY Medicaid program’s needs for business process improvements that support the MITA business process architecture, Information architecture, and technical architecture. This deliverable will also include the MITA Framework Version 2.01, business process model (BPM) Version 2.01 Appendix E. This appendix provides the justification documentation required by CMS for the Implementation Advance Planning Document (IAPD)-planned improvement funding requests for the Medicaid Management Information System (MMIS).

4. Transition Plan – The Transition Plan outlines the recommendations for improvement with broad impact on the program and MITA capability level improvements. The section also includes a recommended prioritization of the improvements with a brief justification. The recommendations take into considerations the federal mandates, Commonwealth goals and objectives, and the To Be capabilities identified during the MITA business process sessions and received from focused area stakeholders.

This document represents Deliverable 1.6: Updated KY As Is Assessment Documentation and will present both DMS and CMS with a description and maturity level for the business processes provided by MITA Framework Version 2.01. This deliverable will describe where the Commonwealth is currently (As Is) and provide the supporting detail for maturity level determination. This document, therefore, will comprise the As Is portion of the MITA SS-A.

2.1 MITA SS-A Summary Findings – Business Processes



Figure 1 below provides a summary of the KY Medicaid Enterprise As Is maturity levels for all eight business areas. Each of these business areas is discussed fully in Section 4, Key Findings As Is Business Assessment, and includes detailed discussion of the factors affecting assignment of MITA Maturity Levels.

Member Management

Provider Management

Contractor Management

Operations Management

Program Management

Business Relationship Management

Program Integrity Management

Care Management

0 5 10 15 20 25 30

6

7

8

16

15

4

2

4

2

1

10

4

0

0

Kentucky As Is Maturity Level Summary

Level 1Level 2

Total Business Processes

MIT

A Bu

sines

s Are

a

Figure 1: Medicaid Enterprise As Is MITA Maturity Levels

The challenges to moving up the process maturity continuum include heavy reliance on manual processes, process fragmentation, and the widespread use of a non-standardized variation among data models. In the next section, the primary factors identified across all sessions that pose a challenge to MITA maturity are listed and explained. These are core issues that must be addressed as the Commonwealth improves its progress through the MITA maturity levels.

2.2 Results of Kentucky’s As Is Assessment – Primary Factors



The Commonwealth currently performs 78 of the 79 MITA business processes. The Authorize Referral Process (OM01) is no longer performed in Kentucky with the transition of members from the Kentucky Patient Access and Care (KenPAC) program to the Managed Care program.

In general, there are six primary factors inhibiting the progression of the 79 MITA business processes. These primary factors must be understood and addressed in order for Kentucky to increase its MITA maturity levels. The primary factors affecting the maturity levels will become more defined and distinct after the To Be portion of the SS-A is completed, and as outlined by the goals and target maturity levels provided in the Gap Analysis deliverable.

1. Need to increase the use of automation (such as workflow, alerts, dashboards, and email).

2. Need to increase interoperability of systems through the use of Service Oriented Architecture (SOA).

3. Automation will improve efficiency and accuracy of information.4. Several processes are using state and local data standards rather than national Health

Information Portability and Accountability Act (HIPAA) and MITA standard formats.5. Multiple sources of data are not integrated.6. Improve web portal functionality to eliminate manual tasks and improve communication.

These themes emerge as various programmatic challenges across the business architecture within the KYME. These challenges were identified during the business process review sessions and technical assessment. The results of the MITA business process assessment are organized by MITA business area and are presented below.



3 KENTUCKY OVERVIEW3.1 Kentucky Medicaid Mission

Owing to the unbridled spirit of its workforce, the mission of Kentucky Medicaid is to provide innovative opportunities to its members that will promote healthy lifestyles, personal accountability, and responsible program governance for a healthier Kentucky.

3.2 Kentucky Medicaid Vision

Kentucky envisions serving as a national model for achieving excellence in Medicaid by increasing the quality of benefit services, transforming care management, updating relevant technology, providing support for an outstanding workforce, and preventing, detecting, and reducing fraud, waste, and abuse.

3.3 Kentucky Medicaid Values

Respect – for all persons with whom we come in contact

Integrity – in all of our transactions and dealings with one another and the public

Competency – in each task we perform

Collaboration – in making decisions that impact others

Accountability – for our decisions and actions

Excellence – in all that we endeavor to achieve

Commitment – to one another, our members and our providers

3.4 Kentucky Medicaid Guiding Principles

1. Do the right thing, the right way, the first time.

2. All decisions must pass the three way test:

Is it legal?

Is it ethical?

Is it moral?

3. Quality service is the most effective service.

3.5 Kentucky Goals and Objectives



The Kentucky Medicaid mission seeks to accomplish the following five goals:

1. Integrate care delivery systems and providers for enhanced access and service to Medicaid members.

a. Redesign the behavioral health care delivery system.

b. Increase emphasis on primary care.

2. Develop mechanisms to utilize available resources to most appropriately meet the needs of members.

a. Tailor services to meet the individual needs by developing varying benefit packages designed to address the different populations covered by the Medicaid program and to establish meaningful benefits based on best practices.

b. Ensure that Medicaid is the payer of last resort by establishing an "opt out" option for those Medicaid members who have access to private insurance coverage and to create a financial incentive for them to choose that option.

c. Utilize lessons learned and best practices through proven, traditional insurance and business models and integrate into the Medicaid program.

3. Encourage Medicaid members to be personally responsible for their own healthcare.

a. Design Disease and Care Management programs to improve the health of individuals with specific chronic conditions.

b. Initiate a health literacy program to make the Medicaid eligible more informed about health, healthcare and services.

4. Redesign the Medicaid program infrastructure to utilize and maximize appropriate business practices.

a. Enhancement of cost conscious activities performed by the MMIS.

b. Explore grant opportunities with various foundations for program planning, education and research.

5. Provide thorough, thoughtful educational materials and resources to members and providers to assist and enrich their participation in the Medicaid program.

a. Develop a model of best practices that will support providers and help empower members to live healthier lives.



4 KEY FINDINGS AS IS BUSINESS ASSESSMENT4.1 Summary

This section includes Kentucky’s current business processes, legal framework, current capabilities, business functions, and underlying business processes. The comprehensive information contained in Section 4 represents Kentucky’s As Is summary Report.

4.2 Business Relationship Management

4.2.1 OverviewThe Business Relationship Management (BR) business area encompasses those relationships that do not require contracts and may or may not require an exchange of data. Some of these relationships may be formalized by Memoranda of Understanding (MOUs), while others are more informal in nature. Electronic exchange of data is not always required, but there may be an exchange of information. These relationships will be more critical as Electronic Health Records (EHRs) become more prevalent and covered entities develop policies regarding how related clinical data may be exchanged.

This business area owns the standards for interoperability between the agency and its partners. It contains business processes that have a common purpose (i.e., establish the interagency service agreement, identify the types of information to be exchanged, identify security and privacy requirements, define communication protocol, and oversee the transfer of information).

Review of the Medicaid Enterprise indicates all Business Relationship Management business processes currently are determined at MITA Maturity Level 1.

BR01 - Establish Business Relationship

BR02 - Manage Business Relationship

BR03 - Terminate Business Relationship

BR04 - Manage Business Relationship Communications

0 1 2 3 4 5

Business Relationship Management Business Area

MITA Maturity Level



Figure 2: Business Relationship Management Summary

The primary factors affecting maturity ratings across the Business Relationship Management business area include the following:

HIPAA Privacy and Security guidelines are met All four business processes are conducted manually with very few, if any, automated

steps Data exchanges are conducted manually between stakeholders Documentation and MOUs are stored in non-standardized, disparate locations and are

not easily accessible MOU forms and documents are not standardized across programs and projects Data accuracy relies on manual efforts due to a lack of automation Updates to documentation are conducted manually via email and document

collaboration between the different programs Communication formats are mostly manual and not standardized

4.2.2 Impact of Managed Care on Business Relationship Management

The switch to a dual-model with the bulk of the members enrolled in a MCO will have the following impacts on the Business Relationship Management business area.

A decrease in the volume of electronically submitted FFS claims and possibly fewer submitters.

An increase in the number of encounter claims submitted by the MCOs

Increased dependence on utilization of standard X12 5010 transactions (e.g. 820, 834, 835) with the MCOs

4.2.3 Business Capabilities MatrixThis section articulates the maturity level of the individual business processes within the Business Relationship Management business area for the Medicaid Enterprise. While all MITA Framework 2.01 capabilities will be addressed for each target maturity level, the table below focuses on the key rationale to support the maturity level determinations.

Table 4: Business Relationship Process Summaries



MITA BUSINESS PROCESS

AS IS MATURITY

LEVELAS IS PROCESS DESCRIPTION – BUSINESS RELATIONSHIP

BR01 Establish Business Relationship

1 1. Process is primarily manual with few automated steps.

2. Data exchange is conducted manually.

3. MOUs are stored in disparate locations.

4. Agreements are stored in electronic formats.

5. No automation of business rules.

BR02 Manage Business Relationship


2. Access to documentation is limited.

3. Data accuracy relies on manual efforts.

4. Updates are conducted via email and document collaboration.

5. Manual processes have lowered stakeholder satisfaction

BR03 Terminate Business Relationship


2. Lack of automation has resulted in lower quality.

3. Process is not automated and can take over 10 days to complete the process.

BR04 Manage Business Relationship Communication

1 1. Process is a mix of manual and automated processes

2. The process is integrated within the Medicaid Enterprise

3. There is some use of non-standardized data

4. Improved timelines and coordination have improved stakeholder satisfaction to level 2.

4.3 Care Management

4.3.1 OverviewThe Care Management (CM) business area illustrates the growing importance of care management as the Medicaid program evolves. Care Management collects information about the needs of the individual member, plan of treatment, targeted outcomes, and the individual’s health status. It also contains business processes that have a common purpose (i.e., identify clients with special needs, assess needs, develop treatment plan, monitor and manage the plan, and report outcomes). This business area includes processes that support individual care management and population management. Population management targets groups of individuals with similar characteristics and needs and promotes health education and awareness.



Care Management includes Disease Management; Catastrophic Case Management; Early and Periodic Screening, Diagnosis, and Treatment (EPSDT); Population Management; Patient Self-Directed Care Management; Immunization and other registries; Waiver Program Case Management; and programs yet to come. With individual patient and case manager access to clinical data and treatment history, Care Management continues to evolve and increase in importance in the Medicaid Enterprise.

Members with special needs are the initial focus of Care Management. As the Medicaid Enterprise evolves, all beneficiaries could have access to care management, including self-directed decision-making.

CM01 - Establish Case

CM02 - Manage Case

CM03 - Manage Medicaid Population Health

CM04 - Manage Registry

0 1 2 3 4 5

Care Management Business Area

MITA Maturity Level

Figure 3: Care Management Summary

The primary factors affecting maturity ratings across the Care Management business area include the following:

The process is mainly manual tasks and ad-hoc reports The focus is on cost containment and cost avoidance rather than improved care. Registries are being integrated within Kentucky Medicaid but some data is stored in

disparate locations Process steps can be time consuming which often results in missed cost savings

opportunities Data accuracy can be compromised due to manual data entry

4.3.2 Impact of Managed Care on Care ManagementThe switch to a dual-model with the bulk of the members enrolled in a MCO will have the following impacts on the Care Management business area.



This process is essentially contracted out to the MCOs for members enrolled in the MCO.

The focus shifts from managing care to monitoring the care delivered by the MCOs.

There would be less reliance on a care management system and more need for a reporting and analytics system.

Kentucky will still need to address outreach efforts required by federal legislation (e.g. ACA)

4.3.3 Business Capabilities MatrixThis section articulates the maturity level of the individual business processes within the Care Management business area for the Medicaid Enterprise. While all MITA Framework 2.01 capabilities will be addressed for each target maturity level, the table below focuses on the key rationale to support the maturity level determinations.

Table 5: Care Management Process Summaries


AS IS MATURITY

LEVELAS IS PROCESS DESCRIPTION – CARE MANAGEMENT

CM01 Establish Case

1 1. Process consists of a mix of manual and automated functions.

2. Internal and HIPAA data standards have been implemented.

3. The process of establishing new case types is not timely.

4. Stakeholder satisfaction is low.

CM02 Manage Case

1 1. Process is primarily manual steps.

2. Information is manually compiled or ad hoc reports may be used to gather information.

3. Compliance is monitored manually.

4. Lack of automation negatively impact timeliness.

5. The accuracy of the information is sometimes suspect or incomplete.

6. The information is not very accessible.




AS IS MATURITY

LEVELAS IS PROCESS DESCRIPTION – CARE MANAGEMENT

CM03 Manage Medicaid Population

1 1. Focused on cost avoidance as first priority.

2. The process is largely manual and relies on ad-hoc reporting.

3. Process uses state-based standards and not HIPAA or MITA standards.

4. Very few state resources dedicated to the process.

5. Stakeholder satisfaction is low.

CM04 Manage Registry

1 1. Process is a mix of automated and manual processes

2. Data accuracy has potential to be lacking.

3. Data is stored in disparate locations.

4.4 Contractor Management

4.4.1 OverviewThe Contractor Management (CO) business area accommodates states that have managed care contracts or a variety of outsourced contracts. Some states may, for example, group Provider and Contractor in one business area. The Contractor Management business area has a common focus (i.e., manage outsourced contracts), owns and uses a specific set of data (i.e., information about the contractor or the contract), and uses business processes that have a common purpose (i.e., solicitation, procurement, award, monitoring, management, and closeout of a variety of contract types).

Creating a separate business area for Contractor Management allows the MITA BPM to highlight this part of the Medicaid Enterprise, which is becoming increasingly important to state Medicaid agencies. Indeed, it is the primary focus in some states that have comprehensive managed care or multiple-contractor operations. In the Contractor Management business area, the many types of healthcare service delivery contracts (i.e., managed care, at-risk mental health or dental care, primary care physician) and the many types of administrative services (i.e., fiscal agent, enrollment broker, Surveillance and Utilization Review (SUR) staff, and third-party recovery) are treated as single business processes because the business process activities are the same, even though the input and output data and the business rules may differ.



CO01 - Produce Administrative or Health Services RFP

CO02 - Award Administrative or Health Services Contract

CO03 - Manage Administrative or Health Services Contract

CO04 - Close-Out Administrative or Health Services Contract

CO05 - Manage Contractor Information

CO06 - Manage Contractor Communication

CO07 - Perform Contractor Outreach

CO08 - Support Contractor Grievance and Appeal

CO09 - Inquire Contractor Information

0 1 2 3 4 5

Contractor Management Business Area

MITA Maturity Level

Figure 4: Contractor Management Summary

The primary factors affecting maturity ratings across the Contractor Management business area include the following:

Process has some automation and electronic storage of documents There is limited use of electronic communication with contractors The process is not very consistent or accurate due to the manual steps The entire business area is labor intensive with several processes still predominately

manual Stakeholder satisfaction varies from acceptable to low

4.4.2 Impact of Managed Care on Contractor ManagementThe switch to a dual-model with the bulk of the members enrolled in a MCO will have the following impacts on the Contractor Management business area.

The MCOs will be contracted with Health Services contracts.

Service Level Agreements (SLA) and Key Performance Indicators (KPI) are now required in the Business Results Condition of the CMS Seven Conditions and Standards.



The MCOs need to be required to report the data necessary to meet the Reporting Condition of the CMS Seven Conditions and Standards

4.4.3 Business Capabilities MatrixThis section articulates the maturity level of the individual business processes within the Contractor Management business area for the Medicaid Enterprise. While all MITA Framework 2.01 capabilities will be addressed for each target maturity level, the table below focuses on the key rationale to support the maturity level determinations.

Table 6: Contractor Management Process Summaries


AS IS MATURITY

LEVELAS IS PROCESS DESCRIPTION – CONTRACTOR MANAGEMENT

CO01 Produce Administrative or Health Services RFP

2 1. Contract data is centralized and stored in electronic format

2. There is coordination between agencies.

3. Communication with the potential respondents is automated.

4. State uses web portal and email for respondent communication.

5. The average RFP takes less than 3 months to produce.

CO02 AwardAdministrative or Health Services Contract

1 1. Process has some automation.

2. Most of the communication with respondents is done through electronic means.

3. The business process makes use of non-standard data and formats but conform to state requirements.

4. Proposal data is verified via phone, fax and mail.

5. Respondents and staff are dissatisfied with burdens of the process.




AS IS MATURITY


CO03 ManageAdministrative or Health Services Contract

1 1. There is centralized tracking of contracts.

2. Coordination exists among agencies and programs for procurement.

3. Contract information is stored electronically.

4. State contracts and content confirms with state standards and improves the accuracy of the process.

5. End to end processing takes less time than a level 1 process.

6. There are problems with lack of consistency in the data and late receipt of updates to information.

7. Accessing information may take several days.

CO04 Close-Out Administrative or Health Services Contract

1 1. Process uses centralized tracking.

2. This process is coordinated with DMS and other agencies’ programs.

3. Communication concerning contracts utilizes some electronic medium but phone and face to face still remain a significant part of the process.

4. The process does utilize non-standard data and formats from multiple sources.

5. The accuracy and data access of this business process has improved over a level 1 assessment.

6. Staff is satisfied with the process.

CO05 Manage Contractor Information

1 1. Process updates the contractor master file from many different fax and paper sources.

2. Staff members rely upon manual and subjective validation methods.

3. Contracts, amendments and related documentation are in electronic format or are scanned and stored electronically.

4. Electronic data sources have increased the ability to access data for all staff.

5. Electronic sources have improved the accuracy of the information.

6. Data is stored electronically in the system but updates are required to be keyed into the system.




AS IS MATURITY


CO06 Manage Contractor Communication

1 1. Communication with contractors occurs via email and telephone.

2. Correspondence to/from contractors is copied and stored in the contract file.

3. Stakeholders rely on a manual communication process. Satisfaction is generally low.

CO07 Perform Contractor Outreach

1 1. Outreach for existing contractors is performed via the Kentucky Portal

2. Outreach is better coordinated because programs are able to share data and performance measures.

3. There is a formal policy for Contractor Outreach.

4. Staff manually verifies the accuracy of information used in the business process.

5. Costs decrease since there is automation and standardization of data.

CO08 Support Contractor Grievance and Appeal

1 1. The current process is entirely paper based.

2. State agencies are standardizing and centralizing some of the administration of this process resulting in greater consistency.

3. Contractors are aware of the Grievance and Appeal process.

4. The current process may require months for resolution.

5. Local standards are used for storing case data resulting in better accuracy in the overall process.

6. Determining the status of appeal or grievance is manual process.

7. There is a formal review process in place.




AS IS MATURITY


CO09 Inquire Contractor Information

1 1. The Inquire Contractor Information is a manual process.

2. Inquiries come into the agency and responses are returned either by phone, fax or mail.

3. DMS has standards for the response.

4. This business process is consistently delivered across Kentucky agencies.

5. Inquires are answered within several days.

6. Most of the data used in responding to queries comes from an electronic source such as the data warehouse.

7. Since this process is so manually intense, there is greater opportunity for errors.

8. Stakeholder satisfaction with this process is low.

4.5 Member Management

4.5.1 OverviewThe Member Management (ME) business area is a collection of business processes involved in communications between the Medicaid agency and the prospective or enrolled members and actions that the agency takes on behalf of the member. These processes share a common set of member-related data. The goal for this business area is to improve healthcare outcomes and raise the level of consumer satisfaction.

This business area is transformed in the future from agency staff performing eligibility and enrollment functions to more patient self-directed decision making. Member Management business processes consolidate many eligibility and enrollment functions into a single, generic business process.

Medicaid eligibility in Kentucky is determined by the Department of Community Based Services (DCBS) using the Kentucky Automated Management & Eligibility System (KAMES). Case workers at local offices in each of Kentucky’s 120 counties use a computer-based interactive interview using the KAMES system. KAMES is used to capture data and process eligibility determinations for various programs, including the Supplemental Nutrition Assistance Program (SNAP, formerly referred to as the Food Stamp Program), Temporary Assistance to Needy Families (TANF), Breast and Cervical Cancer Treatment Program (BCCTP), Presumptive Eligibility (PE), as well as Medicaid.



ME01 - Determine Eligibility

ME02 - Enroll Member

ME03 - Disenroll Member

ME04 - Inquire Member Eligibility

ME05 - Manage Applicant and Member Communication

ME06 - Manage Member Grievance and Appeal

ME07 - Manage Member Information

ME08 - Perform Population and Member Outreach

0 1 2 3 4 5

Member Management Business Area

MITA Maturity Level

Figure 5: Member Management Summary

The primary factors affecting maturity ratings across the Member Management business area include the following:

The management of Member information is automated with some manual processes.

All eligibility determinations and member information management are done by case workers at the county offices using a computer-based interactive interview.

Newest record from KAMES overrides member information in the MMIS making managing member information in the MMIS very difficult

Outreach process is not centralized; outreach efforts are siloed by program or benefit plan

4.5.2 Impact of Managed Care on Member ManagementThe switch to a dual-model with the bulk of the members enrolled in a MCO will have the following impacts on the Member Management business area.

The eligibility determination process remains unchanged.

The management of the enrollment process becomes more important.

Member Communication and Outreach processes become shared responsibilities.



4.5.3 Business Capabilities MatrixThis section articulates the maturity level of the individual business processes within the Member Management business area for the Medicaid Enterprise. While all MITA Framework 2.01 capabilities will be addressed for each target maturity level, the table below focuses on the key rationale to support the maturity level determinations.

Table 7: Member Management Process Summaries


AS IS MATURITY

LEVELAS IS PROCESS DESCRIPTION – MEMBER MANAGEMENT

ME01 Determine Eligibility

2 1. Case Workers use a computer-based, interactive interview using KAMES

2. There are provisions for acceptance of paper applications.

3. System makes rules-based decisions to determine the appropriate program.

4. Data edits and rules are applied which serve to make application of policy more consistent throughout the State.

5. There are many types of data which must be obtained manually via paper forms.

6. Stakeholder satisfaction does not appear to be measured

ME02 Enroll Member

1 1. Eligibility files are received from DCBS, SSA, BCCTP and PE.

2. Enrollment data from KAMES systematically overrides member eligibility in the MMIS.

3. The process is a mix of automated and manual processes.

ME03 Disenroll Member

1 1. KAMES submits eligibility file nightly to MMIS.

2. The process is a mix of automated and manual processes

3. A member may request to be disenrolled.

4. Some termination actions are system initiated.




AS IS MATURITY


ME04 Inquire Member Eligibility

2 1. Eligibility file data is updated nightly.

2. HIPAA 270/271 transactions are supported

3. Provider may call the AVRS system or they may verify eligibility via Web portal.

4. Newly eligible members must wait to receive mailed ID cards or the provider must verify eligibility by telephone.

5. Efficiency rating is improving with increased use to electronic means.

6. Access and accuracy is adequate to support the business process.

7. Stakeholders are somewhat satisfied with results of inquiry.

ME05 Manage Applicant and Member Communication

1 1. Member communications are primarily conducted via paper, phone, and mail service.

2. Member and applicant communication is likely uncoordinated among multiple, “siloed” programs

3. Research is performed manually and responses are often inconsistent; delays are common.

4. Manual and semi-automated steps may require some days to complete response.

5. Responses are made manually and there may be inconsistency and inaccuracy (within agency tolerance level).

6. Stakeholders receive information but there may be delays and inconsistent results.




AS IS MATURITY


ME06 Manage Member Grievance and Appeal

1 1. Member grievance and appeals are filed manually via fax and/or mail service.

2. Verification of member/case information is primarily a manual process.

3. The process is prone to inconsistencies and is labor intensive.

4. The grievance and appeals process is a mix of manual and automated processes.

5. Requests for documents are managed manually.

6. The current business process complies with agency and state requirements for a fair hearing and disposition.

7. Stakeholders are not satisfied with the timeliness, consistency of decisions and delays.

ME07 Manage Member Information

1 1. MMIS is updated based on information that is add/updated/deleted from KAMES, SDX, BCCTP and PE.

2. Data updates are received from disparate sources in indeterminate formats.

3. Manual updates result in inconsistency and mistakes.

4. Numerous staff required to support mostly manual processes.

ME08 Perform Population and Member Outreach

1 1. Outreach programs are “siloed” and not systematically triggered by agency-wide processes.

2. Some educational materials exist in electronic format.

3. Materials are developed and maintained manually in a labor intensive manner.

4. Other than the SCHIP (State Children’s Health Insurance Program) population, no specific targeting is done.

5. Pertinent member materials are posted on websites.

6. Delivery failures due to erroneous contact information or lack of contact information for mobile communities such as migrant workers or the homeless population.

4.6 Operations Management

4.6.1 Overview



The Operations Management (OM) business area is the focal point of most State Medicaid Enterprises today. It includes operations that support the payment of providers, managed care organizations, other agencies, insurers, and Medicare premiums and support the receipt of payments from other insurers, providers, and member premiums.

This business area focuses on payments and receivables and “owns” all information associated with service payment and receivables. Most states have automated operations that support these payments and this area is probably the part of Medicaid that is most representatively aligned for all state Medicaid programs.

Common business processes include validating requests for payment and determining payable amount; responding to premium payment schedules and determining payable amount; and identifying and pursuing recoveries.

Outside the Medicaid Enterprise, numerous other programs within CHFS have a role in a number of processes associated with this business area. This is especially true for any program that covers targeted services for eligible members, receives requests for payment for services rendered, processes payment requests, and makes payments. Fifteen of the Operations Management business processes are at MITA Maturity Level 1, 10 of the business processes are at a MITA Maturity Level of 2, and one process is not currently performed (OM01 – Authorize Referral).



OM01 - Authorize Referral

OM02 - Authorize Service

OM03 - Authorize Treatment Plan

OM04 - Apply Attachment

OM05 - Apply Mass Adjustment

OM06 - Edit Claims-Encounter

OM07 - Audit Claim-Encounter

OM08 - Price Claim-Value Encounter

OM09 - Prepare Remittance Advice-Encounter Report

OM10 - Prepare Provider EFT-check

OM11 - Prepare COB

OM12 - Prepare EOB

OM13 - Prepare Home and Comm. Based Services Payment

OM14 - Prepare Premium EFT

OM15 - Prepare Capitation Premium Payment

OM16 - Prepare Health Insurance Premium Payment

OM17 - Prepare Medicare Premium Payment

OM18 - Inquire Payment Status

OM19 - Manage Payment Information

OM20 - Calculate Spend-Down Amount

OM21 - Prepare Member Premium Invoice

OM22 - Manage Drug Rebate

OM23 - Manage Estate Recovery

OM24 - Manage Recoupment

OM25 - Manage Cost Settlement

OM26 - Manage TPL Recovery

0 1 2 3 4 5

Operations Management Business Area

MITA Maturity Level



Figure 6: Operations Management Summary

The primary factors affecting maturity ratings across the Operations Management business area include the following:

Many processes are a mix of manual and automated tasks There is an increased use of automated tools and standard transactions A number of processes continue to be heavily dependent on paper documentation While the use of non-standardized data is limited, it still resides in a few processes Operations Management processes are not fully centralized within the Medicaid

Enterprise Some processes continue to be accomplished primarily through manual steps and

interventions Stakeholder satisfaction is low or unknown for several processes The lack of workflow and rules engine tools makes the processes more labor intensive

and produces inconsistent results

4.6.2 Impact of Managed Care on Operations ManagementThe switch to a dual-model with the bulk of the members enrolled in a MCO will have the following impacts on the Operations Management business area.

MCOs take on responsibility for authorizing services to members.

Claims processing functions like claim edit and audit are performed by the MCOs for the majority of claims but the process still remains for the FFS claims.

While the MCOs price and pay claims, the Medicaid system does not attempt to price the encounter claims with the Medicaid rate.

Claims will be paid by the MCOs so the payment and remittance processes are significantly reduced.

The Prepare Capitation Premium Payment process (OM15) becomes very important.

4.6.3 Business Capabilities MatrixThis section articulates the maturity level of the individual business processes within the Operations Management business area for the Medicaid Enterprise. While all MITA Framework 2.01 capabilities will be addressed for each target maturity level, the table below focuses on the key rationale to support the maturity level determinations.

Table 8: Operations Management Process Summaries




AS IS MATURITY

LEVELAS IS PROCESS DESCRIPTION – OPERATIONS MANAGEMENT

OM01 Authorize Referral

N/A This process is no longer performed. The KenPAC program members have been transitioned into Managed Care. The referrals are now handled internally by each MCO.

OM02 Authorize Service

1 1. The process is a mix of electronic transactions and manual processes.

2. The Authorize Service request may take many days.

3. The accuracy of results is improving with the increased use of electronic transactions.

4. The satisfaction of stakeholders is improving.

OM03 Authorize Treatment Plan

1 1. The Authorize Treatment Plan is used in the home health and waiver settings.

2. This process is a very manual process.

3. A Treatment Plan prior-authorizes the named providers and services.

4. Stakeholder satisfaction appears not to be measured.

OM04 Apply Attachment

1 1. Attachments must be submitted with a paper claim.

2. The attachment and the claim are imaged and stored in electronic format.

3. There is no way currently to receive an electronic attachment at the present time.

4. Validation of the attachment is a manual process.

5. The satisfaction of the stakeholder is fairly high but it still rated at a level 1.

OM05 Apply Mass Adjustment

1 1. The paper form or list of transactions is entered for adjustment processing which can take several working days to complete.

2. This process is inaccurate and inefficient.

3. Stakeholders’ satisfaction is low due to delays and inconsistencies that are produced in the Mass Adjustment process.




AS IS MATURITY


OM06 Edit Claim/ Encounter

1 1. No sister agency uses the MMIS edit claim process.

2. There is some integration of Claims editing process across the whole Medicaid Enterprise.

3. There are some instances where suspended claims may take days to resolve.

4. The cost effectiveness of the process is low due to high effort needed to change some business rules.

5. Many changes to the edit program may be made via table configuration but some may require coding changes.

6. Stakeholder satisfaction is still at a level 1 but continued effort toward improvement should move this to the next level.

OM07 Audit Claim/Encounter

1 1. Some validations are automated while others require manual review.

2. Any change in business rule requires maintenance that is time consuming and costly.

3. Suspended transactions require many days to resolve.

4. Stakeholder satisfaction appears not to be measured and therefore is considered low.

OM08 Price Claim/Value Encounter

2 1. The majority of Medicaid services are priced automatically.

2. DMS and its vendors use reference data or commercial sources to assign a price to a claim or value an encounter.

3. Pricing changes are made easily to the systems.

4. MMIS is able to support multiple waiver and a-typical programs.

5. The satisfaction of stakeholders and agency staff is greater than a level 1.

OM09 Prepare Remittance Advice

2 1. Currently provide electronic RA to most providers and paper RAs to some providers.

2. RA and encounter report are replaced by HIPAA compliant transactions which use standard codes.




AS IS MATURITY


OM10 Prepare Provider EFT/Check

2 1. Medicaid Enterprise complies with state and industry standards for electronic funds transfer (EFT) and conforms to HIPAA requirements.

2. Paper checks are sent to some submitters. Medicaid Enterprise encourages electronic billers to adopt EFT payment.

3. Calculation of payment and application of payment adjustments may lack accurate information or be performed inaccurately.

4. Medicaid Enterprise manages its own process for Medicaid billers.

5. Stakeholders are satisfied with the process.

OM11 Prepare COB

1 1. COB process is manual.

2. Cost Avoidance is described as Payer to Provider.

3. Payer uses proprietary standard remittance, not HIPAA standard transaction.

4. Manual processes result in relatively low efficiency.

OM12 Prepare EOMB

1 1. Process uses random sampling and is not targeted selected populations.

2. Electronic images of the letters are available to authorized staff.

3. Generation of EOB is automated; distribution is via USPS.

4. Data are selected via table-driven parameters.

OM13 Prepare Home and Community Based Services Payment

2 1. Home and Community Based Services (HCBS) waiver payments are made using the MMIS adjudication and payment cycle.

2. Manual pricing may still occur.

3. The use of automation has improved the quality and accuracy of the data.

4. The efficiency and accuracy of this process has brought the customer satisfaction to a level 2.




AS IS MATURITY


OM14 Prepare Premium EFT

2 1. Process is in compliance with industry standards and conforms to HIPAA standards.

2. Medicaid uses Automated Clearing House (ACH) transactions for the movement of funds.

3. The process may take two days to complete.

4. Increased automation has enabled a cost effective and efficient process.

5. Stakeholders’ satisfaction is fairly high and payees are getting their money faster and more accurately.

OM15 Prepare Capitation Premium Payment

1 1. The process is automated but there is manual intervention in places.

2. State specific business rules have been automated for most situations.

3. Payment calculations are performed nightly during batch processing.

4. Accuracy and consistency is performed at a fairly high level due to the level of automation.

5. Stakeholders’ satisfaction is fairly high.

OM16 Prepare Health Insurance Premium Payment

1 1. The Prepare Health Insurance Premium Payment process is a manual process.

2. The process requires at least 30 days to complete.

3. Access to the data is very limited.

4. The cost effectiveness of the process is low due to the lack of automation.

5. Stakeholders’ satisfaction is very low and there are many issues associated with the process.

OM17 Prepare Medicare Premium Payment

2 1. There is a mix of both automated and manual processes.

2. DMS exchanges information with SSA via electronic interfaces based on HIPAA standards.

3. The process requires fewer than 10 days to complete.

4. Stakeholders’ satisfaction is fairly high.




AS IS MATURITY


OM18 Inquire Payment Status

2 1. Requests are received by the Fiscal Agent (FA) through paper, phone, fax, email, AVRS, and web portal.

2. Current process is a mix of automated and manual steps.

3. Support X12 276/277 transactions

4. Stakeholder satisfaction is good.

OM19 Manage Payment Information

2 1. The Manage Payment Information business process is meeting the needs of managed care and waiver programs.

2. Payment history updates continues to be scheduled around MMIS production cycles

3. Data sources are primarily electronic.

4. Stakeholder satisfaction is good.

OM20 Calculate Spend Down Amount

2 1. The Calculate Spend-Down Amount process operates with a high degree of functionality.

2. Members are made eligible for Medicaid coverage with a deductible amount equal to their spend-down amount for a specified period.

3. The deductible is tracked until the threshold is met.

4. Claims submitted by the members are tested against MMIS payment rules.

5. Stakeholders are extremely pleased with this business process.

OM21 Prepare Member Premium Invoice

1 1. The information is stored in the KAMES system and the vendor’s premium payment system.

2. The process is mostly manual.

3. The data standards being used are state specific.

4. The manual process used generates monthly invoices.

5. The process is not very efficient.

6. Stakeholder satisfaction with the process is very low.

OM22 Manage Drug Rebate

2 1. The Manage Drug Rebate business process uses electronic interchange and automated processes.

2. Centralization and increased automation improves access and accuracy.

3. Continued efforts to centralize this information have brought about improved results.




AS IS MATURITY


OM23 Manage Estate Recovery

1 1. The Estate Recovery Process is a manual paper based process.

2. Non-standardized data and formats require manual compilation.

3. The time taken from start to finish is a minimum of 6 months and usually much longer.

4. The process has a high level of effort and cost due to the lack of streamlining in the process.

OM24 Manage Recoupment

1 1. Paper correspondence is used to communicate overpayments to provider; providers notify DMS by either doing a void or sending a check.

2. Communications are manual and processing is not timely.

3. Non-standardized data and manual processing contribute to inaccuracies that hinder the recoupment process.

4. Stakeholder satisfaction is low due to manual processes.

OM25 Manage Cost Settlement

1 1. The process is a mix of manual and automated steps.

2. An Excel® spreadsheet is used to calculate the cost settlement. Information is then entered into the MMIS (interChange).

3. A letter is generated to the provider notifying them of the results.

4. The process requires more than 4 weeks to be completed.

5. Data consistency is fairly good and HIPAA exchange standards are used.

6. Stakeholder satisfaction is higher than level 1.




AS IS MATURITY


OM26 Manage TPL Recovery

1 1. Current process is a mix of automated and manual steps.

2. The use of electronic interchange has increased.

3. Electronic data from other payers are used for data matches and validation of member TPL data.

4. There are some issues with programs having data silos and non-standard data formats.

5. All data exchanges are HIPAA compliant.

6. The timeliness of the TPL process from end to end is measured in weeks not months.

7. Satisfaction with this process is improved for all stakeholders.

Note: DMS utilizes a TPL contractor Health Management System (HMS) that performs cost avoidance and pay-and-chase activities.

4.7 Program Integrity Management

4.7.1 OverviewThe Program Integrity (PI) business area incorporates those business activities that focus on program compliance (i.e., auditing and tracking medical necessity and appropriateness of care and quality of care, fraud, waste, and abuse, erroneous payments, and administrative abuses).

Program Integrity collects information about an individual provider or member (i.e., demographics; information about the case itself such as case manager ID, dates, actions, and status; and information about parties associated with the case). The business processes in this business area have a common purpose (i.e., to identify case, gather information, verify information, develop case, report on findings, make referrals, and resolve case). As with the previous business areas, a single business process may cover several types of cases. The input, output, shared data, and the business rules may differ by type of case, but the business process activities remain the same.

The two Program Integrity business processes have been determined to be at MITA Maturity Level 1.



PI01 - Identify Candidate Case

PI02 - Manage Case

0 1 2 3 4 5

Program Integrity Management Business Area

MITA Maturity Level

Figure 7: Program Integrity Management Summary

The primary factors affecting maturity ratings across the Program Integrity Management business area include the following:

Data retrieval is automated; data analysis is a mix of manual and automated steps Case identification is not standardized and comes from multiple sources Internal referrals are paper based and communicated manually

4.7.2 Impact of Managed Care on Program Integrity ManagementThe switch to a dual-model with the bulk of the members enrolled in a MCO will have the following impacts on the Program Integrity Management business area.

Fraud prevention becomes a shared responsibility with the MCOs

Case identification and case management activities reduce due to the drop in FFS claims.

4.7.3 Business Capabilities MatrixThis section articulates the maturity level of the individual business processes within the Program Integrity Management business area for the Medicaid Enterprise. While all MITA Framework 2.01 capabilities will be addressed for each target maturity level, the table below focuses on the key rationale to support the maturity level determinations.



Table 9: Program Integrity Process Summaries


AS ISMATURITY

LEVEL

AS IS PROCESS DESCRIPTION – PROGRAM INTEGRITY MANAGEMENT

PI01 Identify Candidate

1 1. Data and policy analysis is a mix of manual and automated steps.

2. The process is duplicated in multiple parts of the organization

3. Case tracking is manual.

4. Case identification is not standardized.

5. Internal referrals are paper based.

PI02 Manage Case

1 1. Process is a mix of manual and automated steps.

2. The process is duplicated in multiple parts of the organization

3. Data is evaluated manually.

4. Case tracking is manual.

5. Internal referrals are communicated manually.

4.8 Program Management

4.8.1 OverviewThe Program Management (PG) business area houses the strategic planning, policy making, monitoring, and oversight activities of the agency. These activities depend heavily on access to timely and accurate data and the use of analytical tools. This business area uses a specific set of data (i.e., information about the benefit plans covered, services rendered, expenditures, performance outcomes, and goals and objectives) and contains business processes that have a common purpose (i.e., managing the Medicaid program to achieve the agency’s goals and objectives such as by meeting budget objectives, improving customer satisfaction, and improving quality and health outcomes).

This business area includes a wide range of planning, analysis, and decision-making activities, including benefit plan design, rate setting, healthcare outcome targets, and cost-management decisions. It also contains budget analysis, accounting, quality assessment, performance analysis, outcome analysis, continuity of operations plan, and information management.

Within the Medicaid Enterprise, there are a number of opportunities for improvement in Program Management business processes. There are 19 total business processes and 15 have been determined to currently be at MITA Maturity Level 1. Four of the processes are at a MITA Maturity Level of 2.



PG01 - Designate Approved Service/ Drug Formulary

PG02 - Develop and Maintain Benefit Package

PG03 - Manage Rate Setting

PG04 - Develop Agency Goals and Objectives

PG05 - Develop and Maintain Program Policy

PG06 - Maintain State Plan

PG07 - Formulate Budget

PG08 - Manage FFP for MMIS

PG09 - Manage F-Map

PG10 - Manage State Funds

PG11 - Manage 1099s

PG12 - Generate Financial and Program Analysis Report

PG13 - Maintain Benefits-Reference Information

PG14 - Manage Program Information

PG15 - Perform Accounting Functions

PG16 - Develop and Manage Perf. Measures and Reporting

PG17 - Monitor Performance and Business Activity

PG18 - Draw and Report FFP

PG19 - Manage FFP for Services

0 1 2 3 4 5

Program Management Business Area

MITA Maturity Level

Figure 8: Program Management Summary

The primary factors affecting maturity ratings across the Program Management business area include the following:

Multiple sources of data are not integrated Decisions are primarily based on fiscal impact rather than clinical data



Information is siloed within each program Processes are labor intensive relying on manual steps and interventions Limited use of automation to complete tasks and route activities Program Management processes are not fully centralized within the Medicaid Enterprise Accounting is a mix of manual and automated functions which makes meeting deadlines

difficult Several functions use data based on local state data standards

4.8.2 Impact of Managed Care on Program ManagementThe switch to a dual-model with the bulk of the members enrolled in a MCO will have the following impacts on the Program Management business area.

The Kentucky Medicaid Program will need to receive complete encounter data in order to complete program analysis, monitoring, and administrative reporting requirements.

DMS is responsible for determine the proper benefit packages for the MCOs to deliver.

DMS remains responsible for program policy.

The shift to managed care will make budgeting more predictable and accurate.

DMS shifts their focus to monitoring performance and ensuring quality of care.

There is an increased need for financial analysis to analyze MCO cost and rates.

4.8.3 Business Capabilities MatrixThis section articulates the maturity level of the individual business processes within the Program Management business area for the Medicaid Enterprise. While all MITA Framework 2.01 capabilities will be addressed for each target maturity level, the table below focuses on the key rationale to support the maturity level determinations.

Table 10: Program Management Process Summaries


AS IS MATURITY

LEVELAS IS PROCESS DESCRIPTION – PROGRAM MANAGEMENT

PG01 Designate Approved Services and Drug Formulary

1 1. The process is a mix of automated and manual steps.

2. The process may take months to complete

3. The process is formalized and documented.

4. The process is manual so there may be more issues with accuracy as a result.

5. Stakeholder satisfaction is low due to the elapsed time.




AS IS MATURITY


PG02 Develop and Maintain Benefit Package

2 1. The department uses tools to extensively analyze data used to help construct and maintain benefit plans.

2. This process uses collaborations with the waiver programs and other agencies to define shared services.

3. Benefit Packages may be changed to respond to member, market, economic and best practices needs.

4. Benefit packages are limited for traditional Medicaid.

5. Some flexibility is utilized in benefit packages in the waiver programs.

PG03 Manage Rate Setting

1 1. Manage Rate Setting is a mixture of manual and automated steps.

2. Information used in the process comes from multiple sources and does not reside in a single repository.

3. The process uses standardized data and HIPAA standards.

4. Increased automation shortens the time required to complete rate setting.

5. The cost effectiveness of the process is better than a level 1 and so is the efficiency.

PG04 Develop Agency Goals and Objectives

1 1. The process has some automation to enable it to be more efficient.

2. Spreadsheets are used to track the process.

3. Medicaid’s upper management consults with other agency heads to form goals and objectives.

4. The accuracy of this business process is good and up to date.

5. Stakeholder satisfaction with this business process is high and has increased to a level 2.

PG05 Develop and Maintain Program Policy

1 1. Process is duplicated in multiple parts of the organization.

2. Policy development is a manual process which impacts the accuracy of the results.

3. Access to data is limited.




AS IS MATURITY


PG06 Maintain State Plan

1 1. Revisions in the State Plan are transmitted to CMS via email.

2. The State Plan does not reside on the DMS portal

3. An internal tracking sheet is used to make sure the management chain is aware of changes involving the State Plan.

4. DMS does collaborate with other state agencies when modifying the State Plan.

5. The process of maintaining the State Plan meets state objectives. It also meets state and federal guidelines.

6. Stakeholders’ satisfaction with the process is negatively impacted by the manual nature of the current process.

PG07 Formulate Budget

1 1. The process is a mixture of manual and automated processes.

2. The state meets current standards and data comes from multiple sources in standard formats.

3. Data used in the process is verified in both manual and automated ways.

4. The majority of the information comes from the Decision Support System (DSS), MMIS and Electronic Medical Administration Record (eMAR).

5. The stakeholders are pleased with the final outcome.

PG08 Manage FFP for MMIS

1 1. The process that uses inputs from automated systems but the interfaces are manual and time consuming.

2. Information from eMARS and MMIS and other sources must be tied together.

3. The state uses local standards for extracting data and it uses file formats developed by state vendors and/or state staff.

4. Medicaid needs to improve its level of collaboration with other agencies.

5. It takes considerable time to complete the process.

6. The overall stakeholders’ satisfaction is low.




AS IS MATURITY


PG09 Manage FMAP

1 1. Process relies on manual processes to develop, maintain and create rules used to monitor and assign the correct Federal Management Assistance Percentages to services expenditures and recoveries covering Medicaid operations.

2. State and Federal standards are used to govern this business process.

3. Reviews, audits and monitoring of calculations enable an acceptable level of accuracy.

4. Staff uses multiple data sources to govern this process.

5. Stakeholder satisfaction with this process is at a lower level due to the manual nature of this business process.

PG10 Manage State Funds

1 1. Manage State Funds is handled by the Commonwealth staff using information from eMARS and MMIS.

2. The process is primarily manual.

3. Standards are siloed within systems.

4. Collaboration is required between various state agencies in managing these funds.

5. Due to the manual nature of this process, there are errors created as a result.

6. Stakeholder satisfaction with this process is low and there is much room for improvement.

PG11 Manage 1099s

2 1. The process uses a mix of automated and manual steps.

2. The process uses national data standards for the production of 1099s.

3. Automation has improved the timeliness, accuracy and efficiency of this process.

4. Additional improvements in this process have resulted in a solid level 2 rating for this business process.

PG12 Generate Financial and Program Analysis

2 1. Business process is increasing its use of electronic interchange and automated processes

2. Department is centralizing and standardizing data.




AS IS MATURITY


PG13 Maintain Benefits/Reference Information

1 1. The process is primarily paper/phone/fax based processing and some proprietary EDI.

2. Programs create inconsistent rules across the Department and apply their own rules inconsistently

3. Clinical data is not used in the decision process.

PG14 Manage Program Information

1 1. Local data standards are used.

2. Reports used to manage program information are not automatically distributed.

3. The process is subject to long delays depending on the complexity of the request and the availability of technical staff.

4. The process relies primarily on staff to manually perform actions.

PG15 Perform Accounting Function

2 1. The Perform Accounting Function is a mixture of commercial off-the-shelf (COTS) components and manual processes.

2. The Accounting Function is collaborative in terms of working with Finance Cabinet and Cabinet of Health and Family Services.

3. Due to the high degree of automation, the timeliness of this business function is at a level 2.

4. Accuracy and consistency of data used in this business process has improved due to standards and increased automation.

5. There is real time access to data used in this process.

6. This process is highly efficient and the stakeholders involved with this business process are satisfied with the process.

PG16 Develop and Manage Performance Measures and Reporting

1 1. The process is a mix of manual and automated processes to gather data.

2. All calculations are automatically performed to produce needed measures.

3. Data and measure verification is a manual step.

4. Satisfaction with this business process is relatively high due to the degree of automation.




AS IS MATURITY


PG17 Monitor Performance and Business Activity

1 1. The Department evaluates the effectiveness of the MMIS contract based on key operational measures.

2. Other key contracts have report cards or scorecards used to evaluate the effectiveness of the vendor.

3. The process is a blend of manual and automated steps and uses local standards and methodologies.

4. Access to data in the warehouse is widespread and very accessible.

PG18 Draw and Report FFP

1 1. Draw and Report FFP is mostly a manual process.

2. Staff enters information into eMARS based on reports generated from MMIS.

3. The process is time consuming for staff.

4. Manual intervention in this process is costly in terms of staff time.

5. The process is not easily changed.

6. The overall stakeholders’ satisfaction is low with this process.

PG19 Manage FFP for Services

1 1. The state complies with federal rules for calculation of FMAP for each covered service.

2. This process is not easily changed due to how the process was implemented within the system.

3. Manual steps result in less accuracy and less efficiency.

4. Stakeholder satisfaction is low with this process.

4.9 Provider Management

4.9.1 OverviewThe Provider Management (PM) business area is a collection of business processes that focus on recruiting potential providers, supporting the needs of the population, maintaining information on the provider, and communicating with the provider community. The goal of this business area is to maintain a robust provider network that meets the needs of both beneficiaries and provider communities and allows the State Medicaid agency to monitor and reward provider performance and improve healthcare outcomes.



In reviewing the Provider Management business area, all seven business processes are determined to be at a MITA Maturity Level 1, while a number of these processes are approaching MITA Maturity Level 2 capabilities.

PM01 - Enroll Provider

PM02 - Disenroll Provider

PM03 - Inquire Provider Information

PM04 - Manage Provider Communication

PM05 - Manage Provider Grievance and Appeal

PM06 - Manage Provider Information

PM07 - Perform Provider Outreach

0 1 2 3 4 5

Provider Management Business Area

MITA Maturity Level

Figure 9: Provider Management Summary

The primary factors affecting maturity ratings across the Provider Management business area include the following:

Stakeholder satisfaction is unknown Process continues to rely on hardcopy provider agreements and supporting documents

Some forms are available on the Department’s website Grievances and appeals continue to rely on hardcopy documentation Processes are sometimes accomplished manually or require manual intervention to

complete Provider Management processes are not fully centralized within the Medicaid Enterprise There is only limited use of automated validation and data interchange

4.9.2 Impact of Managed Care on Provider ManagementThe switch to a dual-model with the bulk of the members enrolled in a MCO will have the following impacts on the Provider Management business area.

Commonwealth may be required by ACA to enroll all MCO providers in the Medicaid program in order to meet new screening requirements



Maintaining provider network information would be a shared responsibility.

Outreach to providers would be a shared responsibility.

Call volume into the provider call center is reduced

4.9.3 Business Capabilities MatrixThis section articulates the maturity level of the individual business processes within the Provider Management business area for the Medicaid Enterprise. While all MITA Framework 2.01 capabilities will be addressed for each target maturity level, the table below focuses on the key rationale to support the maturity level determinations.

Table 11: Provider Management Process Summaries


AS ISMATURITY

LEVELAS IS PROCESS DESCRIPTION – PROVIDER MANAGEMENT

PM01 Enroll Provider

1 1. Providers currently have the ability to enter application through web entry or submit a hardcopy application.

2. Enrollment verification is primarily manual with some interface support.

3. Verify with external entities by sending inquiry data sets.

4. System receives NPI and cross-references to KY Medicaid identification number.

5. Stakeholder satisfaction is unknown.

PM02 Disenroll Provider

1 1. Disenrolling providers is both a mix of manual and automated steps.

2. Disenrollment is a standalone process within Medicaid Enterprise.

3. Disenrollment data are manually entered and subject to inconsistencies.

4. Lack of automation and data standards negatively impact accuracy.

5. Stakeholder satisfaction is unknown.




AS ISMATURITY


PM03 Inquire Provider Information

1 1. Requests for provider information are received through the web portal and by phone. Phone inquiries must be manually researched by the FA.

2. Staff research and respond to requests manually.

3. Manual responses have a higher probability of being inconsistent.

4. Web responses are performed in real-time.

5. Stakeholders receive the information they need.

PM04 Manage Provider Communication

1 1. Communications from providers are primarily by phone, mail, and email; and must be manually researched.

2. Responses are inconsistent and manual

3. There may be delays in responses

4. Provider communication is not coordinated among multiple, siloed programs and not systematically triggered by State-wide processes

PM05 Manage Provider Grievance and Appeal

1 1. This is an all-manual process. Grievances and appeals are filed via fax and USPS.

2. No standards beyond general requirements for establishing a case.

3. Requests for documents are managed manually.

PM06 Manage Provider Information

1 1. Changes to provider registry are managed manually.

2. Accuracy of data is manually verified.

3. Staff performs file updates manually.

4. Updates are made to data manually. Inconsistencies and inaccuracies can go undetected.




AS ISMATURITY


PM07 Perform Provider Outreach

1 1. Outreach communications, such as mailings, newsletters, web pages, and email are produced and distributed to targeted providers.

2. The Perform Provider Outreach and Education business process is primarily manual. It is labor intensive and time consuming. There is some targeting of providers.

3. Fiscal Agent and Pharmacy Benefit Administrator (HPES and MMA) conduct workshops as a medium for provider outreach and education.

4. Fiscal Agent produces a quarterly newsletter.

5. Materials are available on the web, but hardcopy mailings continue to occur.

6. The efficacy of outreach materials is not tracked or measured.

7. Some inter-agency coordination on provider outreach among siloed programs.



5 CONCLUSIONBased on an updated review of current operations, it was determined that Kentucky’s Medicaid business processes operate at a mix of MITA Maturity Levels 1 and 2. These results primarily stem from the existence of processes that are manual and paper-based, lack of enterprise-wide data standards, limited access to data for reporting and analysis, incomplete or confusing reporting, and the use of multiple sources of data that are not integrated.

Kentucky is focusing on responding to the significant changes in the health care industry and state Medicaid programs that are due in the next several years. The Medicaid programs are addressing the Affordable Care Act, CMS Seven Conditions and Standards, health information exchange, health insurance exchange, changes to data content (ICD-10), as well as other Commonwealth and federal initiatives to improve the quality of care and lower administrative costs. Addressing the significant industry-wide changes is consuming the majority of Kentucky’s resources.

Kentucky will be reviewing its current capabilities and determining it’s To Be goals (Deliverable 1.7 Updated To Be Analysis). Once the To Be goals have been determined, a Gap Analysis (Deliverable 1.8) will be completed and will identify the gaps for moving each capability for each business process to the desired level of MITA maturity. Several of the business process capabilities today that reside at MITA Maturity Level 1 or 2 will likely be improved with the implementation of the existing planned federal legislation and initiatives. The Transition Plan (Deliverable 1.9) will describe the approach to implementing the desired changes. It may be possible to address several of Kentucky’s goals and objectives during the implementation of the required federal legislation and initiatives.


Documents

Document Title - Finance and Administration Cabinet · Web viewDMS exchanges information with SSA via electronic interfaces based on HIPAA standards. The process requires fewer than