DHS/DMH/The Collaborative
Contractual Overview Presentation
Scott Permentier, LSW, MBA, CCEP
Chief Executive Officer
February 13, 2013
February 14, 2013
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Introductions
About the DHS/DMH, Administrative Service Organization
and the Illinois Mental Health Collaborative for Access and
Choice (The Collaborative)
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Recovery and Resilience
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Clinical Services/Medical
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Compliance/Quality
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Provider Relations
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Scott Permentier, Chief Executive Officer
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Bryce Goff, Director of Recovery and Resilience
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Pat Palmer, Director of Clinical Services
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Todd Kasdan, MD, Director of Medical Services
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Shawn Wilson, Director of Compliance
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Aissa Bell, Director of Provider Relations
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As the state mental health authority, DHS/DMH is
responsible for ensuring that those most in need have
access to appropriate mental health services that comply
with federal and state statutes and regulations
Ensure access for those most in need of mental health
service
Ensure that services meet standards of quality relative to
mental health services
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Ensure prudent stewardship of taxpayer dollars
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Establish all policies and procedures for the system of care
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The Illinois Mental Health Collaborative for
Access and Choice is:
◦ A partnership between the DHS/DMH and
ValueOptions to improve and advance mental
health services
◦ An ASO created to help DMH make the best use of
limited resources to serve people in need of mental
health assistance
◦ Committed to the Recovery and Resilience of
children and adults with mental illnesses
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A health solutions company designed to
ensure that:
◦ The right services are provided
◦ In the right amount
◦ To the right person
◦ At the right time
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ValueOptions is the company contracted by
DHS/DMH to provide ASO services
These services are provided under the name
“Illinois Mental Health Collaborative for
Access and Choice”
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The contract is set to expire June 30, 2015
There are two (2), one (1) year contract
extensions that may be exercised by
DHS/DMH that could continue the contract
until June 30, 2017
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The Collaborative operates two (2) offices
in IL:
◦ Chicago
◦ Springfield
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Clinical
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Finance
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Management Information Systems
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Provider Relations
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Quality Management
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Recovery and Resilience
Clinical Overview
Patricia Palmer, LCSW, CADC, Clinical Director
Callie R. Lacy, LCPC, Clinical Supervisor
Sue Kapas, LCPC, Clinical Quality Assurance Advisor
Todd H. Kasdan, MD, Medical Director
The Utilization Management (UM) Program is the vehicle through
which DHS/DMH ensures that individuals being served receive:
◦ The services best suited to support their recovery needs
and preferences
◦ Cost effective services in the most appropriate treatment
setting
◦ Services consistent with medical necessity criteria and
evidence-based practices
By implementing the UM Program, DHS/DMH strives to achieve
a balance between:
◦ The needs, preferences, and well-being of persons
in need of mental health services
◦ Demonstrated medical necessity
◦ The availability of resources
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UM is dynamic and evolutionary
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UM must be based on data
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Individuals accessing services should meet a consistent
threshold of medical necessity statewide
Authorization must be clinically focused and conducted
by qualified staff
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The Medical Necessity Criteria (MNC) are published by IL
DHS/DMH
These criteria should be used by providers to guide them
in making consistent admission, continuing service, and
termination of service decisions for each consumer
Providers must use these criteria consistently, regardless
of whether or not DHS/DMH or its designee externally
authorizes the service
Provider adherence to these criteria may be subject to
post- payment review
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Assertive Community Treatment (ACT)
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Community Support Team (CST)
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Community Support Group (CSG)
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Psychosocial Rehabilitation (PSR)
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Therapy Counseling
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Individual Care Grant (ICG)
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Permanent Supportive Housing (PSH)
 Including Williams Class members
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Region 1 Crisis Care
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Inpatient CHIPS
Mental Health Crisis Residential
Substance Abuse Crisis Residential
Acute Community Care
Northwest Crisis Care
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Inpatient CHIPS
Mental Health Crisis Residential
Acute Community Care
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Provider will contact the Collaborative to request services
Collaborative clinical care managers (CCMs) review
submitted documents for adherence to Medical Necessity
Criteria (MNC) via:
◦ Treatment Plan Goals
◦ Status Updates and Progress
◦ A rating scale
 LOCUS Scoring for adults
 Ohio Scales for Children/Adolescents
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If the MNC are met for the service(s), the Collaborative
CCM will enter an authorization
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If medical necessity IS established, request is
authorized by CCM and communicated to the
provider
If medical necessity is NOT established, the CCM
contacts the provider to seek clarification and offer
education/consultation regarding authorization
criteria
◦ The Collaborative and the provider will reach
mutual agreement with respect to next steps (e.g.,
additional information will be submitted for
review, alternative service will be considered, etc.)
◦ If mutual agreement has NOT occurred and
provider believes medical necessity is present, the
CCM will forward information to a Collaborative
Physician Advisor (PA) reviewer
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PA reviews and either authorizes OR denies
authorization
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In the case of a Clinical denial of authorization, a
Reconsideration Request or Appeal (depending on
the service/level of care) may be initiated
This review will be conducted by a Physician Advisor
(PA – a physician licensed in the State of Illinois and
board-certified in the specialty of psychiatry)
• Not the same PA who issued the original denial
• Not a subordinate of the PA who issued the
original denial
◦ Review outcome  Either:
 Overturn of the original denial decision
 Upholding of the original denial decision
Reconsideration Requests and/or Appeals can be
Clinical or Administrative in nature
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Clinical
◦ Related to Medical Necessity Criteria
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Administrative
◦ Administrative = based on reasons other than lack of medical
necessity
◦ Examples of administrative denials
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Consumer not eligible due to geographic residency
Diagnosis not present in eligible population universe
Service requested is not covered
Request is outside of timeframe
Focus on Persons Served
and Recovery
Bryce Goff
Director, Recovery and Resilience
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Concept of recovery includes:
– Individuals with serious mental illnesses or serious
emotional disorders can create a life of meaning and
purpose
• Person-centered care - Focus on helping individuals
achieve personal goals as opposed to merely
managing symptoms
• Family support and involvement
• Providing hope as the cornerstone of recovery
People who have mental illnesses:
– Form a partnership with their providers
– Have a voice in their care
– Guide their treatment planning process
– Use their strengths to achieve goals
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The Collaborative builds upon and works with the
established DHS/DMH Recovery Services Development Group
The Collaborative draws on ValueOptions’ extensive
experience in empowering consumers
On the national level:
◦ Clarence Jordan – ValueOptions’ Vice President for
Recovery and Wellness
 National recovery and consumer movement leader
 Training and consultation for providers, service center
employees, persons served
 Facilitating integration of recovery and wellness
principles throughout ValueOptions
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Certified Recovery Support Specialists (CRSS) at the Service
Center level
◦ Director of Recovery in senior level position on
management team
◦ Peer and Family Support Specialists
 Facilitate consumer communications and education
 Consultation and support to community and providers
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Community training on recovery
◦ Providers
◦ Persons Served
◦ Family Members
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Involvement of persons with lived recovery
experience in development and implementation of
initiatives
Certified Recovery Support Specialists employed
throughout the organization
Community education about mental illness and
recovery
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Warm Line
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Recovery and Empowerment Statewide Calls
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Recovery Services Development Snapshots
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CRSS Trainings and Provider Forums
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Recovery and Empowerment Handbooks
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Wellness Recovery Action Plan Training
Support
Recovery Oriented Consultation to all
Collaborative Departments
Compliance/Quality Management
Shawn Wilson, CCEP
Compliance/QA Departmental Director
Bobbie Fracassi
QM Specialist/Resolution Coordinator
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Maintain several QM functions to ensure quality of
operations and regulation compliance
QM functions ensure VO contractual obligations are
performed satisfactorily
Compliance function ensures operations meet all
legal requirements (HIPAA/HITECH/mandated
reporting, etc.)
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The Collaborative receives and processes
consumer- and family-generated complaints
regarding DMH service providers
Formalized process between ValueOptions and
DMH
Process ensures all allegations are:
◦ Taken seriously
◦ Reviewed in an objective and timely manner
◦ Results are communicated to necessary entities
 Call: (866) 359 - 7953 and file your complaint
or grievance with our Resolution Coordinator
 Write
to:
Illinois Mental Health Collaborative
Attn: Resolution Coordinator
P.O. Box 06559
Chicago, IL 60606
Provider Relations (PR)
Aissa Bell
Director, Provider Relations
Aissa Bell
Director
Amy Montgomery
Chris McConkey
Training Coordinator
Clinical Coordinator
Chicago
Liaisons
4
Springfield
Liaisons
3
A. Training and Technical Assistance
B. Provider Monitoring
C. Management of the Collaborative Web Site
D. Support of Provider Database Verification
Maintenance
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Via webinar on a variety of subjects
On-site at the time of monitoring reviews in
an effort to assist and guide providers with
improving documentation practices
Individually as requested by the provider
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This contract year, the Collaborative is responsible for 5
different types of reviews:
 PPR (Post-Payment Review)
 Two Types: Standard Post-Payment Review, ICG Post Payment
Review
 Evaluates provider’s compliance with 11 specific Rule 132 items
 Length of Review is 1-2 days depending on the number of
claims reviewed
 The number of claims depends upon the number of postpayment reviews the provider is receiving and the number of
claims the provider has submitted during the billing period
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Billing period if reviewed last year: 60 days after last review
up to date claims pulled.
Billing period if not reviewed last year: 12 months back and
up to the date claims pulled.
DMH Contract Managers follow through on Plans of
Improvement
Note: Same tools are used for both PPR and ICG PPR. If
provider is receiving both types of Post-Payment Reviews,
separate reports are left with provider for each type of review.
 ACT (Assertive Community Treatment)
 Measures a provider’s delivery of ACT services to the fidelity
model
Typical length is one full day per team being reviewed
With a few minor modifications, this scale is the
Dartmouth Assertive Community Treatment Scale (DACTS)
developed by Teague, Bond, and Drake (1998)
 CST (Community Support Team)
 Measure a provider’s delivery of CST services according to
the definition and intent of the service
 Typical length is one full day per team being reviewed
The review is conducted using a tool developed by a
workgroup of DMH and the IL PR team
 Certification
 Evaluates compliance of Rule 132 (a much broader review than PPR )
 Typical length of review is three days.
 Reviewers use DHS/BALC established tools
 DHS/BALC office follows through with providers post-review
 ICG Documentation Reviews
 Reviews service documentation and focuses on the rehabilitative
nature of services provided and coordination with other entities and
includes a review of the provider’s policies and procedures related to
elopement
 Typically length is one day
 The review is conducted using a tool developed by a workgroup of DMH,
DHS C and A office and the IL Collaborative PR team
 DHS/C and A office follows through with providers post-review
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In partnership with DHS/DMH and
DHS/DORS, assistance with supported
employment fidelity monitoring
Up to 33 provider programs
The purpose of provider database verification is to ensure that
data in our system is accurate and up-to-date
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Providers who are receiving a monitoring visit:
 Receive an encrypted email with an attached prepopulated
PDV form documenting the provider’s
information that is currently in our system. Providers
make any corrections or changes and give to reviewers at
the time of the monitoring visit
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Providers who are NOT receiving a monitoring visit:
 The Contract Manager will be contacting you to verify the
information
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Today’s presentation will be available online at:
www.illinoismentalhealthcollaborative.com
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You can follow these steps:
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Step 1: Go to www.illinoismentalhealthcollaborative.com
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Step 2: Click on “Providers”
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Step 3: Click on “Provider Information”
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Step 4: Under Provider Trainings, click on this
PowerPoint
Questions?