External Protocols for FY12 Post-Payment, Clinical Practice and Guidance (CPG) and Fidelity Reviews (ACT/CST)

All reviews will continue to be announced with the exception being Post-Payment Review (PPR)/certification reviews for out-of-state ICG providers. These PPR's won't be announced as certification reviews are unannounced. PPR's are conducted by a team of at least two Collaborative Regional Liaisons, with the Team Leader being the designated Liaison prior to the review. Clinical Practice and Guidance (CPG) and Assertive Community Treatment (ACT) and Community Support Team (CST) fidelity reviews will be conducted by a team of at least one Collaborative Regional Liaison and at least one DHS/DMH Regional Contract Manager.

Scheduling of Reviews

Each type of review (PPR, CPG, ACT fidelity and CST fidelity) are separate reviews with separate reports and scores. PPR reviews are conducted first, followed by CPG which is then followed by any fidelity reviews scheduled. During FY12, CPG reviews will be conducted for providers who scored a "3" or below during their FY11 CPG review and additional providers will be selected across all regions so that 23 total CPG reviews will occur in FY12. Fidelity reviews will be conducted for all ACT and CST providers. Post payment reviews will not be coordinated with BALC Certification reviews. The Collaborative Clinical Coordinator is responsible for coordinating reviews with DHS/DMH staff, as applicable, and distributing a review schedule. This schedule is a confidential document.

Reviews are being scheduled to occur at least 9-12 months from the date of the last review in order to ensure the largest claim sample possible. The review schedule is very tight and it is not possible to change scheduled review dates, with the exception of an emergency or unusual situation. Providers may contact the Collaborative Clinical Coordinator of Provider Relations to discuss the situation. If something comes up after the review has been scheduled that would affect the ability to conduct the review, the DHS/DMH review lead and the Collaborative Clinical Coordinator needs to be notified. It will be these individuals' responsibility to make the final decision as to whether or not the scheduled review dates will be changed.

Out -of-state ICG Providers also receiving a Certification review

Because these are out-of-state reviews and must be planned well in advance, the Collaborative Training Coordinator will contact providers 2-3 months prior to the review and give them an option of providing up to 3 "blackout" dates that would not be good review dates for the provider. Reviews will not be scheduled on selected blackout dates.

Provider Notification

A claim run will be collected and organized a week prior to the review, for use by the review team. Providers (with exception of out-of-state ICG providers) will be notified one week prior to an impending review by the Collaborative Training Coordinator. Information regarding the date of the review, the names of reviewers and the records being reviewed will be related verbally at this time. The Collaborative Training Coordinator will gather information about the provider for the reviewers and answer provider questions. Following the phone contact, providers will receive a secure email from the Collaborative Training Coordinator containing a list of consumer names and associated RIN's for the records to be reviewed.

Sampling Methodology and Claim Review Period

Post Payment Review

In order to establish a sampling methodology for post-payment review (PPR) for FY12, the Collaborative was given the following guidelines from DHS/DMH:

  • The sampling methodology selected must be reflective of the volume of claims each provider has submitted during the specific identified claim period rather than a flat number of 100 claims per provider.
  • The claim period will vary from provider to provider, but will begin 60 days following the conclusion of the FY11 review and ending up to the date of the FY12 review.
  • The claim run will only include adjudicated claims.
  • The sampling methodology must be statistically sound such that findings can be used for recovery and potential extrapolation.
  • OAS RAT-STATS, 2007, version 2 Software will be the chosen sampling tool.

Based upon this request, the Illinois Mental Health Collaborative for Access and Choice will provide sample size calculations that are statistically valid for the defined confidence level and margin of error. The Collaborative will utilize the following sampling methodology for FY12:

  1. A statistically sound random sample of all adjudicated claims per specified provider will be selected for post-payment review using the specified OAS RAT-STATS, 2007, version 2, Software.
  2. The sample of claims will be determined using the sample calculator within OAS RAT- STATS, 2007, version 2, Software to reach a 90% confidence level with a 16% desired precision range (margin of error +/- 8%).
    1. To guarantee the 16% desired precision range, an anticipated rate of occurrence of 50% will be used when calculating the number of claims to be reviewed per provider.
    2. The number of claims each provider submitted during the provider's identified unique claim period (universe size) will be determined using ValueOptions' IntelligenceConnect reporting system.
    3. Once the sample size has been determined using OAS RAT-STATS, 2007, version 2 Software, a provider specific claim run will be developed using the ValueOptions© IntelligenceConnect reporting application.
    4. Claim runs will be developed for each provider approximately two (2) weeks prior to the scheduled review by the Provider Relations Training Coordinator.

Clinical Practice and Guidance (CPG) Sampling

In determining the providers to receive a CPG review during FY12, the following criteria were used:

  1. Review providers who scored 3 or below during FY11.
  2. A sample of additional providers will be selected across all regions.

Ten Medicaid records and two non-Medicaid records will be randomly selected from the overall PPR claim run for each provider.

ICG PPR in conjunction with a standard PPR for a community provider

A flat number of ten (10) claims will be randomly selected from all claims submitted per provider with a fund source as ICG or ICGC using the ValueOptions© IntelligenceConnect reporting system.

Fidelity Reviews

A flat number of ten (10) records will be randomly selected from all claims submitted per provider.

Out-of-state ICG Providers also receiving a certification review

For PPR: A flat number of ten (10) claims will be pulled from all claims submitted per provider with a fund source as ICG using the ValueOptions© IntelligenceConnect reporting system.

For Certification: Six records, which will be comprised of the same records reviewed for PPR will be reviewed. In the event that the provider serves less than six Illinois consumers, all Illinois consumer records will be reviewed.

Plans of Improvement and Follow Up

Providers should begin making indicated changes to their procedures to become compliant with requirements immediately following the exit conference. A formal PPR plan of improvement is required if the following thresholds are not met for individual items: for items 1, 5 and 6 the threshold is a score of 90%; for all remaining items the threshold is a score of 80%. For CPG, a Plan of Improvement is required for any item scoring below 4.0. For fidelity reviews, a score less than 5 for any item requires a Plan of Improvement. DHS/DMH Regional staff is responsible for approving and monitoring the formal plan of improvements.

Additional follow up including a return review may be enacted if a provider has a significantly low overall score.

Policy Pertaining to Conflict of Interest

The Collaborative has a Conflict of Interest policy in place which prevents Collaborative Regional Liaisons from participating in the monitoring of providers for which the Regional Liaison has other vested interests or potential conflicts with the provider.

The Collaborative Clinical Coordinator maintains an updated list of providers who would pose a conflict of interest situation for specific Regional Liaisons. The Director of Provider Relations for the Collaborative is responsible for ensuring compliance with this policy, and making any adjustments to it. The Director is the final authority in determining whether or not a conflict of interest exists.

Policy Pertaining to Handling Problem Situations While at the Provider Site

In the event that a reviewer encounters a problem situation while at the provider site, reviewers are instructed to contact the Clinical Coordinator for the Collaborative who will also notify DHS/DMH.

In the event that a reviewer encounters a problem situation during Clinical Practice and Guidance Reviews, while DHS/DMH staff is present, the DHS/DMH Contract Manager takes the lead in resolving the issue and notifies the Regional Executive Director.

Reviewers' Guidelines While On-site

Reviewers will:

  1. Arrange (lead will facilitate) a meeting place and time with other team members and enter the provider site together as a group.
  2. Wear identification at all times.
  3. Maintain the confidentiality of all consumer health care information and provider records, including not leaving consumer or provider records unattended.
  4. Document all data on Collaborative forms and/or database.
  5. Ensure that when data documentation is done manually, that handwriting is legible and written in ink.
  6. Be responsible for ongoing quality assurance throughout the review, e.g. ensuring that data is being recorded on the most recent and correct document and that reports contain accurate information.
  7. Report all mandated abuse and/or neglect allegations immediately to appropriate provider staff, which are then required to file a report with Office of Inspector General, the DCFS Hotline or Department of Aging in conjunction with the Regional Liaison. The DHS/DMH Regional Director and Collaborative Director of Provider Relations are also to be notified by the Regional Liaison. If the provider refuses to file a report, the Regional Liaison is required to do so. For out-of state ICG providers follow direction outlined in "Internal Protocols for Out-of-State ICG Reviews".
  8. Immediately consult with the provider Executive Director or designee upon identification of any instance that poses an immediate risk to consumer safety or service delivery, including but not limited to: inadequate staff levels, closure of sites, or uncredentialed staff dispensing medications. Within four hours the Collaborative Director of Provider Relations must be notified by the lead Regional Liaison, who will then contact the DHS/DMH Provider Relations lead and appropriate DHS/DMH regional staff.
  9. Turn cell phones to mute or vibrate throughout the course of the review. All necessary phone calls must be conducted in a private area away from the review area.
  10. Present a professional appearance, attire, and demeanor.
  11. Ensure that the least amount of disruption to the provider and the provider's services occurs throughout the course of the review.

Entrance Conference

Upon arrival at the site:

  1. The Lead Regional Liaison will identify him/herself to the provider receptionist and ask to speak with the provider contact person.
  2. The review team will conduct an entrance conference with the provider contact person, Program or Clinical Director, and other staff the provider deems important. In the event that BALC is also conducting a review at the same time, BALC will initiate the entrance conference.

During this conference the review team will:

  • Introduce themselves to provider staff.
  • Distribute business cards of review team members to provider staff.
  • Ask all meeting attendees to sign an attendance sheet, including name and title.
  • Explain the scope and process of the Post-Payment (and Clinical Practice and Guidance/fidelity Reviews, if applicable). The lead reviewer needs to make the following statement: "This review covers PPR (and CPG/fidelity reviews, if applicable) and is distinct from BALC's certification reviews."
  • Inform providers about the exact records needed for PPR and time span being covered.
  • Secure names and contact information for provider staff members who are responsible for various review subject matter and general questions. If desired, reviewers may request that, when possible, a provider staff person assist with locating and accessing needed information throughout the course of the review.
  • Project an estimated length of time for the review and verify the provider's business hours.
  • Inquire about where staff may conduct the review, e.g. a conference room or other private working area the provider selects. Discuss with the provider the importance of having a quiet, private area in which to conduct the review.
  • Inquire as to how the provider's records are maintained and, if necessary, staff who will be available to assist with any electronic record system.
  • Discuss with staff the importance of only a minimum number of provider staff being present during the actual review and only as necessary to locate documents and/or assist with electronic files. This will allow for an efficient and effective use of time.
  • Share the Provider Database Verification (PDV) with the provider and make arrangements for obtaining it before departure.
  • Answer any provider questions concerning the review process.

Final Day

In the event that a provider is having a CPG review or fidelity reviews, the DHS/DMH Contract Manager will inform the provider contact person of the anticipated time for the exit conference. The provider will be given, at minimum, two hours notice in order to allow the provider time to notify staff and adjust schedules, if necessary.

Review team members, including DHS/DMH Contract Managers, will take time prior to the exit conference to confer about the findings of the reviews. This pre-exit conference should take place even when the Contract Manager is participating in the exit by way of a teleconference and is not present at the provider site. The lead Collaborative Regional Liaison is responsible for entering data regarding the reviews, printing the reports and providing the DHS/DMH Contract Manager with a copy of the reports prior to the exit conference when possible, or upon availability of encrypted e-mail. When completing reports related to CPG and fidelity reviews, Collaborative staff and the DHS/DMH Contract Manager will develop the comments section of the report together.

In the event that there are significant findings, the lead reviewer should brief the designated provider contact in advance of the exit to ensure their understanding.

Exit Conference

At the time designated for the Exit Conference, the lead Regional Liaison (or DHS/DMH Contract Manager if CPG/fidelity reviews have taken place) will:

  1. Re-introduce the team, distribute an attendance sheet to record the names and titles of the conference participants and thank the provider for their time and cooperation.
  2. Clarify how questions will be addressed during the presentation of findings. The presenting reviewer may choose to have all questions held until the end of the specific section, or may choose to take questions as they arise.
  3. Utilize the PPR, CPG, ACT and CST Exit Conference Talking Points.
  4. Recognize positive findings and discuss outcome of all reviews, beginning with PPR and moving into CPG and then fidelity reviews as applicable.
  5. For Certification Reviews (Applies to Out-of-State ICG providers only):
    1. First explain the levels and process for full surveys:
      1. Level 1 - No Plan of Correction (POC) or focus survey. Explain that while no POC is required to be submitted at Level 1, the agency MUST correct any citation made.
      2. Level 2 - POC and focus survey next year.
      3. Level 3 - The Collaborative will return within 90 days of the acceptance of the POC. The agency must be operating at least at a level 2 at that time.
      4. Level 4 - The Collaborative will return within 60 days of the acceptance of the POC. The agency must be operating at least at a level 3 at that time. If the agency is operating at a level 2 or above at that time, no further survey will be done until the next annual. If the agency is operating at a level 3, another survey will be done in 30 days. At that time the agency must be operating at least at a level 2.
    2. Explain to the provider that a failure to make corrections and move to the next required level will result in certification revocation.
    3. Explain the POC process (levels 2-4), give the agency a copy of the POC Submission Criteria and explain those criteria as follows:
      1. Address how each specific citation on the Notice of Violation (NOV) has been or will be corrected;
      2. Address how the agency will correct the overall systemic problem(s) which led to the specific citations, e.g., lack of supervision, lack of training, lack of internal time frame compliance monitoring;
      3. Give the date(s) on which the agency will begin using each component of its POC and the date(s) on which the agency expects to show results;
      4. Identify the specific staff person(s) by name, title or position, who will be responsible for each component of the POC; and
      5. State how the agency will determine if the corrections are successful or need to be modified and the staff person(s) responsible for making the determination.
    4. State each finding clearly and give at least one example of non-compliance. There will be nothing included on the NOV that is not presented at the Exit Conference.
    5. If the agency can promptly demonstrate that it was in compliance with a standard included in the NOV, but the reviewer missed it, an adjustment to the NOV will be made at this time. HOWEVER, if the agency makes a correction that removes the problem that caused the citation, the citation will remain and the agency must address it in the POC, if required.
  6. All review reports must be signed by the entire review team (Collaborative and DHS/DMH staff) and the provider. The original signed reports will be returned to the Springfield Collaborative office by the lead Liaison and placed in the provider file. Leave a copy of the completed Post-Payment Summary and the PPR Billing Issues Summary along with all other applicable review reports with the provider contact person.
  7. Explain to the provider that a copy of the reports will be forwarded to DHS/DMH for review and that the assigned Contract Manager and/or C and A staff will be following up with the provider on any required Plans of Improvement. The Collaborative will maintain the confidentiality of the review contents.
  8. Return all provider materials and have the provider sign off that all provider records were returned to provider at the conclusion of the review.
  9. Distribute the Post-Payment and Clinical Practice and Guidance Review Questionnaire and self-addressed stamped envelope to the provider contact person. This is a survey where providers can give their feedback on the process. Inform the provider that the questionnaire is also available for on-line completion on the Collaborative website.

Transportation of Confidential Records

All reviewers must comply with the ValueOptions© Policy: LC403 - Safeguards for the Secure Transmission and Use of Confidential Information Off-Site, Revised 12/17/09.