OptumHealth NYC BHO Provider Training
Agenda
• Introductions
• Overview of Optum
• Review of Contract between Optum and the Offices
• Provider Tools & Submission Process
• Initial start up experience
• Questions and Answers
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
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Optum New York Staff
• William Fishbein, Executive Director Optum New York City BHO
– Amy Freeman, Behavioral Health Clinical Manager
– Margaret “Peggy” Elmer, Behavioral Health Clinical Manager
– Joni Richter, Behavioral Health Intake Manager
– Erik Geizer, Quality Assurance/Training Manager
– Linda West, Reporting & Technology Manager
– Michael Silver, Psychiatrist
– Marc Minick, Community Liaison
– Mark Simmons, Community Liaison
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
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Optum Overview
Optum Organizational Overview
• Optum is a health services business dedicated to making the health
system work better for everyone
• We are comprised of three market-leading business segments:
– OptumHealth
– OptumInsight
– OptumRx
• Optum serves the entire health ecosystem
– 250,000 health professionals and physician practices
– 6,200 hospitals and facilities
– more than 270 state and federal government agencies
– over 2,000 health plans; two of every five FORTUNE 500 employers;
and one in every five U.S. consumers.
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
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Our Business Context
UNH=Publicly Traded Registrant
(NYSE)
UHG
UnitedHealthcare-Health Benefits
• Health care coverage and benefits
businesses, unified under a master brand
Optum—Health Services
• Information and technology-enabled
health services platform, encompassing:
– Employer and Individual
– Technology solutions
– Community and State
– Intelligence and decision support tools
– Medicare and Retirement
– Health management and interventions
– Administrative and financial services
– Pharmacy solutions
Helping people live healthier lives
Helping to make the health care system work
better for everyone
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Contract Review
NYC BHO – Contracted Region
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
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Populations covered under the program
• All fee-for-service admissions to OMH-licensed psychiatric units (all
ages) in general hospitals (Article 28 hospitals).
• Fee-for-service children and youth admitted to OMH licensed private
psychiatric hospitals (Article 31 hospitals).
• Fee-for-service direct admissions to OMH State-operated children’s
psychiatric centers or children’s units of psychiatric centers.
• Fee-for-service OASAS Certified Part 816 Inpatient Detoxification
Services (Article 28/32).
• Fee-for-service OASAS certified hospital (Art 28/32) or freestanding
(Article 32 only) Part 818 Chemical Dependence Inpatient
Rehabilitation Services.
• Each new episode of care initiated by Article 31 OMH designated
Specialty Clinics for children/youth (up to 19th birthday) diagnosed as
having a Serious Emotional Disturbance (SED) who are covered by
Medicaid Managed Care
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
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Functions of the BHO include:
Concurrent
Review
Discharge
Planning &
Tracking
Tracking of
Children with SED
• Optum will complete initial reviews for applicable services of Fee-For-Service Medicaid
members within 72 hours after admission or by 5pm of the next business day following
notification of the admission by the provider, whichever is later. Follow-up reviews will
be conducted at regular intervals.
• Optum will engage with the inpatient provider with respect to discharge planning for
applicable admissions
• Enhanced efforts will be employed for inpatients identified as “High Need Individuals”
• Each new episode of care initiated for a Medicaid Managed Care SED child will be
tracked for reporting back to the State
Provider Profiling • Historical Clinical data will be provided by the Offices to the BHOs
/Analytics
• Data elements specific to each inpatient admission and provider will be collected by the
BHO and shared with the Provider and the Offices.
Community
• Metric Reporting will be provided back to the Offices
Liaisons
Facilitation of
Cross System
Linkages
Quality Initiative
• Optum will work with the Offices and the Providers to determine cross system linkages
for adults and children with mental health conditions and substance use disorders
• Optum will devise a quality assurance program to monitor the quality of work
performed within the contract
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
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Review of Contract
The Offices
• Supplies Optum
with guidance to
perform tasks
• Supplies
historical clinical
data
• Supports access
to cross systems
Optum
Provider Community
•Notify Optum of
admission
(Portal, Fax or Telephonic)
•Notify Optum regarding
Children with SED
• Performs initial/
concurrent reviews
• Monitoring discharge
planning & postdischarge services
Provider Community
• Follows concurrent
review & discharge
monitoring processes
• Tracking of children
with SED
• Provider profiling
• Facilitation of cross
system linkage
• Quality Initiative
• Treatment History
Form
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
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What we need from you:
Partner with Us
• Submit requested information to be used in initial/concurrent reviews, discharge
planning/tracking, SED tracking, and cross system facilitation
• Use your dedicated Care Advocate and Community Liaison as a part of your team
• Follow the concurrent review & discharge planning/tracking processes
Engage in the
Process
• Identify Cross System Linkages
• Provide data as requested
• Use the tools provided
• Don’t hesitate to ask us questions
• Clinical questions can be directed to the Care Advocate or to:
NYCBHO.Clinical@optum.com
Ask Questions
• General questions can be directed to the Executive Director & Community Liaisons or to
NYCBHO.General@optum.com
• ProviderConnect technical questions/issues can be directed to:
NYCBHO.tech@optum.com.
Other
• Let us help you!
• We want your feedback.
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
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Provider Tools & Submission Processes
Provider Tool Review- Methods for submission
• Individual Information Matrix
Fax
- Within 24 hours of admission
- Concurrent Review at established intervals
- Discharge by the date of discharge but no later than within 24 hours post discharge .
Fax #
Telephonic
Portal
• Clinical Fax: (877) 283-0555
• Toll-free: (866) 505-3398
• Dedicated Care Advocate assigned by Facility
• New provider portal: www.optumhealthnyc.com
• ProviderConnect software
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
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Submission time frames
•
Childen with Serious Emotional Disturbance (SED) Report
– Submitted for each new episode of care for SED children covered by Medicaid managed care
– Providers to complete and submit within 3 business days of initiation of services
– Submit via fax, portal, or telephonic
•
Individual Information Matrix Form (inpatient providers)
•
Admission
– Providers to notify their assigned BHO within 24 hours of admission, except that for
admissions which occur on a weekend or holiday such notification would be required by
5 P.M. of the next business day following such week-end or holiday.
•
Concurrent Review
– Optum will complete initial reviews for applicable services of Fee-For-Service Medicaid
members within 72 hours after admission or by 5pm of the next business day following
notification of the admission by the provider, whichever is later. Follow-up reviews will
be conducted at regular intervals.
•
Discharge Planning
– Provider to complete and submit by the date of discharge but no later than within 24
hours post discharge.
•
Forms located on the Optum NYC BHO Provider Portal : www.optumhealthnyc.com
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
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Experience since start up
• Volume
– 65 admissions per day (average)
– 40% portal, 38% fax, 22% telephonic
• Major initial activities
– Initiating review process
– Provider outreach
– Provider training
– Connecting with stakeholder groups
– Completion of staff hiring and training efforts
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
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Initial challenges
• Different review process
• Provider resources
• Usage of web portal
• Data submission for SED children
• Engagement of some inpatient providers
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
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Challenges on the near horizon
• Working with health homes
• Integration of peer support services
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
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Questions?