Summary of Exploratory Data Analysis

1January 2011

Recovery focus, right services, right amounts, right time

Duty to manage risk as well as scarce resources

With appropriate UM strategies, assure that people move thru the system to lesser levels of care as appropriate, assuring more intensive services are available to those in need

2January 2011

Looked at criteria and models of authorization from other states and jurisdictions

Looked at other options◦ Absolute benefit limits embedded in Medicaid

State Plan which do not allow for any extensions◦ Reduction of Medicaid benefits to more narrow

benefit package◦ Cuts in Medicaid rates◦ 100% (pre)authorization of all services

The threshold model adopted seemed the best option among difficult choices

3January 2011

Utilization Management should focus on outliers◦ Much less administrative cost to the system since

review is only required of individuals with unique use patterns

◦ Review process is used not to limit benefits, but to make sure that those individuals with higher needs are appropriately getting their needs met

◦ Approximately 75% of the individuals served in the mental health system may NEVER require any external authorizations

4January 2011

UM is dynamic and evolutionary.

As additional data, new research, and other new information occurs with experience, the UM Program will evolve and change.

5January 2011

UM must be based on data.

The UM Program must use data to identify patterns of utilization,

work with clinicians to determine if the patterns and variations are desirable or not,

and work with providers to make needed improvements.

6January 2011

Individuals accessing services should have a consistent threshold of medical necessity statewide.

The UM Program must provide clear guidance for medical necessity decisions so that all individuals accessing services have consistent and equitable access to specific services.

7January 2011

Authorization must be clinically focused and conducted by qualified staff.

Where authorization is determined to be necessary, it must be based on clinical information and reviewed by staff at the independent license level (LPHA).

8January 2011

PSR is intended to be an intensive, time-limited, curriculum-based service focused on increasing specific skills to support an individual’s recovery

The expectation is that as the person acquires skills, they will be assisted as needed in practicing those skills in natural settings through community support services

9January 2011

While DMH acknowledges there may be activities that are NOT Medicaid services that are needed by some individuals,

the continued provision of PSR to meet those needs which are outside the intended purpose of the service increases the risk to the mental health system in the event of federal audit for lack of active treatment and evidence of continued rehabilitation.

10January 2011

Spent on PSR FY09: 28 Million Number of consumers: 9329 Average amount per consumer: $3,000 Average units per consumer: 600 Range of units: 1 - 9,000

11January 2011

896 consumers or 10% of the population have usage patterns that are considered statistically “distant” from the normal usage pattern, i.e. are extreme values

Over the course of a year,◦ 10% of PSR consumers received 43% of PSR

dollars in FY09◦ For every 1 dollar spent on the larger group, 7

dollars was spent on the “high utilizer”.

12January 2011

% of Consumers % of Cost

13January 2011

Spent on Therapy/Counseling FY09: ◦ Adults - 29.2 Million◦ Children/Adolescents – 12.9 Million

Number of consumers: ◦ Adults - 51,939◦ Children/Adolescents – 22,865

Average amount per consumer: ◦ Adults - $561◦ Children/Adolescents - $565

14January 2011

% of Consumers % of Cost

Hours of Service

15January 2011

% of Consumers % of Cost

Hours of Service

16January 2011

17January 2011

Individuals enrolled in Medicaid whose services are reimbursed by DMH.

The UM program DOES NOT cover:◦ SASS◦ ICG

The HFS Integrated Care Pilot is also separate from DMH programs.

18January 2011

The Collaborative will continue to provide authorizations for services covered by the UM program after the conversion to HFS for claim submission.

19January 2011

The UM program covers the following DISTINCT Rule 132 services:

Therapy/Counseling PSR

◦ PSR means PSR group and PSR individual CSG

◦ CSG means Community Support Group.◦ CSG does NOT include CSI, CSR individual or CSR

group

ACT and CST authorizations will also continue.

20January 2011

Medical Necessity Criteria were also provided for Community Support Individual, but this service DOES NOT require external authorization for FY11.

21January 2011

The threshold for therapy/counseling is 40 units.

This 40 units includes all three modalities (individual, group, family)

All units of therapy/counseling billed for an individual by a provider will count towards the 40 unit threshold.

PSR and CSG have a threshold of 800 units combined.

Units are in 15 minute increments.

22January 2011

The tracking of thresholds must be done at the provider level.

Because providers have up to one year to submit claims, DMH and the Collaborative cannot produce real-time reports for providers on claims submissions.

23January 2011

Providers should submit requests for authorization in advance of meeting the threshold for individuals, if they believe the individual is going to need continued service beyond the threshold of units

The turn-around time for the initial decision is 7 business days, and this should be included in the timing of submission for authorization decisions

24January 2011

The electronic authorization form contains both REQUIRED fields and OPTIONAL fields

The optional fields are meant to give the Collaborative Clinical Care Manager additional information which is commonly considered helpful in providing a more complete clinical picture.

Medications are an OPTIONAL field

25January 2011

The LPHA is not required to be the person making the authorization request

Providers may request as many user names/passwords as they would like for using the ProviderConnect system.

If a provider wants to limit access for claims submission to only select staff, then they can indicate that on the form when requesting the access for submitting authorizations.

26January 2011

Providers should submit sufficient documentation of:

Medical Necessity for the continued service

Progress in Treatment

27January 2011

Mental Health Assessment and current Treatment Plans MUST be submitted

Additional documents providers MAY submit would include progress notes, treatment summaries or other clinical documentation

Additional documentation may include clinical documents completed by any clinical staff, not just the LPHA

28January 2011

Supporting Documentation may be attached electronically to the request, or may be faxed to the Collaborative at (866-928-7177).

Faxed documents need to be sent under separate cover sheets for each individual, clearly indicating the individual’s name and the service(s) being requested for authorization.

All documents must be sent within 1 business day of completion of the electronic form to be considered as part of the initial determination decision.

29January 2011

Collaborative Clinical Care Managers will ◦ Consider all the clinical evidence submitted in the

documents◦ Use the published Medical Necessity Criteria and

Guidance ◦ Authorize services demonstrated to be medically

necessary◦ In situations where the CCM believes medical

necessity is not indicated, the CCM will then consult with a Collaborative psychiatrist, to determine whether to authorize the request.

◦ A determination to deny authorization can only be made by a psychiatrist.

30January 2011

The guidelines were written with the intention of being broad enough to allow for the exercise of clinical judgment and flexibility as new treatment practices emerge

Nothing within them is meant to preclude the provision of medically necessary services to any particular group of individuals who do have a diagnosis of a mental illness

31January 2011

Collaborative CCMs WILL NOT deny authorization of any specific service based solely on an individual’s diagnosis

32January 2011

Diagnosis of mental illness is and has always been required for reimbursement under Rule 132. ◦ Persons with dual diagnoses will continue to be

eligible for services reimbursed by DMH.◦ Consistent with Federal Medicaid requirements,

services billed to Medicaid must be to address the symptoms related to the diagnosed mental illness.

The list of diagnoses eligible for reimbursement from DMH is extensive and has not been changed.

33January 2011

The Collaborative will make the decision within 7 business days.

Decisions will be posted to ProviderConnect when made

Letters will also be mailed to the provider’s postal address

Notices will not be sent via e-mail

34January 2011

If an initial determination is made to deny authorization, the provider may request a reconsideration

Additional supporting documentation may be sent to be considered by the Collaborative Physician Advisor during this review◦ PA will be Board Certified in Psychiatry and licensed to

practice in IL The turn-around time for this review is 14 days Services provided during this time will be

eligible for reimbursement

35January 2011

If the Collaborative PA upholds the initial denial determination, there is an appeal process through the Director and finally through administrative law through HFS.

36January 2011

37January 2011