Concurrent Review

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OptumHealth NYC BHO Provider Training
Agenda
• Introductions
• Overview of Optum
• Review of Contract between Optum and the Offices
• Admission & Discharge Review
• Provider Tools
– Tool Review
– Forms & Submission Process
– Optum/New York Web site
– ProviderConnect
• Question and Answer Session
• Wrap Up and Closing
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2
OptumHealth New York City BHO Staff
• William Fishbein PhD, MBA, Executive Director, OptumHealth NYC BHO
– Amy Freeman, LMSW, Clinical Program Manager
– Margaret “Peggy” Elmer, LMSW, Clinical Program Manager
– Erik Geizer,MS, LMHC, CGAP, Quality Assurance/Training Manager
– Linda West, BS, Reporting & Technology Manager
– Michael Silver, MD, Psychiatrist
– Marc Alan Minick, PhD, Community Liaison
– Mark Simmons, LCSW-R, Community Liaison
– Sybil Nurse-Reeves, LCSW-R, Community Liaison
– Approximately 60 employees – highly educated and experienced
– Master’s level clinical employees, “Clinical Care Managers” (MSW,
LMHC, CASAC, etc.)
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3
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.
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5
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
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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.
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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
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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 Clinical Care Manager 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 Clinical Care Manager or to:
[email protected]
Ask Questions
• General questions can be directed to the Executive Director & Community Liaisons or to
[email protected]
• ProviderConnect technical questions/issues can be directed to:
[email protected]
Other
• Let us help you!
• We want your feedback.
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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 Clinical Care Manager assigned by Facility
• New provider portal: www.optumhealthnyc.com
• ProviderConnect software
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Fax Submission Option
•
Individual Information Matrix Form
– 3 components of the form:
• 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 concurrent reviews for applicable services of
Fee-For-Service Medicaid members at regular intervals.
• Discharge Planning
– Provider to complete and submit by the date of discharge but no
later than within 24 hours post discharge.
•
Form located on the Optum NYC BHO Provider Portal :
www.optumhealthnyc.com
•
Submit forms to the Optum NYC BHO clinical fax number: (877) 283-0555
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Admission Information
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Is there OASAS consent on File? YES / NO
Date:
Facility Name:
BHO Clinical Care Manager Assigned:
Facility Contact Name:
Facility Contact Phone:
Facility Contact Fax:
Individual Name:
Medicaid ID:
Date of Birth:
Gender:
County of Residence:
Date of Admit:
Time of Admit:
Age Group of the Individual:
Admission Type: Inpatient Psychiatric, Substance Abuse Rehab, Inpatient Detox
Diagnosis(es) at Admission:
– Axis I:
– Axis II:
– Axis III:
– Axis IV:
– Axis V:
• Reason(s) for Admission (Why now?):
• Readmission to Facility within 30 days for Inpatient Psychiatric/45 days for SA Rehab or Detox?
• Readmission to same facility:
• *Please complete & submit within 24 hours following admission or by 5 p.m. the next business day following weekend
and holiday admissions.
• **If this is a readmission within 30 days for inpatient/detox or within 45 days for rehabilitation, send prior discharge plan
with Matrix submission.
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Feedback from Optum after Admission Notification
• Optum will generate a Treatment History Form regarding the Individual
admitted by the Facility within 72 hours after admission or by 5pm of the next
business day following notification of the admission by the provider.
• See next slide
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Treatment History Form Information
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Facility Name:
Phone:
Individual Name:
High Need Individual:
Date of Admit:
Date of History Transmission:
•
Last six (6) months of behavioral health services utilized by individual:
Facility/ Provider
Facility Contact:
Fax:
Medicaid ID:
MH readmission w/in 30 days:
Time of Admit:
Time of History Transmission:
Dates of Service
Type of Service
•
Most recent diagnosis(es):
– Axis I:
– Axis II:
– Axis III:
– Axis IV:
– Axis V:
•
There is/ is not additional treatment history information available on the individual. (circle one)
•
*Facility is responsible for gaining executed release of information and sending to OptumHealth for the release of
substance abuse treatment services.
• OASAS Consent Form
http://www.oasas.ny.gov/mis/forms/trs/trs-51.pdf
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Concurrent Review
• Dedicated Clinical Care Manager to be assigned by Facility.
• Check www.optumhealthnyc.com
- Notice of Preliminary Finding- Verbal
- Notice of Clinical Determination - Letter
• See next slide
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Concurrent Review Information
• What has worked in the past for treatment of individual?
• What strengths do the individual and/or family system have that we can build
on?
• What is being done differently this time?
• Current status of individual, including mental status examination
results:
• Status/Progress with Treatment Plan:
• Has a Wellness Recovery Action Plan (WRAP) been initiated with the
individual?
• If no, why?
• Current Diagnosis(es):
-Axis I:
-Axis II:
-Axis III:
-Axis IV:
-Axis V:
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Concurrent Review Information
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Physical & behavioral assessment findings:
Current Status of Individual, including mental status examination results?
Current Diagnosis:
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V:
For an admission from the community, what type of housing did the individual reside in?
If individual was admitted from an institutional setting, what type of setting was the sending
facility?
What has worked in the past for treatment of individual?
What strengths do the individual and/or family system have that we can build on?
What is being done differently this time?
Status/Progress with Treatment Plan:
Assessment for case management completed?
If case management is needed and individual is not currently enrolled, referral made?
Has a Wellness Recovery Action Plan (WRAP) been initiated with the individual?
If no, why?
Preliminary Discharge Plan:
If this is a readmission, key factors in why the prior discharge plan didn’t meet the member’s needs?
Anticipated discharge date:
Expected Length of Stay:
Days
Barriers to Discharge (biopsychosocial):
Referral to local peer/family services programs/supports?
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Concurrent Review Information
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Individual involved in discharge planning?
Individual’s family involved in discharge planning?
Contact with medical provider(s):
Detail?
Contact with behavioral provider(s):
Detail?
Is the individual enrolled in Managed Care?
Is the individual enrolled in a Health Home?
Did the individual have a care coordinator prior to admission?
Case manager/ Care coordinator engaged in hospitalization?
Name of case manager/care coordinator:
If child/adolescent, other systems engaged?
Other Issues / Notes?
Medications
Name
Dosage
Frequency
• If more rows are needed to list medications, please list them here:
• Discontinued?
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Discharge Planning Information
•
•
•
•
Date of Discharge:
CM/Care Coordinator?
Individual Leave Against Medical Advice?
Diagnosis(es) at Discharge:
– Axis I:
– Axis II:
– Axis III:
– Axis IV:
– Axis V:
• Medications:
Name
Dosage
Time of Discharge:
Frequency
• Does the individual have a sufficient amount of medication until his/her follow up
appointment?
• If no, why?
• Was case summary and discharge plan sent to the outpatient provider?
– If yes, what date?
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Discharge Planning Information
• If the individual has a care coordinator (i.e. ACT, OMH TCM, Children's HCBS Waiver, MATS, and
Health Home), was he/she informed of the discharge? <drop down>
• If the individual is assigned to a MCO, have they been contacted for post discharge physical health
care needs? <drop down>
• Peer/Family Support Service/Program Referral:
– If yes, name & contact information:
• For a discharge to the community, what type of residence is he/she being discharged to:
• If the individual is being discharged to an institutional setting, what type? <drop down>
• Has the individual been provided with written instructions for what to do in the event of a crisis prior to
his/her first post-discharge appointment?
– If no, why?
• If individual is under 18 years, linkage of children with other service systems (e.g. juvenile justice,
educational system, child welfare)?
• Follow up appointments, inclusive of case management:
Provider #1 Name:
Provider #3 Name:
Provider ID:
Provider ID:
Contact Information:
Contact Information:
Date/Time of Appointment:
Date/Time of Appointment:
Service Type:
Service Type:
Provider #2 Name:
Provider #4 Name:
Provider ID:
Provider ID:
Contact Information:
Contact Information:
Date/Time of Appointment:
Date/Time of Appointment:
Service Type:
Service Type:
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Review of Process - MH Inpatient
Action
Time Frame
Report in
Provider
Profile
Medicaid FFS beneficiary admitted for inpatient mental health
treatment
Admitting facility submits Individual Information Matrix via provider
portal, fax or telephone to NYC BHO
Within 24 hrs of admission or by 5
p.m. the next business day following
weekend and holiday admissions
•BHO sends Treatment History Form to facility via fax, encrypted e-mail
or provider portal
•BHO CCM contacts designated facility clinician, reviews admission
information, and schedules first concurrent review
Within 72 hrs of admission or by 5
p.m. the next business day following
notification of the admission by the
provider, whichever is later
•BHO CCM and designated facility clinician conduct concurrent reviews
•BHO CCM documents facility compliance with required elements of
treatment planning, treatment and discharge planning
At least every 5 days*
Consumer’s clinical condition no longer justifies continuing
inpatient stay
During concurrent review, BHO CCM tells facility liaison that
continuing inpatient stay may no longer be justified and that BHO CCM
is sending the case for review by a BHO psychiatrist to make the
determination
Within 24 hours of concurrent review
If the BHO psychiatrist concurs that continuing inpatient stay is no
longer justified, BHO CCM gives verbal Notice of Preliminary Finding to
the facility liaison
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Review of Process - MH Inpatient - continued
Action
Time Frame
Report in
Provider
Profile
Potential Provider Responses
Provider submits request for reconsideration and additional clinical
information to support the need for continuing inpatient stay;
(1) Within 24 hrs of receipt of Notice
of Preliminary Finding
BHO psychiatrist completes review of additional clinical information and/
or doc-to-doc consultation to facility physician; communicates
reconsideration determination to the facility and if ongoing care is
determined to be required, BHO CCM continues concurrent reviews.
Within 24 hours of receipt of
Reconsideration Request
BHO issues Notice of Clinical Determination if the reconsideration
review determines that the individual does not require treatment in an
inpatient setting and the individual is not discharged by the facility. BHO
CCM communicates the Notice of Clinical Determination to the facility
liaison verbally and in writing by portal, fax, or secure email.
Within 72 hours of Notice of
Preliminary Finding
OR
Provider discharges consumer and submits required discharge
information via portal, fax or secure e-mail; BHO closes case
2) Within 48 hrs of receipt of Notice
of Preliminary Finding
OR
BHO has received no discharge information and no request for
reconsideration…
BHO issues Notice of Clinical Determination to facility-designated
representative via fax or secure e-mail and sends copy to the Offices
(3) Within 48 hours of receipt of
Notice of Preliminary Finding
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Review of Process - MH Inpatient - continued
• NOTE: The Offices will waive the review requirement for maximum concurrent
review intervals for individuals the BHO designates as “Long Stay” when all of
the following criteria are met:
• The individual meets the criteria for inpatient care
• The individual presents with symptoms and/or history that demonstrates
a significant likelihood of deterioration in functions/relapse if transitioned
to a less intensive level of care
• The BHO Clinical Care Manager and provider concur that the current
treatment and discharge plans best meet the individual’s needs
• The individual’s discharge is delayed pending availability of resources
that both the provider and BHO believe are necessary to maintain the
individual outside of the current hospital setting (e.g. intermediate care
inpatient, residential treatment, or foster care beds)
• For Long Stay individuals, the BHO Clinical Care Manager should schedule
follow up reviews at intervals deemed appropriate based upon clinical
judgment.
• Notices of Preliminary Finding and Clinical Determination will not apply to
individuals designated as Long Stay.
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Review of Process
• SA Inpatient Detox
– Same process as MH Inpatient, however concurrent reviews
conducted at least every 2 days
• SA Inpatient Rehab
– Same process as MH Inpatient, however concurrent reviews
conducted within 21 days of admission and every 7 days thereafter
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Telephonic Submission Option
• Call Optum Intake at (866) 505-3398 for initial admission 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.
• Make sure all of your information is ready when calling Optum Intake
– Use Individual Information Matrix form as a guideline. Form located on the
Optum NYC BHO Provider Portal : www.optumhealthnyc.com
• Ongoing concurrent reviews will be conducted in partnership with assigned
Optum Clinical Care Manager.
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Provider Portal Submission Optum
• Provider Portal:
– Use ProviderConnect via www.optumhealthnyc.com for online entry
of data from Information Matrix form:
• Initial Admission
• Concurrent Review
• Discharge Planning
Intake Authorization &
Treatment History
`
Provider
Optum Provider
Agency User
Connect
Secured Internet
Connection
Optum Care
Management System
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OptumHealth NYC BHO Provider Portal
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OptumHealth NYC BHO Provider Portal Page
.
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ProviderConnect Login
.
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ProviderConnect Login
(cont.)
.
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ProviderConnect News
.
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ProviderConnect Main Menu
.
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Individual Search
.
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Individual Search
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Admission Notification
.
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Admission Notification
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Saving updates- Admission
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Concurrent Review- Logging into Provider Connect
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Individual Search - Concurrent Review
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Concurrent Review
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Concurrent Review
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Concurrent Review
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Concurrent Review
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Concurrent Review
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Concurrent Review
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Concurrent Review
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Concurrent Review
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Concurrent Review
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Concurrent Review
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Current Medications
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Adding Medications
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Saving updates- Concurrent Review
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Discharge- Logging into Provider Connect
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Individual Search- Discharge
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Discharge
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Discharge
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Discharge
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Discharge
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Saving updates- Discharge
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Children with Serious Emotional Disturbance (SED) - Logging into
Provider Connect
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Individual Search- SED
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Children with Serious Emotional Disturbance (SED)
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Children with Serious Emotional Disturbance (SED)
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Children with Serious Emotional Disturbance (SED)
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Saving updates- SED
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Next Steps
• Complete and submit Facility Information Form, if not yet submitted, to Suzanne Feeney via:
– Fax at: (518) 951-2481
– email at [email protected]
– Mail at: 900 Watervilet-Shaker Road, Suite 103, Albany, NY 12205.
• Providers who select ProviderConnect as their submission option should contact the Optum
Help Desk to request a User ID/Password at (866) 505-3398/prompt 4
• Optum will post Clinical Care Manager/Facility assignments and contact information on our
Provider Portal at:
– www.optumhealthnyc.com
• Start to notify Optum of admissions as of 1/3/2012.
– Fax - Clinical Fax: (877) 283-0555
– Telephonic - (866) 505-3398
– Provider Portal (ProviderConnect) - www.optumhealthnyc.com
• If you are using the Optum Provider Portal ‘ProviderConnect’ and have technical questions or
encounter a problem, contact Optum (866) 505-3398/prompt 4 or email us at
[email protected]
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Questions?
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