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Thursday, February 23, 2012

La Medicaid Reform (CCNs)

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10.6.2011 State Approves CCN Contracts, Provider Handbooks

As published in the Making Medicaid Better enewsletter...

The Department of Health and Hospitals (DHH) has moved one step closer to implementation of Coordinated Care Networks this week with final approval from the state Division of Administration (DOA) to contract with all five entities recommended to administer CCNs.

Contracts for CCNs have now been fully executed with Amerigroup of Louisiana, Amerihealth Mercy of Louisiana and Louisiana Healthcare Connections for CCN-Prepaid plans, and Community Health Solutions of America and UnitedHealthcare of Louisiana for CCN-Shared Savings plans.

With approval of the final contracts by DOA, each CCN has moved into the readiness review phase of the implementation process. During this phase, operations will be reviewed by DHH staff and the DHH External Quality Review Organization, IPRO, and the CCNs will demonstrate network adequacy. A review of systems and financials will also be conducted by Mercer. The contracts will also be reviewed by the Centers for Medicare and Medicaid Services (CMS), the federal agency that monitors the state's Medicaid Program. Once reviews are complete and provider networks are established, CCNs can begin enrolling Medicaid recipients in their networks, with the first group in Geographic Service Area A (the greater New Orleans and Northshore areas) "going live" Feb. 1, 2012.

Also, this week, DHH has approved and posted online　provider handbooks　for each of the CCNs. Handbooks serve as a written resource for health care providers regarding each CCN and their policies, procedures, services and protocols. Details on provider rights and responsibilities, prior authorization and referral processes, medical necessity standards, chronic care management programs, quality performance requirements, grievance and appeals procedures and much more are included. A link to the CCN handbooks can be found on the Making Medicaid Better Web site by clicking

here.

DHH schedules provider Q & A calls

DHH will host a series of conference calls Oct. 11, 12 and 13 to answer provider questions about the implementation of CCNs. Medicaid staff directly involved in CCN development will be on the call to answer questions.

A brief introduction and update of the CCN implementation will be provided by Medicaid staff, but the bulk of the conference call will be devoted to provider questions and answers.

DHH is asking that providers participate in the call for their provider type and Geographic Service Area (GSA), as noted below, to accommodate the limited number of call-in lines and ensure the most efficient use of call time. The conference call schedule is as follows:

Tuesday, October 11	10　 to 11 a.m. - 　Hospitals Only (Statewide) 4 to 5 p.m. - Physicians (GSA "A" - Regions 1 & 9) 5:30 to 6:30 p.m. - Hospitals Only (Statewide)
Wednesday, October 12	2　 to 3 p.m. - All Other Providers ( GSA "A" - Regions 1 & 9) 4 to 5 p.m. - Physicians (GSA "B" - Regions 2, 3 & 4)
Thursday, October 13	Noon to 1 p.m. - Physicians (GSA "C" - Regions 5, 6, 7 & 8) 4 to 5 p.m. - All Other Providers (GSA "B" - Regions 2, 3 & 4) 5:30 p.m. to 6:30 p.m. - All Other Providers (GSA "C" - Regions 5, 6, 7 & 8)

If you are unable to participate on your region's assigned date and call time, you may call in on another date. The call-in information for all calls is:

Call-in line - #1-888-278-0296
Access Code - #7299088

DHH is asking that all participants register here for the conference call of their choice by close of business Oct. 10. Due to limited call in lines, this will help ensure that all interested parties have an opportunity to participate. At the time of registration, providers will have the opportunity to submit questions or issues they would like addressed during the meeting.

DHH to release companion guides for CCN quality, systems

DHH will issue four new guides this week providing written instruction for CCNs on the quality and systems aspects of CCN implementation and ongoing management.

The Quality Companion Guide will provide CCNs with guidance on core quality improvement activities, performance improvement projects, performance measure specifications and validation processes. TheQuality Companion Guide was drafted by DHH's External Quality Review Organization, IPRO.

Earlier this week, DHH issued a revision to the　Shared Savings　and　Prepaid　Systems Companion Guides　(two separate guides), outlining the requirements for data exchanges and file formats. The guides address the roles of all related parties involved in data processing, including the DHH Fiscal Intermediary (Molina), the Enrollment Broker (Maximus), CCNs and DHH. The guides also include details on encounters, claims submissions, payment, reporting, coding (denials, descriptions, edits, corrections, and resubmissions), electronic data interchange testing and systems certification.

Systems issues are also addressed in DHH's recently released 834 Companion Guide, which addresses the file exchange requirements of the Enrollment Broker (Maximus) in conjunction with the CCNs, DHH and the DHH Fiscal Intermediary (Molina).

Announcements

ADVOCATE CONFERENCE REGISTRATION:

Spaces are still available for non-profit and health care advocacy groups wishing to participate in DHH's day-long, CCN Advocates' Conference. The event will take place Friday, Oct. 14 from 9 a.m. to 4 p.m. at the Holiday Inn at 9940 Airline Drive in Baton Rouge. Click here to register.

The conference is specifically designed for community-based organizations and other advocates who work with Medicaid and LaCHIP recipients. Because providers cannot assist recipients in enrolling (as they are contractors of specific plans and this presents a potential conflict of interest), this conference is not for health care providers. There is no cost to attend and lunch will be served. Seating is limited to 300.

Provider Q and A

Q. What is the deadline for providers to sign a contract with a CCN in order to be assured inclusion in the initial printing of the CCN's provider directory?　　　　

A. The CCN implementation schedule has been updated to adjust for the Feb. 1, 2012 go live date. For providers to be included in the initial CCN provider directory, all providers must meet the contacting deadline for their Geographic Service Area as follows: 　

GSA A - Oct. 31, 2011
GSA B - Dec. 30, 2011
GSA C - Feb. 27, 2012

Q. A CCN is urging me to contract with them. They have informed me that, if I do not contract with them, they will make a total of three attempts to contract with me. If I refuse all three times, they can later pay me 90% of the Medicaid fee-for-service (FFS) rate as an out-of-network provider. Is this accurate?　　　　　

A. A CCN must reimburse an out-of-network provider 100% of the Medicaid FFS rate for emergency services. For services that do not meet the definition of emergency services, a CCN is not required to reimburse non-network providers more than 90% of the published Medicaid FFS rate in effect on the date of service. The CCN must first demonstrate it has attempted to contact the provider three times with the intention to contract with the provider before reimbursing at the 90% rate. However, these three documented attempts cannot begin before October 4, 2011, the date all CCNs contracts were executed by the state.

All attempts to contract with a provider must be made in good faith, by the CCN, in writing. 　This can include correspondence that outlines contract negotiations between the parties, including rate and contract term disclosure. The potential network provider has 10 calendar days to accept, reject or fail to respond to the request, verbally or in writing.

If you have questions about Coordinated Care Networks, contact DHH's Coordinated Care Network staff at

This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

9.15.11 A Baton Rouge judge refused Wednesday to block the state from signing contracts with three private insurance companies chosen to take part in Louisiana’s new health-care delivery system for the poor. State District Judge William Morvant rejected arguments from an attorney for Aetna Better Health Inc. — which failed to get some of the business — that Aetna will be irreparably harmed if the state is allowed to move forward with the three winning proposals. Read the entire article at The Advocate.

9.9.2011 MEDICAID UPDATE: CCNs Stalled by Courts
On Tuesday, September 6, 2011, a state judge issued a temporary restraining order blocking the La. Department of Health and Hospitals (DHH) from implementing its Coordinated Care Networks (CCNs) until the court system could review the selection process and criteria used in the selection of the CCN participants. In late August, companies who were not selected as CCNs protested the final selections, first with DHH and then with the Department of Administration. The restraining order was requested by Aetna, one of the entities not a selected as a CCN. Therefore, there are no contracts in effect between the state of Louisiana and the CCN providers at this time.

On July 25, 2011, DHH announced the five entities recommended to administer CCNs in the state. This program will transform the way two-thirds of the state's Medicaid recipients receive health care services. The entities selected are Louisiana Healthcare Connections, Inc. (whose parent company is Centene), Amerihealth Mercy of Louisiana, Inc., AmeriGROUP Louisiana, Inc., UnitedHealthcare of Louisiana, Inc. and Community Health Solutions of America, Inc.　

LSMS believes that it would be premature to enter into a contract until all financial provisions are made known and DHH has completed its negotiations with the selected companies. However, as physicians begin the process of reviewing contracts, there are some basic guidelines that should be used in the evaluation process, including:

The contract should contain all financial data necessary to determine what, when and how you are to be paid for each service rendered under the contract. Be careful to identify the length of the contract, how it can be amended by both parties and any language that calls for automatic renewal or roll over of certain contract provisions.
Review the contract with your accounting firm and/or financial advisers to determine whether or not you can reasonably provide the services at the rates and frequency of payment outlined under the contract.
Carefully review the sections dealing with quality measures and make sure you agree with how the information is gathered, analyzed and reported.
Make sure there are no provisions in the contract that may obligate you to be a part of any other provider or physician network operated by the insurance plan in Louisiana or in any other state.
Make sure you fully understand and or able to comply with any provisions contained in the contract requiring the use of Electronic Health Records and associated technology.
Take precautions when reviewing the contract for any provisions that may provide ownership or access rights to your patient records and/or patient data.

7.29.2011 UPDATE: DHH Responds to LSMS Request
On July 12, 2011, LSMS Executive Vice President Jeff Williams requested clarification from DHH Secretary Bruce Greenstein regarding the new audit process for Medicaid claims and the delaying of provider payments by up to 14 days. DHH Secretary Bruce Greenstein responded to the request and provided a calendar for providers to better understand the new payment system.

7.25.2011 DHH Announces Five Contract Recommendations for Coordinated Care Networks to Improve Health Outcomes for Louisiana Medicaid Recipients

The Louisiana Department of Health and Hospitals today announced the five entities recommended to administer Coordinated Care Networks (CCNs), which will transform the way two-thirds of the State's Medicaid recipients receive health care services. Medicaid will offer two types of CCNs, prepaid and shared savings, and will implement the networks within three Geographic Service Areas (GSA), enrolling recipients in phases. Entities were allowed to propose networks for a specific GSA, or multiple areas. All of the CCNs being recommended by the evaluation teams would serve all GSAs. The recommended CCNs are:

CCN-Prepaid: Louisiana Healthcare Connections, Inc (whose parent company is Centene); Amerihealth Mercy of Louisiana, Inc; andAmeriGROUP Louisiana, Inc.

CCN-Shared Savings: UnitedHealthcare of Louisiana, Inc. and Community Health Solutions of America, Inc.

7.12.2011 LSMS Seeks Clarification on DHH Auditing Process, Delayed Payments

LSMS Executive Vice President Jeff Williams requested clarification from DHH Secretary Bruce Greenstein regarding the new audit process for Medicaid claims and the delaying of provider payments by up to 14 days. Read the letter.

7.5.2011 DHH Announces New Auditing Process, Provider Payments Delayed Up to 14 Days
Beginning this week, the Louisiana Department of Health and Hospitals is phasing in increased time for review of claims for Medicaid services to help root out fraud and abuse in the system. The goal of the program is to step up the Department's efforts to combat waste, fraud and abuse in the Medicaid system. It is estimated that nationally as much as 10 percent of Medicaid and Medicare expenses are diverted by wasteful, fraudulent and abusive activities. Because of the additional review time, health care providers will be paid one day later than usual beginning this week with automated payments hitting bank accounts on Thursday instead of Wednesday. The same schedule will apply throughout the month of July. In subsequent months, the payments will continue to be pushed out further in a similar manner until there is a full additional 14-day window for claims reviews.

4.27.2011 DHH Issues Update to Medicaid Providers on Makena
DHH Secretary Bruce D. Greenstein and Medicaid Medical Director Dr. Rodney Wise issued the following update to Medicaid providers today regarding the hormone progesterone, commonly known as 17P, which, despite its proven effectiveness in dramatically reducing the risk of a repeat premature birth, has recently been priced at a rate that may keep it out of reach for many Louisiana mothers. Read the letter.

4.5.2011 Update on La Medicaid Coordinated Care Networks (CCN)

As the Department of Health and Hospitals (DHH) continues its plan to implement the new Coordinated Care Networks (CCN) program for Medicaid recipients many of our member physicians are receiving “Letters of Intent” from the various insurance companies who are proposing to become one of the CCNs through the request for proposal process. The LSMS urges it members to read these Letters of Intent (LOI) carefully before signing them. DHH has issued very informative contract checklists that physicians can use to make sure the LOI they are given match all of the requirements set forth by DHH. It is vitally important that physicians use these checklists when reviewing any LOI.

DHH has clearly stated that the proposers can not change the LOI form and that the physician by signing a LOI is not contractually obligated to contract with the proposer if they are awarded one of the contracts to become a CCN. These LOI are being used to show DHH that the proposer has meet their obligation to build an adequate network of providers to take care of the patients assigned to their network. DHH will use the information from the LOI’s to evaluate the bids submitted and to award contracts, so physicians need to carefully consider whether they are operationally and logistically able to meet all of the challenges posed by the change to a CCN program before signing any LOI. It is in the best interests of all physician to consult with their accountant and/or business manager to make sure the practice can operate under the new CCN program. Contrary to what some of our members have been told by various providers, not signing a LOI at this point does not prohibit the physician from signing a contract with a CCN later on in the process of conversion. If a proposer tells you that you must sign now or you will be prevented from applying later, you should report that proposer to DHH. The LSMS will continue to monitor the process of CCN implementation and will provide updates as information becomes available.

DHH Documents

It is the opinion of the LSMS that members should not assume that any of the entities who are submitting proposals to DHH will be officially approved as a plan provider (network). Discussions with these entities with the objective of becoming more familiar with their plan provisions and physician participation requirements would be appropriate if you have an interest in joining a CCN network in Phase 1, 2 or 3 of the implementation of the program. However, it would be premature to enter into a contract until all financial provisions are made known and DHH has completed its negotiations with potential network plans. There are critical details remaining to be developed regarding crucial program functions within the regions, important service and delivery obligations as well as program reporting and data requirements for participating medical providers. At the point at which a physician begins the process of reviewing contracts, there are some basic guidelines that should be used in the evaluation process:

The contract should contain all financial data necessary to determine what, when and how you are to be paid for each service rendered under the contract. Be careful to identify the length of the contract, how it can be amended by both parties and any language that calls for automatic renewal or roll over of certain contract provisions.

Review the contract with your accounting firm and/or financial advisers to determine whether or not you can reasonably provide the services at the rates and frequency of payment outlined under the contract.

Carefully review the sections dealing with quality measures and make sure you agree with how the information is gathered, analyzed and reported.

Make sure there are no provisions in the contract that may obligate you to be a part of any other provider or physician network operated by the insurance plan in Louisiana or in any other state.

Make sure you fully understand and or able to comply with any provisions contained in the contract requiring the use of Electronic Health Records and associated technology.

Take precautions when reviewing the contract for any provisions that may provide ownership or access rights to your patient records and/or patient data.

Online Resources

LSMS Resource: Enhanced CCN Program Details
La. Medicaid Reform Updates: www.makingmedicaidbetter.com
La. Medicaid website: www.lamedicaid.com
DHH News: http://new.dhh.louisiana.gov

3.1.2011 LSMS Supports Physician, Patient Choice in Revamp of Louisiana Medicaid Program. Read the press release.
More information: Enhanced CCN Program Details

2.18.2011 DHH Notice of Intent to Medicaid Providers, Anticipates April 2011 Release of Request for Proposals for CCNs. Providers may begin receiving provider participation solicitations from networks. Read the letter.