Professional Development & Training Series: Behavioral Health Quality Assurance (BHQA) Staff Specialty Mental Health Services: CCR Title 9 and Medical Necessity June 2017 Title San Francisco Department of Public Health Behavioral Health Services Quality Management Clinical Documentation Improvement Program (CDIP) Subtitle 1 Staff contact: Joseph A Turner, PhD (joe.turner@sfdph.org) version 1 (6/2/17)
Agenda Problem: People Do Not Understand… Quality assurance … Let’s learn the “theory” behind the practice ( 30mins ) Managed care… Let’s learn about a public model ( 30mins ) Medical necessity … Let’s improve our skills in this area ( 60mins ) Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 6/2/2017 2
Handouts Build a binder for workshop materials: Powerpoint : steal these slides for your training! CDIP CCR Title 9: a must-have reference for a true QA professional CDIP Medical Necessity Tool: let’s standardize this work Bonus Materials : know your history and profession. Read about SF managed care (circa 1995) and conceptual issues in medical necessity Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 6/2/2017 3
“Quality Assurance” in Your Organization Agency-Level Definition of QA: What is your job title ? What are you monitoring/improving ? What is the impact of your work (how does your work make a difference)? What are you major work activities? Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 6/2/2017 4
“Quality Assurance” in Your Organization Tar arget get/F /Focu ocus of of Example Wor Example W ork k Job Title ob Title Impa Impact of ct of W Wor ork Wor ork Act Activi ivities ties Calculate/report Mitigate financial Director of Quality Monitoring contract monthly UoS (for risk + grow Management UoS + PURQC CFO) and PURQC business (for program) example above is from prior job Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 6/2/2017 5
Jargon Check: Quality Assurance …organized system to monitor & improve quality …retrospective …real -time comparison against investigation of a standard processes Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 6/2/2017 6
Switching Gears… Dif Differ erent pe ent people define ople define QA/QI/Q A/QI/QM M differently… …how does your organization see qa/qi/qm? …how do managed care organizations see it? Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 6/2/2017 7
Managed Care INSURANCE COMPANY they sell you the policy Step tep 1 MANAGED CARE ORG. COMPANY they administer the benefits of the policy Step tep 2 Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 6/2/2017 8
Managed Care I have limited money to I can keep the savings if I take care of MANAGE the money EVERYBODY! well! : \ MANAGED CARE ORGANIZATION COMPANY Step tep they hold the risk 3 Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 6/2/2017 9
Managed Care PROVIDER Step tep 4 they deliver the service PIGGY BANK therapist MANAGED CARE ORG. COMPANY clients they pay provider & save (hopefully) Invoice • 100 Units of Therapy • 200 Units of TCM Step tep 5 Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 6/2/2017 10
Managed Care How Do Managed Care Organizations Manage Their Risk ? Gatekeepers! (no accessing specialists without permission) Utilization Management (monitoring for too much/little) 11 Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 6/2/2017
Managed Care Utilization Management (monitoring for too much/little) is the service medically necessary ? Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 6/2/2017 12
Switching Gears… QA A people people ar are fr e frequent equently in y involv olved ed in in “Utilization Management”… …balancing the needs of a population & limited dollars …how does CA do Managed Care for Medicaid? Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 6/2/2017 13
California’s Managed Care Medicaid Program Insurance Company (California State) Managed Care Org (SFDPH-BHS) Provider (you) Customer/Client (our clients) Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 6/2/2017 14
California’s Managed Care Medicaid: Three Benefits “Medi - Cal Insurance” Physical Health Mental Health Drug Medi-Cal Medi-Cal Medi-Cal (ODS) San Blue BHS BHS Francisco Cross (County (County Health Partner. MHP) SUDP) Plan Plan • Specialty • Physical health care • SMHS SUD • Mild/Moderate MH care • Moderate • Moderate to Severe to Severe • Autism Spectrum/BHT MH care SUD care Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 6/2/2017 15
California’s Managed Care Medicaid Program You build a publicly funded managed care Medicaid program by following blueprints & rules! “CCR Title 9” (a regulation) Blueprint (build a County Mental Health Plan) Rules (operate a County Mental Health Plan) 16
California’s Managed Care Medicaid & CCR Title 9 California Law California Regulation CA Governor CA Governor CA Dept of… Transportation, Housing and CA Assembly Senate Community Development, Real Estate, Aging, Social Services, Consumer Affairs, Fish & Game, Health Care Services The 27 Regulatory “Titles” of the California Code of Regulations (CCR) The 29 California Codes (Ca lifornia’s Statutory Law) Title 1: General Provisions Title 15: Crime Prevention & Corrections Business & Professions Code Fish & Game Code Public Contract Code Title 2: Administration Title 16: Professional & Vocational Regulations Civil Code Food & Agricultural Code Public Resources Code Title 3: Food & Agriculture Title 17: Public Health Code of Civil Procedure Government Code Public Utilities Code Title 4: Business Regulations Title 18: Public Revenues Commercial Code Harbors & Navigation Code Revenue & Taxation Code Title 5: Education Title 19: Public Safety Corporations Code Health & Safety Code Streets & Highways Code Title 7: Harbors & Navigation Title 20: Public Utilities & Energy Education Code Insurance Code Unemployment Insurance Code Title 8: Industrial Relations Title 21: Public Works Title 9: Rehabilitative & Developmental Services Elections Code Labor Code Vehicle Code Title 22: Social Security Title 10: Investment Title 23: Waters Evidence Code Military & Veterans Code Water Code Title 11: Law Title 24: Building Standards Code Welfare & Institutions Code Family Code Penal Code Title 12: Military & Veterans Affairs Title 25: Housing & Community Development Financial Code Probate Code Title 13: Motor Vehicles Title 26: Toxics Title 14: Natural Resources Title 27: Environmental Protection Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 6/2/2017 17
California’s Managed Care Medicaid & CCR Title 9 The 27 Regulatory “Titles” of the California Code of Regulations (CCR) Title 1: General Provisions Title 15: Crime Prevention & Corrections Title 2: Administration Title 16: Professional & Vocational Regulations Title 3: Food & Agriculture Title 17: Public Health Regula gulations tions = Title 4: Business Regulations Title 18: Public Revenues BL BLUEP UEPRINTS RINTS & & Title 5: Education Title 19: Public Safety RULE ULES Title 7: Harbors & Navigation Title 20: Public Utilities & Energy Title 8: Industrial Relations Title 21: Public Works Title 9: Rehabilitative & Developmental Services Title 22: Social Security Title 10: Investment Title 23: Waters Title 11: Law Title 24: Building Standards Code Title 12: Military & Veterans Affairs Title 25: Housing & Community Development Title 13: Motor Vehicles Title 26: Toxics Title 14: Natural Resources Title 27: Environmental Protection Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 6/2/2017 18
California’s Managed Care Medicaid & CCR Title 9 California Code of Regulations (blueprints + rules): Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 6/2/2017 19
California’s Managed Care Medicaid & CCR Title 9 CCR Title 9 = Rehabilitative & Developmental Services Division 1 = Department of Mental Health Chapter 11 = Medi-Cal Specialty Mental Health Services Subchapter 3 = Specialty Mental Health Services Other than Psychiatric Inpatient Hospital Services Regula gulations tions = BLUEP BL UEPRINTS RINTS & & RULES ULES Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 6/2/2017 20
California’s Managed Care Medicaid & CCR Title 9 Domain Detail Document Reference • § 1830.205 & Medical Medi-Cal criteria (diagnosis, impairments, interventions) • § 1830.210 Necessity (Non- EPSDT criteria Hospital) (p75) • § 1810.204 Definitions of Definition of assessment, plan development, etc. Services (p4-) • Non- Academic educational services Subchapter 4, • Reimbursable Vocational services with actual work/training as the Article 3 (ps Services purpose 92-93) • Recreation • Socialization without systematic individualized feedback • Board/care costs of Adult Residential, Crisis Residential, etc. • Services provided in an IMD (21yo-64) Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 6/2/2017 21
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