“Tropical Texas Behavioral Health provides quality
behavioral healthcare with respect, dignity and cultural
sensitivity, through the efficient and effective delivery of
services.”
QUALITY MANAGEMENT PLAN
FY 2009-2010
TABLE OF CONTENTS
I.
Purpose
II.
Plan Development
III.
Center Mission Vision and Core Values
IV.
Goals
V.
Quality Assurance Structure and Design
VI.
Collection and Measurement of Data
VII.
Assessment of Data
VIII.
Improvement
IX.
Deficit Reduction Act/Corporate Compliance
Appendix A:
TTBH Organizational Chart
Appendix B:
Corporate Compliance Documentation and Claims
Integrity Plan
Appendix C:
Utilization Management Plan
TTBH QM PLAN
Page 2
TROPICAL TEXAS BEHAVIORAL HEALTH
QUALITY MANAGEMENT PLAN
I. PURPOSE
The goal of the quality management program is to improve outcomes for the recipients of mental
health and mental retardation services authorized and managed by the Center. To accomplish
this, the Center combines the use of information technologies with continuous quality
improvement processes to provide quality assurance oversight of authority, administrative, fiscal
and service delivery performance. The quality management program ensures that the Center’s
Executive Management Team (EMT), Board of Trustees, Committees and Advisory Groups
have the information needed to make management decisions that support the provision of the
highest quality services.
The Center’s performance of these oversight functions significantly effects the outcomes for
individuals, the cost to achieve successful outcomes and the perception of clients and families of
the quality and value of services. The Center has implemented system wide performance
evaluation and improvement measures for its network of service providers as well as its business
and administrative functions.
The quality management process is vital to demonstrating best value, balancing service cost and
quality.
II. PLAN DEVELOPMENT
The Center’s Quality Management Plan is a functional and dynamic document, evolving over
time. The Plan addresses the following quality management initiatives: oversight of the Center’s
authority and provider functions; increased accountability; compliance with the requirements and
objectives of the performance contract and Resiliency and Disease Management (RDM); and the
integration of Local Planning and Network Development, considering public input in
determining best value and standards for customer service and quality client care.
The quality oversight responsibilities built-in to the Center’s role as the local authority include
the management and maximization of resources within the local communities to serve as many
individuals as possible while obtaining the best results; monitoring client satisfaction as it
pertains to provider choice and service quality, and objective evaluation of service providers.
As the Center prepares for a fee-for-service environment, it must be increasingly efficient in its
use of available funds to obtain the highest quality of services. Quality oversight in this area
ensures objective monitoring and evaluation of service delivery, provider performance, and the
improvement of deficient or non-compliant practices.
TTBH QM PLAN
Page 3
To ensure compliance, the Center will continue to utilize a Performance Improvement and
Compliance Committee (PICC) to analyze performance, especially as it pertains to the
evaluation of high impact areas. Areas requiring evaluation and oversight are identified in
statute, in the requirements of the performance contract, by contract performance and
accountability data stored in the state’s Mental Retardation and Behavioral Health Outpatient
Warehouse (MBOW), and in any plans of correction resulting from external reviews by the
various agencies regulating Center services and functions.
The QM Plan supports the Center’s Local Plan, developed with the input of clients, families,
stakeholders and other members of the community. Quality oversight of this area includes
reviewing and monitoring progress made toward achieving goals and objectives, and modifying
the strategies to achieve these as indicated. The effectiveness of the QM Plan is monitored
through reports made to the PICC, EMT, Board of Trustees, and other oversight committees and
advisory groups.
One of the biggest challenges for FY 2008 was the preparation for the initial survey by the
Commission on Accreditation of Rehabilitation Facilities (CARF). The programs accredited by
CARF are: Assertive Community Treatment-Mental Health Adults; Outpatient TreatmentMental Health Adults; Outpatient Treatment-Mental Health Children and Adolescents; and
Residential Treatment-Integrated DD/Mental Health Adults. The programs received three-year
accreditation, a tribute to the high quality of services these programs provide and to the support
services standards that were realized.
III.
CENTER MISSION, VISION and CORE VALUES
The QM Plan is driven by and supports the Center’s Mission and Vision:
MISSION STATEMENT: Tropical Texas Behavioral Health provides quality behavioral
healthcare with respect, dignity and cultural sensitivity, through the efficient and effective
delivery of services.
VISION STATEMENT: Tropical Texas Behavioral Health continues its commitment to
excellence and will be an innovative provider of comprehensive and compassionate behavioral
health services. We will treat all stakeholders with honesty, fairness and respect.
PHILOSOPHY/CORE VALUES:
Ethical
Tropical Texas Behavioral Health (TTBH) is committed to abide by all honest,
legal and moral principles in its operations.
Competent
TTBH is committed to providing efficient and quality services through qualified,
trained and credentialed professional staff.
Trustworthy TTBH is committed to responsibly provide an organized system of care through
the careful and planned expenditure of all available resources.
TTBH QM PLAN
Page 4
Dedicated
TTBH is committed to the caring support of the individuals it is privileged to
serve.
Quality
TTBH is committed to the provision of excellent customer service driven by the
needs of all people it serves.
Advocate
TTBH is committed to furthering the interests of those served and to help them
lead meaningful lives as members of the community. This includes helping them
to achieve their right to belong, to be valued, to participate and to make
meaningful contributions.
IV.
GOALS
The Quality Management Plan is consistent with the organization’s mission and reflects the
coordinated activities and input of the Quality Assurance Division, various administrative
functions including fiscal services and information technologies, service delivery areas, and
internal and external stakeholders including Center governance and leadership. The tables that
follow reflect many of the Center’s current goals and objectives identified in the current Strategic
Plan. They address the Management of Human Resources, Management of Fiscal Resources,
Management of Service Delivery, Public Relations Activities, and Standards Compliance.
Progress toward these goals is reported semi-annually to the Planning and Network Advisory
Council (PNAC) and Board of Trustees. Areas identified as needing improvement may prompt
the formation of a Performance Improvement Team (PIT) to further analyze and develop
solutions for complex concerns. These goals are continuously reassessed in relation to the
Center’s past performance as well as trends in behavioral healthcare throughout the state and
across the nation.
TTBH QM PLAN
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TROPICAL TEXAS BEHAVIORAL HEALTH
FY 2009
Strategic Plan
TTBH QM PLAN
Page 6
Management of Human Resources
1. Function and Purpose:
This will be evidenced by the development and maintenance of an effective management team; maintaining staffing levels that ensure appropriate
quality of services and safety for consumers; providing an effective mechanism for staff orientation and ongoing training and development; and
ensuring that a positive and growth-oriented system of employee performance and evaluation is developed and implemented.
NOT MET
(No score)
MEETS
score
1
EXCEEDS
score
2
COMMENDABLE
<3
3.0-3.24
3.25 - 3.59
3.6 +
< 2.5
2.5 - 2.74
2.75 - 3.14
3.15 +
A.2. Score in "Supervision" section
<3
3.5 - 3.74
3.75 - 3.89
3.9 +
A.3. Score in "Overall Satisfaction" section
<3
3.4 - 3.59
3.6 - 3.79
3.8 +
> 40%
39% - 35%
34% - 30%
≤ 29%
> 45%
45% - 40.1%
40% - 35.1%
≤ 35%
4+
3
2
1
>2
2
1
0
score
3
A. Staff satisfaction survey results are positive
and compare to national benchmarks.
(5pt scale, 5 is highest)
A.1. Score on "Grand Mean"
A.1. Score in "Communication" section
B. Overall employee turnover is minimized
B.1. Turnover in Csmngr/Svc Coord/ QMHP/
QMRP is minimized
B.2 Physician vacancies
(expressed as FTE average per month)
C. Number of adverse HR related outcomes
Totals :
Total possible score for this section:
Sum of scores for this section:
Score
0
0
0
21
0
0.0000
Notes for questions relating to MHCA national benchmarks:
TTBH QM PLAN
TTBH score last year
National Data Base last year
A.
3.46
3.56
A.1.
A.2.
A.3.
3.14
3.94
3.82
3.13
3.97
3.84
Page 7
Management of Fiscal Resources
2. Function and Purpose:
An acceptable annual fiscal audit is approved by the Board of Trustees (Board); acceptable controls in place for management of Center funds
with timely reporting of financial status to the Board; and the development and implementation of a balanced operating budget
(major funding reductions outside of the Center’s control will be taken into consideration if applicable).
NOT MET
(No score)
MEETS
score
1
EXCEEDS
score
2
COMMENDABLE
1. Debt Service Coverage Ratio
≤ 1.0
1.0 - 1.24
1.25 - 1.74
1.75+
2. Days of Operating Reserve
≤ 50
50 - 70
71 - 89
90 +
3. Acid Test Ratio
< .5
.25 - .99
1 - 1.74
1.75 +
Qualified
Missed deadline
No penalties
Ahead of deadline
Opinion
Unqual. opinion
for deadline
Unqual. opinion
score
3
A. Identified financial indicators:
B. FY External Audit Outcome - deadlines
qualified vs. unqualified opinion
Unqual. opinion
C. Medicaid and other 3rd party claims
1. Monthly average of MH claims billed
< $375K
$375K - $399K
$400K - $499K
$500K +
2. Percent of Medicaid/Medicare
claims billed within 45 days
< 65%
65% - 74%
75% - 84%
85% +
3. Uncollectable / billing write-offs
> 1.2%
1.19% - 1%
.99% - .75%
.74% - 0
Over
budget
Met budget, to
1% ahead
1.1 - 2.0%
ahead
> 2.0%
ahead
Revenue
decreases
$0 - $250K in
new funds
$250K-$499K
new funds
> $500K
new funds
D. Budget projections and targets
E. Revenue budget growth
Totals :
Total possible score for this section:
Sum of scores for this section:
Score
0
0
0
27
0
0.0000
Notes on Financial Indicators - state "acceptable ranges for centers" are: 1. > 1.25; 2. 60-90 days; 3. >.25
TTBH QM PLAN
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Management of Service Delivery Systems
3. Function and Purpose:
Include the development and implementation of a system for long and short-range planning; maintenance of a coordinated system of services
designed to meet the needs of the consumers the system is intended to serve, which is both effective and efficient and incorporates a quality
assurance oriented program evaluation to provide constructive feedback to program and unit managers.
NOT MET
(No score)
MEETS
≤ 2.9
3.0 - 3.5
3.51 -3.99
4+
A.1. MR services - Overall quality of care & reputation
≤ 2.9
3.0 - 3.5
3.51 -3.99
4+
A.2. MH services - Overall quality of care & reputation
≤ 2.9
3.0 - 3.5
3.51 -3.99
4+
B. Implementation of Local Planning Network Development
B.1. Submission of board approved plan to DSHS
After
deadline
10/1/2008
9/30/2008
Prior to 9/30/08
After
deadline
At
deadline
≤10 days prior
to deadline
≥10 days prior
to deadline
≤ 79%
79%-86%
87%-92%
93%+
2. Utilization of state psychiatric bed days
≥ 110%
105 - 109%
100 - 104%
< 100%
3. % of enrollment dates met for HCS
and TxHmLvg Medicaid Waivers
≤ 90%
90-92%
92-96%
97%+
≤ 49%
50 - 54%
55 - 59%
> 60%
≤ 49%
50 - 54%
55 - 59%
> 60%
A. % of physicians using telemedicine for emergency
consultation
≤ 69%
70-79%
80-89%
90%+
B. % of FTE physicians using electronic medical record
< 45%
60-74%
75 - 84%
85% +
No
progress
by 5/1/09
by 4/1/09
by 3/1/09
No
progress
by 9/1/09
by 8/1/09
by 7/1/09
PROGRAM SERVICES
A. Average customer rating of their overall care
(based on national benchmarks, 3=good, 5=excellent).
B.2. Release/publication of procurement doc
C. Clinical Outcomes
1. % of MH consumers served who receive their 1st
service encounter within 14 days of their intake
D. Productivity: % of the following staff meeting target
1. Csmngrs/Rehab Specs/Therapists (MH services)
2. Service Coordinators (MR services)
score
1
EXCEEDS
score
2
COMMENDABLE
score
3
PHYSICIAN SERVICES
C. Pharmacy - provision of services to patients with
Medicaid and other 3rd party payor sources.
C.1. Development of baseline for average pharmacy
cost per physician
Totals :
Total possible score for this section:
Sum of scores for this section:
Score
TTBH QM PLAN
0
0
0
41
0
0.0000
Page 9
Public Relations Activities
4. Task and Purpose:
Oversees and participates in public relations activities. Ensures establishment and maintenance of relationship with the public, and projects a
positive and cooperative image of the center, including a constructive working and communicative relationship with the Commissioners' Courts,
local advisory and support groups, elected officials, as well as other stakeholders.
A. Average monthly number of
stakeholder activities participated
in / made presentations for agency
B. Agency average monthly participation in
activities at a state/federal level for Agency
including advocacy, policy, and funding
efforts/initiatives
NOT MET
(No score)
MEETS
<3
3
4
5+
0
1
2
3
Totals :
Total possible score for this section:
Sum of scores for this section:
Score
TTBH QM PLAN
score
1
0
EXCEEDS
score
2
0
COMMENDABLE
score
3
0
6
0
0.0000
Page 10
5. Task and Purpose:
Standards Compliance
Demonstrated by ensuring all programs and services are operated in compliance with state contracts, appropriate regulations, standards
and laws, Texas Administrative Code, rules, public responsibility laws, Mental Health Code, etc; and by ensuring
the Center performs acceptably on evaluation site visits such as Quality Assurance / Program / Fiscal Reviews, CARF surveys, etc.
NOT MET
(No score)
MEETS
not accredited
Provisional
One Year
Three Year
A.2. Maintain Accreditation - internal review
deadline missed
at deadline
≥10 days of deadline
≤10 days of deadline
A.3. Correct deficiency - performance evals
not implemented
by 5/1/09
by 4/1/09
by 3/1/09
A.4. Correct deficiency - MR consumer mtgs
not implemented
by 3/1/09
by 2/1/09
by 1/1/09
A.5. Correct deficiency - Patient handbook
not corrected
by 4/1/09
by 3/1/09
by 2/1/09
A.6. Correct deficiency - Medication coord
not corrected
by 2/1/09
by 1/1/09
by 12/1/08
A.7. Correct deficiency - Med satisf assessment
not corrected
by 2/1/09
by 1/1/09
by 12/1/08
< 91%
95 - 97%
98 - 99%
100%
C. # of external audits with significant
deficiencies cited and confirmed
>2
2
1
0
D. Total annual sanctions or penalties
from DSHS or DADS are minimized
> $80,000
$65,001 $80,000
$40,001 $65,000
$0 $40,000
A. CARF Accreditation
A.1. Secure Accreditation
B. Plans of Correction submitted on time for
all audit / reviews
Totals :
Total possible score for this section:
Sum of scores for this section:
Score
TTBH QM PLAN
score
1
0
EXCEEDS
score
2
0
COMMENDABLE
score
3
0
30
0
0.0000
Page 11
Average Rating for Section
x
Weight
=
Total Weighted Score
Finance
0.000
x
20
=
0.00
Human Resources
0.000
x
20
=
0.00
Service Delivery
0.000
x
30
=
0.00
Public Relations
0.000
x
10
=
0.00
Standards Compliance
0.000
x
20
=
0.00
Overall Score:
0.00
TTBH QM PLAN
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V. QUALITY ASSURANCE STRUCTURE AND DESIGN
The Center’s Quality Management processes include such quality oversight activities as:
developing performance measures based on identified weaknesses; monitoring performance
measures to determine effectiveness; and recommending additional and/or alternative
improvement activities. Quality Management activities are intended to be proactive, flexible,
objective and responsive to the unique characteristics of programs and services. In order to
accomplish this, it is necessary to consider the service types, applicable standards and the needs
of specific service areas and programs. To this end, numerous technical assistance and support
groups and reporting systems are in place to address the challenges and issues facing different
service areas and programs. The Center has been restructured to efficiently serve the needs of the
clients and meet its stated goals and objectives (see Attachment A: TTBH Organization Chart).
This structure provides continuity across the Center and its providers. The procedures and
methodologies used by the Center to execute specific quality management activities include the
following:
The Center has designated the EMT, the membership of which includes the Chief Executive
Officer, Chief Operating Officer, Chief Administrative Officer, Chief Medical Officer and the
Chief Financial Officer, to oversee internal quality assurance activities. The role of the EMT is
long-term in nature and places a heavy emphasis on leadership and motivation. The Management
and Information Systems (MIS) Department participates in quality management functions
through the development of customized data reports used by management to make decisions
pertaining to service delivery. Standing items on the EMT agenda include performance
indicators requiring continuous oversight. Additional agenda items are recommended for review
as needed.
The Center utilizes a number of standing Committees to review and monitor client service
activities and functions. Committees carry out a major portion of quality assurance activities and
impact policy, procedures and practices. Committees include representation from all involved
service areas in order to make use of the varied expertise and experience of Center staff,
providers and other stakeholders. Current Center committees include, but are not limited to, the
Performance Improvement and Compliance Committee (PICC), Clinical Records Committee
(CRC), Rights and Ethics Committee, Death Review Committee, Medical Staff Committee,
Utilization Management (UM) Committee and Staff Advisory Committee (SAC).
The role of the Performance Improvement and Compliance Committee (PICC) is to analyze
results of key performance indicators, address trends and monitor plans of improvement.
Through these activities the PICC is usually the group that completes the first steps of the
Center’s performance improvement process. The PICC is comprised of executive and program
management staff. Areas assessed and overseen by the PICC for performance improvement
include results of monthly supervisor documentation reviews, client satisfaction surveys, data
verification reviews and external program reviews, timeliness of service data entry, corrective
action plans, Health Information Management (HIM) reviews of form completion (e.g. privacy,
financials, consents, authorizations, treatment plans, etc.), client rights reports (i.e. allegations,
rights violations, complaints, technical assistance and appeals), and critical incidents.
TTBH QM PLAN
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Once a process requiring improvement is identified, the PICC may organize a Performance
Improvement Team, a group of staff with specific knowledge of the processes charged with
developing necessary performance improvement actions in accordance with a specified reporting
deadline.
A Performance Improvement Teams (PIT) may be established for the purpose of reviewing
specific areas of concern and completing the four steps of the Center’s improvement process,
referred to as PDCA: Planning the improvement action; Doing (test the action); Checking to
determine the effect of the action; and Acting to implement the action on a wide scale. A PIT
may be made up of staff from a single program or multiple programs based on similarity of
functions. PITs provide a means for:






Ongoing self-assessment of processes, standards and outcomes;
Proactive improvement, rather than reactive response;
Identifying training needs;
Service driven program improvements;
Quality beyond standards compliance; and
Improved teamwork and trust.
The Rights and Ethics Committee meets at least quarterly. The charge of the Rights and Ethics
Committee is to review, approve and monitor restrictions placed on clients’ rights on behalf of
Tropical Texas Behavioral Health in compliance with all applicable laws, rules and regulations.
The efforts of the Rights and Ethics Committee are aimed at continuous improvement of the
quality and appropriateness of client care. Furthermore, the committee ensures that any
restrictions are ethical, humane and in the best interest of the client.
The Rights and Ethics Committee is responsible for review activities including, but not limited
to:





The use of emergency intervention and/or behavior management included in a Person
Directed Plan;
Approval or disapproval of all experimental, nonstandard and research procedures;
Approval and monitoring of any program designed to increase appropriate behavior(s)
that involves restrictions to an individual’s rights;
Approval and monitoring of other programs that, in the opinion of the committee, involve
risks to protection and rights of individuals served; and
Approval and monitoring of the use of psychotropic medications for behavior
management.
The Rights and Ethics Committee oversight responsibilities include, but are not limited to, the
review of behavior management plans, representative payee activities, dietary restrictions,
guardianship of persons served and any other rights restrictions upon approval of the person
served and/or LAR. The Rights and Ethics Committee reports to the PICC on an as needed
basis.
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The Center’s Client Rights Department also plays a key role in the protection of client rights
through the tracking and reporting of allegations of client abuse, neglect and exploitation, and the
implementation of related employee training. All new employees receive training pertaining to
Client Rights and the Prevention of Abuse, Neglect and Exploitation within the first two weeks
of employment and are required to pass a related competency exam. All current employees,
contractors, volunteers and interns receive refresher trainings annually, or more frequently if
needed, including a competency exam. The Center’s Client Rights Department also documents
and tracks all allegations of abuse, neglect and exploitation, reports related concerns or trends to
the PICC and EMT for appropriate action, and implements additional or more frequent employee
training as indicated.
The Center’s Utilization Management (UM) program is responsible for the authorization and/or
denial of services based on protocols developed by funding entities and applicable legal and
regulatory requirements. UM protocols are reflective of Performance Contract requirements,
UM guidelines related to RDM and associated Fidelity requirements. The UM Committee meets
monthly and currently analyzes more than thirty data elements related to service access and
delivery and utilization of resources. The data are tracked and trended for performance
improvement as indicated. As positive and negative trends are identified, service and
administrative departments are identified for commendation or advised of the need for corrective
actions and performance improvement, respectively. As with all performance indicators, areas
identified as especially complex or in need of significant improvement may require the
involvement of a PIT.
Included in the data reviewed by the PICC and UM Committees are the results of the Texas
Implementation of Medication Algorithms (TIMA) Studies. Center medical staff have been
trained to utilize the treatment guidelines set forth in TIMA to systematically treat severe and
persistent mental illness. The TIMA Studies are designed to evaluate provider compliance with
the clinical and documentation requirements of the program. The QA Division supports
administrative staff in the performance of internal reviews of physicians’ and nurses’
documentation to ensure compliance with TIMA requirements and related contract guidelines,
and will use the findings to identify necessary corrective measures. The Metabolic Syndrome
and Patient and Family Education Program (PFEP) studies have occurred with data reported to
medical leadership.
VI.
COLLECTION AND MEASUREMENT OF DATA
The Center is dedicated to the continuous improvement of the behavioral health services it
provides and will periodically evaluate the effectiveness and efficiency of, access to, and
satisfaction with those services, and modify service delivery and administrative processes as
appropriate based on the evaluation of review findings. Clinical outcomes and business
performance indicators will be evaluated based on benchmarks and targets set forth in the
Department of State Health Services and Department of Aging and Disability Services
performance contracts, CARF requirements as applicable and the Center’s internal performance
standards.
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Data pertaining to the efficiency and effectiveness of services and access to services are obtained
using from reports available in the MBOW as well as internally developed performance and
productivity reports.
Service access, efficiency, effectiveness and related satisfaction indicators apply to all clients
served. Efficiency indicators apply only to the Center, and measure the agency’s productivity
and the extent to which available resources are used to achieve the greatest effect.
Client and family satisfaction are evaluated using semi-annual national satisfaction survey tool
administered by the agency. Further, the Center’s mental health and mental retardation services
Outcomes Management Questionnaires also collect and measure response data related to access
to services and client satisfaction, and are administered to clients periodically during, and in
some cases, after their treatment.
Additionally, the data from the following areas are collected and reported to monitor
performance:















Financial Data
Data Verification (MH and MR)
Internal and External program reviews (MH and MR)
Interest Lists
CARE reports
Anasazi Client Data System
Performance Contract and MBOW reports
Management Reports
Strategic Plan
Corporate Compliance
Provider Profiling Reports
Staff Training Curriculum and Performance Evaluation Data
Key Performance Indicators
Satisfaction Surveys
Risk Indicators-Critical Incident Reporting System
VII. ASSESSMENT OF DATA
The processes described above will allow for comparative analyses of clinical outcomes and
satisfaction for individual clients, specific clinic sites and overall business performance over
time. The data will be used to assess the Center’s performance and determine strengths,
weaknesses, and opportunities for improvement. At least annually, the QA Division will provide
a summary analysis of the outcomes management data to the Center’s Executive Management
Team to recommend necessary administrative and/or service delivery improvements.
Monitoring
All of the services provided by the Center will be monitored at least annually.
TTBH QM PLAN
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The following services are available to all clients:





Education around eligibility for services
Case Management
Treatment Planning/Person Directed Planning
Crisis Services
Benefits Eligibility Assessment
The following services are available to adults with specified mental health diagnoses and
children that demonstrate severe emotional disturbance:







Psychiatric Services
Medication Related Services
Behavioral Skills Training
Inpatient Services
Medication Training and Supports
Patient Assistance Program
Jail Diversion
The following services are available to adult mental health clients:






Supported Employment
Supported Housing
Assertive Community Treatment (ACT)
Client Peer Support
Projects for Assistance in Transition from Homelessness (PATH)
Texas Correctional Office on Offenders with Medical or Mental Impairments
(TCOOMMI)
The following services are available to child and adolescent clients:











Wraparound Planning
Transition Planning
Juvenile Justice
Family Psycho-education
Flexible Community Supports
Intensive Case Management
Routine Case Management
Family Support Groups
Family Partner Services
Counseling
TCOOMMI
The following services are available to clients with a diagnosis of Mental Retardation:
TTBH QM PLAN
Page 17









Service Coordination
Supported Employment-Employment Assistance
Supported Employment-Individualized Competitive Employment
Skills Training-Day Habilitation Program
ICF-MR Residential Services
Home and Community Support (HCS) Waiver
Texas Home Living Waiver
In-Home Family Support
Permanency Planning
The following services will be monitored quarterly due to critical importance:




Continuity of Care
Medicaid Billing
Utilization Review
NGM
Trending and Reporting Findings
The results of the analyses including any identified trends will ultimately be sent to the PICC,
EMT and Board of Trustees for recommended action. Reports will also be sent to service area
managers, the Client Rights Officer, and other program managers and supervisors as indicated.
Corrective measures and improvements are monitored through follow-up reviews tracked by the
QA Division.
VIII. IMPROVEMENT
Data collected will be analyzed at least quarterly to determine trends. The collected data will
guide the development of plans of improvement. Data indicating negative outliers will be
addressed through Performance Improvement Teams and/or brought to the attention of the EMT
for recommended action. While positive outliers will become best practices, serving as
benchmarks for the Center’s continuous quality improvement processes, remedial action will be
taken to address unacceptable levels of performance outcomes. Submission of plans of
improvement to the QA Division will be required to address negative outliers. Follow-up
activities and monitoring will be included in the plans to ensure maintenance of improvements.
Identified program deficiencies will be prioritized for resolution by the PICC and EMT.
Subsequent performance will be evaluated to determine the effectiveness of each plan of
improvement.
IX.
DEFICIT REDUCTION ACT AND CORPORATE COMPLIANCE
The Deficit Reduction Act (DRA) of 2005, Federal Anti-kickback Statute, Federal False Claims
Act and Medicaid Fraud Prevention Act established a number of processes that healthcare
organizations were required to put into practice to evidence corporate compliance. The Center
has developed and implemented a fraud and abuse compliance program and policy (see
Attachment B: Policy # SS1-05.04, Corporate Compliance Documentation and Claims Integrity
TTBH QM PLAN
Page 18
Plan) specifying the responsibilities and obligations of its employees, volunteers and contracted
providers regarding submission of reimbursement claims to Medicare, Medicaid and other
government payers for services rendered. The policy also applies to all business arrangements
with physicians, vendors and other person who may be impacted by federal or state laws relating
to claims fraud and abuse. The Center’s policy, Corporate Compliance training curriculum and
employee handbook contain detailed information concerning the False Claims Act,
administrative remedies, civil and criminal penalties for false claims and information regarding
whistleblower protections under the law.
As stated in the policy, a report reflecting the Center’s corporate compliance activities for the
preceding fiscal year and planned activities for the upcoming year is provided annually to the
EMT and Board of Trustees. The most recent report was delivered August 28, 2007.
TTBH QM PLAN
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Appendix A
Board of Trustees
Chief Executive Officer
Chief Financial Officer
Chief Medical Officer
Accounting
Physician Svcs
Contracts
UM / Continuity
of Care
Revenue
Enhancement
Pharmacy
Services
Crisis Respite /
After Hrs Crisis
Oversight
MIS
Chief Administrative
Officer
Chief Operations Officer
Harlingen Svc Center
Brownsville Svc Center
Edinburg Svc Center
MR Services
Intake / Crisis /
Mobil Crisis
Outreach Team
Intake / Crisis /
Mobil Crisis
Outreach Team
Intake / Crisis /
Mobil Crisis
Outreach Team
Authority
Services
Case
Management
Case
Management
Case
Management
Supportive Emp
& Housing
Supportive Emp
& Housing
Supportive Emp
& Housing
MR Eligibility &
Svc Access
Rehabilitation
Rehabilitation
Rehabilitation
Youth & Family
Services
Youth & Family
Services
Counseling
Counseling
Counseling
HIM
HIM
HIM
TCOOMMI
San Benito ISD
Grant
Donna ISD Grant
Cameron County
ACT
Nursing
Jail Diversion
ICF-MR
Programs
PATH
HCS Programs
Substance
Abuse
Nursing
Provider
Services
DON
Consumer
Benefits /
Eligibility
Safety Officer /
Environ. Svcs
Manager
Cultural
Adaptation Grant
Nursing
HIM Coord
Corp Compl
Privacy
Human
Resources
Service
Coordination
Youth & Family
Services
Purchasing
Quality
Assurance &
Planning
RGV Provider
Svcs
Tx Hm Lvg
Waiver Svcs
Training &
Volunteer Svcs
Rights &
Community
Relations
Special Projects
Hidalgo County
ACT
Cultural
Adaptation Grant
Nursing
012208
TTBH QM PLAN
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Appendix B
Operating Policies:
SS1-05.04
Effective Date:
January 1, 2007
Revised:
November 2007
CORPORATE COMPLIANCE
DOCUMENTATION AND CLAIMS INTEGRITY PLAN
I.
PURPOSE:
A.
It is the practice of Tropical Texas Behavioral Health (TTBH) to obey the law and
to follow ethical business and service practices especially as it pertain to
quantitative and qualitative documentation requirements of professional services
and fee and claims billing. TTBH requires its employees, volunteers and contract
providers to be fully informed about and in compliance with all applicable laws
and regulations and regulatory requirements.
B.
TTBH has developed a fraud and abuse compliance program which sets out the
responsibilities and obligations of all employees, volunteers and contract
providers regarding submissions for reimbursement to Medicare, Medicaid and
other government payers for services rendered by TTBH and any of its
employees, volunteers and contract providers, subsidiaries, divisions and
contractors. In addition, this Plan is intended to apply to all business arrangements
with physicians, vendors and other persons which may be impacted by federal or
state laws relating to claims fraud and abuse.
C.
In order to support this commitment, TTBH has established the following:
TTBH QM PLAN
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1.
Designation of a TTBH official (Corporate Compliance Officer)
responsible for directing the effort to enhance compliance, including
implementation of the Plan.
Odilia Garcia
Email: odgarcia@ttbh.org
Phone: 956-289-7087 / 1-877-289-5880
Fax: 956-289-7128
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
II.
Incorporation of standards and procedures which guide TTBH employees,
volunteers and contract providers and others involved with operational
practices and administrative guidelines;
Identification of legal issues that may apply to business relationships;
Development of compliance initiatives/requirements at the unit level;
Coordinated training of clinical and administrative staff, volunteers, and
contract providers concerning applicable compliance requirements and
TTBH procedures;
A uniform mechanism for employees, volunteers and contract providers,
to raise questions and receive appropriate guidance concerning operational
compliance issues;
Regular review and audit to assess compliance to identify issues requiring
further education and to identify potential problems;
A process for employees, volunteers and contract providers, to report
possible compliance issues and for such report to be fully and
independently reviewed by the Corporate Compliance Officer;
Enforcement of standards through well publicized disciplinary guidelines.
Formulation of corrective action plans to address any compliance
problems which are identified;
Regular review of the overall compliance effort to ensure that operational
practices reflect current requirements that other adjustments are made to
improve TTBH operations;
Coordination between TTBH departments and divisions and contract
providers to ensure effective compliance in areas where activities might
overlap.
SCOPE
A.
This Plan applies to all TTBH staff, volunteers, contractors, and service activities
and administrative actions governed by federal and state regulations related to
health care providers.
B.
It is the intent of TTBH that the scope of all documentation and claims
compliance polices and procedures should promote integrity, support objectivity
and foster trust between providers and clients and payors.
TTBH QM PLAN
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III.
IV.
COMPLIANCE OFFICER
A.
The primary responsibility for implementing and managing TTBH’s compliance
plan shall be assigned to the TTBH Compliance Officer. The Compliance Officer
will report documentation and claims issues directly to the Chief Executive
Officer (CEO) and to the Chief Administrative Officer (CAO) and as required, to
the governing body of TTBH. The TTBH Board of Trustees endorses this activity
and requires that all TTBH staff, volunteers, contract providers and affiliates to
comply with state and federal guidelines related to billing and claims as well as
federal and state laws related to fraud, waste and abuse.
B.
The Compliance Officer will, with oversight of the CEO and the CAO and the
assistance of the TTBH legal counsel where appropriate, perform the following
activities:
1. Review and amend as necessary, the Code of Conduct for all TTBH
employees, volunteers and contract providers.
2. Assist in the review, revision, and formulation of appropriate guidelines for all
activities and functions of TTBH, which involve issues of compliance.
3. Develop methods to ensure TTBH employees, volunteers and contract
providers and vendors are aware of the TTBH Code of Conduct and Corporate
Compliance Policy and understand the importance of compliance.
4. Developing and delivering educational and training programs.
5. Coordinate compliance reviews and audits in accordance with TTBH
procedures.
6. Receive and investigate instances of suspected compliance issues, as set forth
in Sections IX, X and XI of this Plan.
7. Assist in the development of appropriate corrective actions as set forth in
Section XI of this Plan.
8. Prepare Annual Compliance Review, as set forth in Section XII of this Plan.
9. Prepare Annual Corporate Compliance Work Plan, as set forth in Section XIII
of this Plan
10. Prepare proposed revisions to the Compliance Plan, as set forth in Section
XIV of this Plan.
11. Provide other assistance as directed by the CEO and CAO.
COMPLIANCE COMMITTEE
A.
A Compliance Committee is established to assist the Compliance Officer in the
development, implementation and monitoring of compliance efforts. The
Compliance Committee will consist of members appointed by TTBH’s CEO.
Members of the committee will be representative of individuals involved in the
billing and claims process of the TTBH and will serve two (2) year terms. The
Compliance Officer will serve as the chair of the committee.
B.
The committee’s responsibilities include’
1.
Analyzing the organization’s regulatory environment;
TTBH QM PLAN
Page 23
2.
3.
4.
5.
6.
7.
V.
Assessing existing and future policy and procedure needs to assure
compliance;
Working with appropriate units, as well as affiliated providers to develop
standards of conduct and policies and procedures which promote
adherence with TTBH Compliance Plan;
Recommending and monitoring the development of internal systems and
controls to carry out TTBH’s standards, polices and procedures as part of
daily operations;
Determining the appropriate strategy/approach to promote compliance
with the program and detection of any potential violations, such as through
hotlines and other fraud reporting mechanisms;
Developing a system to solicit, evaluate and respond to complaints and
problems;
Monitoring internal and external audits and investigations for the purpose
of identifying compliance issues by TTBH and its contracts and
implementing corrective and preventive actions plans as necessary.
STAFF TRAINING
A.
All staff, volunteers and contract providers providing services or involved in the
billing and claims process must participate in billing and claims compliance
training. This training shall be documented and all staff must demonstrate
competency before they are allowed to submit bills and claims of services
rendered. Individual staffs are responsible for maintaining compliance with TTBH
billing and claims procedures and their managers are required to assure staff
under their supervision is performing as required. TTBH has also adopted a Code
of Conduct to guide all of its business activity.
B.
All new hires receive Corporate Compliance training at new employee
orientation. They demonstrate corporate competence and acknowledge the Code
of Conduct as a condition of TTBH employment. All staff will attend Corporate
Compliance training, demonstrate corporate citizenship and acknowledge the
Code of Conduct annually thereafter. Management staff may request additional
Corporate Compliance training at any time.
C.
STAFF EDUCATION
1.
Claims Development and Submission
TTBH will provide no less than one (1) hour annually of training related
to one or more of the following areas to direct service and billing and
claims staff;
a.
TTBH’s compliance program,
b.
An overview of the fraud and abuse laws as they relate to the
claim development and submission process,
c.
The consequences to both individuals and TTBH of failing to
comply with applicable laws.
TTBH QM PLAN
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2.
Payments for Referrals and Related Fraud and Abuse Issues.
TTBH will provide the following education to employees, volunteers and
contract providers involved in negotiating business relationships with
physicians, providers, and vendors on behalf of TTBH. Such training will
include, at a minimum, not less than one (1) hour annually of training
relating to one or more of the following subjects:
a.
TTBH’s compliance program;
b.
An overview of the fraud and abuse laws as they relate to
prohibitions against payments for referrals, kickbacks and
rebates, and other illegal inducements; and
c.
The consequences to both individuals and TTBH of failing to
comply with applicable laws.
3.
Documentation.
TTBH shall document the training provided to each employees, volunteers
and contract providers. The documentation shall include the name and
position of the employees, volunteers and contract providers, the date and
duration of the educational activity or program; and a brief description of
the subject matter of the education.
All training materials and curriculum directed to address regulatory
compliance issues will be reviewed and updated as needed by the
Compliance Officer.
D.
STAFF CODE OF CONDUCT
A.
This Code of Conduct has been adopted by the Board of Trustees of
TTBH to provide guidance to TTBH employees, volunteers and contract
providers as it relates to documentation, billing and other claims related
issues. This Code adheres to and promotes TTBH’s Mission and Goals
and is required of all staff at all times. TTBH’s Mission and Goals may be
found in the Employee’s Handbook.
B.
The Principles set forth in this Code of Conduct shall be distributed to all
employees, volunteers and contract providers upon hire and periodically
thereafter. All employees, volunteers and contract providers are
responsible to ensure their behavior and activities are consistent with this
Code and understand that failure to maintain this Code may result in
termination of employment.
C.
As used in this Code of Conduct, the terms “officer,” “director,”
“employees, volunteers and contract providers,” include any persons who
TTBH QM PLAN
Page 25
fill such roles or provide services on behalf of TTBH or any of its
divisions, subsidiaries, or operating or business units.
Principle 1 – Service Delivery
TTBH provides quality behavioral healthcare with respect, dignity
and cultural sensitivity, through the efficient and effective delivery
of services. TTBH continues its commitment to excellence and will
be an innovative provider of comprehensive and compassionate
behavioral health services. We will treat all stakeholders with
honesty, fairness and respect.
Principle 2 – Legal Compliance
All employees, volunteers and contract providers of TTBH will
strive to ensure all activity by or on behalf of the organization is in
compliance with applicable federal and state laws and regulations.
Principle 3 – Business Ethics and Relationships
To fulfill TTBH’s commitment to the highest standards of business
ethics and integrity, employees, volunteers and contract providers
will accurately and honestly represent TTBH and will not engage
in any activity or scheme intended to defraud anyone of money,
property or honest services. Business transactions with vendors,
contractors, and other third parties shall be transacted free from
offers or solicitation of gifts and favors or other improper
inducements in exchange for influence or assistance in a
transaction.
Principle 4 – Human Resource
TTBH is an equal opportunity employer and does not discriminate
in its hiring practices. Employee files are confidential, and access
to them is limited to the individual and his/her supervisory
personnel and any other persons who have obtained the
employee’s consent. Other access is only permitted by applicable
law and regulation.
Principle 5 – Conduct
At time of orientation, all employees read and sign polices related
to ethical conduct, conditions of employment, sexual harassment,
and drugs and alcohol in the workplace. Failure to adhere to these
standards of conduct will result in disciplinary action, which could
include termination.
Principle 6 – Confidentiality
TTBH employees, volunteers and contract providers shall strive to
maintain the confidentiality of clients and other confidential
TTBH QM PLAN
Page 26
information in accordance with applicable legal and ethical
standards and all federal and state laws.
Principle 7 – Conflicts of Interest
Directors, officers, committee members and key employees,
volunteers and contract providers owe a duty of loyalty to the
organization. Persons holding such positions may not use their
positions to profit personally or to assist others in profiting in any
way at the expense of the organization.
Principle 8 – Protection of Assets
All employees, volunteers and contract providers will strive to
preserve and protect TTBH’s assets by making prudent and
effective use of TTBH’s resources and properly and accurately
reporting all activities and costs.
Principle 9 – Marketing, Public Affairs & Outreach Programs
TTBH’s marketing, public affairs and outreach programs are
designed to inform interested parties about our programs and
services we provide. These programs include but are not limited to
advertising, direct mail, media relations, publications, public
policy advocacy, speaking engagements, events and seminars. We
are committed to promoting truthful and accurate information at all
times to all audiences. Our marketing, public affairs and outreach
programs comply with ethical standards of leading industry and
professional associations.
VI.
PHYSICIAN CONTRACTS
A.
It is the policy of TTBH that all Federal and state anti-kickback and physician
self-referral laws, which prohibit the offer or payment of any compensation to any
party for the referral of clients, be followed. All physician contracts shall be
reviewed and approved by legal counsel prior to the execution to avoid violation
of federal anti-kickback or self-referral laws.
B.
To comply with applicable laws regarding client referrals, TTBH:
1.
Shall comply with the polices governing gifts set forth in TTBH
Handbook;
2.
Shall not submit nor cause to be submitted a bill or claim for
reimbursement for services provided pursuant to a prohibited referral.
TTBH also shall ensure that any physician with whom an agreement is executed, and/or
who serves as an attending physician in the facility, has current valid licenses as required
by law and has not been excluded from participation in the Medicare and Medicaid
programs.
TTBH QM PLAN
Page 27
VII.
DOCUMENTATION AND CLAIMS AUDITS
A.
Ongoing review and audit of all TTBH operations, including contracted services
will occur under the supervision of the TTBH Compliance Officer. Such reviews
and audits will be regular and ongoing, the results of which will be reported to
TTBH’s CEO, the Compliance Committee and the Board of Trustees.
B.
The TTBH Compliance Officer may, after consultation with the CEO and TTBH
legal counsel, engage external experts to perform focused reviews as needed.
Monitoring shall occur at the provider level as well as with through third party
review coordinated by the Compliance Officer. Billing and claims issues
identified through reviews shall be reported by the TTBH Compliance Officer to
the CEO and TTBH’s legal counsel and others as needed.
C.
In order to assure compliance with Medicare/Medicaid and other government
funded healthcare payment programs. TTBH has adopted a billing audit
procedure to assist in its efforts to monitor the accuracy of claims. This procedure
is adopted to ensure that representative claims from all of TTBH’s individual and
institutional providers are periodically reviewed in a manner that will enable
TTBH to promptly identify deficiencies in the claim development and submission
process, which could result in inaccurate claims.
D.
AUDIT PROCESS
TTBH will conduct audits in accordance with the schedule set forth below. The
audits will be executed in accordance with the polices and procedures contained
in the applicable auditing tool or protocol utilized by TTBH. TTBH will devote
such resources as are reasonably necessary to ensure that the audits are initiated
by persons with appropriate knowledge and experience to reflect changes in
applicable laws and regulations.
E.
AUDIT PLAN
1.
Chart Audits. It is the policy of TTBH and the responsibility of each
department manager to ensure that employees, volunteers and contract
providers who have a direct impact on the claim development and
submission to process are provided adequate and appropriate training. One
mechanism for ensuring the accuracy of TTBH’s claims is to ensure that
each new employee, volunteers and contract providers adequately
understands the essential elements of his/her jobs functions. In furtherance
of this objective, it is the policy of TTBH to review the work of
employees, volunteers and contract providers in the manner set forth
below:
TTBH QM PLAN
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2.
Billers and Coders. Each employee, volunteer and contract provider
whose principle function includes the billing or coding of claims to be
submitted to the Medicare or Medicaid program shall have all of such
employee’s, volunteer’s and contract provider’s claim related work
reviewed by the employee’s, volunteer’s and contract provider’s
supervisor for a period of not less than 15 days following the
commencement date, or such later date as the manager is satisfied that the
accuracy of the employees, volunteers and contract provider’s claims
justify cessations of the reviews.
a.
Registration. The work of every employee, volunteer and
contract provider new to registration shall be reviewed for a
period of not less than 30 days following the commencement
date, or such later date as the manager is satisfied that the
accuracy of employee’s, volunteer’s and contract providers’
claims justify cessation of the reviews.
b.
Combine with Clinical Staff. Patient care providers shall be
provided written guidelines with respect to documentation
services rendered by such providers at least one (1) time during
the first 60 days of employment of client care personnel, the
providers (manager, supervisor, or other appropriate persons)
shall review all of the provider’s documentation to ensure that
the provider is accurately and completely documenting the
services rendered by the provider. For the purpose of this policy,
the term provider includes physicians, nurses, allied health
professionals and other persons who may document the delivery
of services in the TTBH’s records (including medical records).
c.
Period Audits. TTBH will conduct periodic audits of claims
submitted to the Medicare and Medicaid programs. At a
minimum, TTBH’s audit activities shall consist of: (1) individual
provider audits – the audit of not less than 100 claims annually of
a sample randomly selected within an individual program site.
Focus audits may also be conducted on individual staff.
d.
Complaint Audits/Focused Reviews. Upon receipt of a credible
allegation or complaint alleging improper or inaccurate billing
practices at TTBH, TTBH shall undertake a review of the matter,
including an extensive audit as dictated in the TTBH Corporate
Compliance Policy.
VIII. COST REPORT SUBMISSIONS
TTBH QM PLAN
Page 29
A.
TTBH is required to submit various cost reports to federal and state governments
in connection with its operation and to receive payment. Such reports will be
prepared as accurately as possible and in conformity with applicable law and
regulations. If errors are discovered, billing personnel shall contact an immediate
supervisor promptly for advice concerning how to correct the error(s) and notify
the appropriate payor. In some instances errors shall also be reported to the TTBH
Compliance Officer if it is suspected that the error has affected the TTBH wide
billing process or jeopardized the TTBH’s on-going participation in federally
funded programs.
B.
In the preparation of cost reports, for Medicare or Medicaid or any other state or
federal cost reporting documents, all employees, volunteers and contract
providers involved in the preparation shall ensure that:
1.
2.
3.
4.
5.
IX.
Information provided for or used in the cost report is adequately supported
by documentation.
Non-allowable costs are properly identified and removed;
Statistics are based on reliable information;
Related parties are identified and their services treated in accordance with
program rules; and
Costs claimed in non-conformity with program rules, as interpreted by the
Medicare or Medicaid program or the fiscal intermediary, either are
disclosed in a letter accompanying the cost report or are in protested
amounts.
REPORTING COMPLIANCE ISSUES
a.
Billing and claims shall be made only for services provided to clients, directly or
under contract pursuant to all terms and conditions specified by the government or
third-party payor and consist with industry practice. TTBH and its employees,
volunteers and contract providers shall not make or submit any false or
misleading entries on any bills or claim forms, and no employees, volunteers and
contract providers shall engage in any arrangement or participate in such an
arrangement at the direction of another employees, volunteers and contract
providers (including any supervisor), that results in such prohibited acts. Any
false statements on any bill or claim form shall subject the employees, volunteers
and contract providers to disciplinary action by TTBH, including possible
termination of employment.
b.
False claims and billing fraud may take a variety of different forms, including but
not limited to, false statements supporting claims for payment, misrepresentation
of material facts, concealment of material facts or theft of benefits or payments
from the part entitled to receive them. TTBH and employees, volunteers and
contract providers shall specifically refrain from engaging in the following billing
practices:
TTBH QM PLAN
Page 30
1.
2.
3.
4.
5.
6.
7.
8.
9.
Making claims for items or services not rendered or not provided as
claimed;
Submitting claims to any payor, including Medicare and Medicaid, for
services or supplies that are not medically necessary;
Submitting claims for items or services that are not provided as claimed;
Submitting claims to any payor, including Medicare and Medicaid, for
individual items or services when such items or services either are
included in the TTBH’s per diem rate or are of the type that may be billed
only as a unit and not unbundled;
Double billings (billing for the same item or service more than once);
Paying or receiving anything of financial benefit in exchange for Medicare
or Medicaid referrals (such as receiving non-covered medical products at
no charge in exchange for ordering Medicare-reimbursed products); or
Billing clients for services or supplies that are included in the per diem
payment from Medicare, Medicaid, a managed care plan or other payor.
Submitting a false statement, false information, or misrepresentation or
omitting pertinent facts to obtain a greater compensation than the provider
is legally entitled.
Submitting false statement, false information, or misrepresentation, or
omitting pertinent facts on any application or any document requested as a
prerequisite for payment.
c.
If an employee, volunteer or contract provider has any reason to believe that
anyone (including themselves) is engaging in false billing practices, that
employee, volunteer or contract provider shall immediately report the practice to
TTBH’s Compliance Officer at 956-289-7087. All reports to the TTBH
Compliance Officer remain confidential.
d.
Failure to act when an employee, volunteer or contract provider has knowledge
that someone is engaged in false billing practices shall be considered a breach of
that employee’s, volunteer’s or contract provider’s responsibilities and shall
subject him/her to disciplinary action by TTBH, including possible termination of
employment and prosecution.
e.
Questions about operational issues should be directed to person(s) having
supervisory responsibility for a specific clinical provider, program or unit.
Training materials will instruct TTBH employees, volunteers and contract
providers that they need to report to the TTBH Compliance Officer any activity
that they believe to be inconsistent with TTBH policies and or legal requirements.
The materials will explain how the Compliance Officer can be contacted.
f.
Employees, volunteers and contract providers must immediately report all known
or suspected instances of documentation and claims fraud to the Compliance
Officer. Employees, volunteers and contract providers who become aware of
potential violations of professional licensing and certification requirements are to
TTBH QM PLAN
Page 31
report them immediately to their immediate supervisor and to the Compliance
Officer.
X.
g.
The Qui Tam Act/Whistleblowers Protection Act protects all employees,
volunteers and contract providers who report in good faith of known or suspected
compliance issues. No employees, volunteers or contract providers shall be
subjected to retaliation or harassment of any kind. Concerns about possible
retaliation or harassment should be reported to the Compliance Officer, who will
immediately report to the CEO.
h.
TTBH Compliance Officer will maintain a log of compliance concerns that are
reported to the Compliance Office. All reports will be undertaken with a
preliminary investigation, which will determine if a full investigation is
warranted. In instances where a full inquiry is not warranted, the log should
explain why no investigation was undertaken. This log will record the issue, the
clinical providers, units, departments and/or organizations affected, the result of
the any investigation and whether the issue has been addressed. Each month, a
copy of this log will be provided to the CEO. The log reports should note any
issues, which remain open. This log is to be treated as a confidential document
and access should be limited to those people at TTBH who have responsibility for
compliance matters.
COMPLIANCE HOTLINE
TTBH has established a telephone “Hotline” to permit compliance issues to be reported
on a confidential basis. The Hotline 1-877-289-5880 is available 24 hours a day, seven
days a week, and the Compliance Officer will ensure that training and educational
materials include information on how the Hotline is accessed and all other reporting
mechanisms.
XI.
INVESTIGATING COMPLIANCE ISSUES
A.
Whenever conduct is inconsistent with TTBH’s Corporate Compliance operating
procedures and is reported, the TTBH Compliance Officer should determine
whether there is reasonable cause to believe that a material compliance issue may
exist. If a preliminary review indicates that a problem may exist, an inquiry into
the matter will be undertaken. Responsibility for conducting the review will be
decided on a case-by –case basis. The results of the inquiry will be made available
to the CEO and CAO.
B.
TTBH employees, volunteers and contract providers will be expected to cooperate
fully with inquiries undertaken pursuant to this plan. To the extent practical and
appropriate, efforts should be made to maintain the confidentiality of such
inquiries and the information gathered.
TTBH QM PLAN
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C.
Investigation of all calls and reports of potential fraud shall occur according to the
following guidelines:
1.
Purpose of the Investigation. The purpose of the investigation shall be to
identify those situations in which the laws, rules and standards of the
Medicare and Medicaid programs may not have been followed; to identify
individuals who may have knowingly or inadvertently caused claims to be
submitted or processed in a manner which violated Medicare or Medicaid
laws, rules or standards; to identify individuals who may have knowingly
or inadvertently violated the Codes of Conduct; to facilitate the correction
of any practices not in compliance with the Medicare or Medicaid laws,
rules and standards; to implement those procedures necessary to insure
future compliance; to protect TTBH in the event of civil or criminal
enforcement actions, and to preserve and protect TTBH’s assets.
2.
Control of Investigations. All reports received, whether by a manager of
a TTBH program component or directly through an internal audit shall be
forwarded to the Compliance Officer. The Compliance Officer will be
responsible for directing the investigation of the alleged problem or
incident or recommending that legal counsel conduct the investigation.
Under the direction of the CEO, in undertaking this investigation, the
Compliance Officer may solicit the support and assistance of legal counsel
and internal or external auditors, and internal or external resources with
knowledge of the applicable laws and regulations and required polices,
procedures or standards that relate to the specific problem in question.
3.
Investigative Process. Upon receipt of an employee’s, volunteer’s or
contract provider’s complaint, report or other information (including audit
results), which suggests that the existence of a serious pattern of conduct
in violation of the compliance polices, or applicable laws or regulations,
an investigation under the direction and control of the Compliance Officer
shall be commenced. Steps to be followed in undertaking the investigation
shall include at a minimum:
a.
TTBH QM PLAN
The Compliance Officer will notify the CEO and the CAO of the
nature of the compliant and the Compliance Officer will conduct
a preliminary investigation into the allegation to determine the
level of investigation necessary based on the seriousness of the
allegation. After the CEO and CAO review the preliminary
investigation, they will determine and advice the Compliance
Officer whether to proceed with a full formal investigation. In
some instances a complaint may be resolved with a simple phone
call while others will require a formal investigation. If the
Compliance Officer has reasonable cause to believe that a risk
issue exits, the Compliance Officer will report the issue to the
CEO and CAO who will make a case by case decision as to
Page 33
whether an employee, volunteer or contract provider should be
removed from his/her work area during the investigation.
b.
The investigation shall be commenced as soon as possible but in
no more than five (5) business days following the receipt of the
compliant or report. A full investigation will not exceed more
than 30 business days. In instances where additional time is
needed, a request by the Compliance Officer with an explanation
as to the reason why may be sent to and approval may be granted
by the CEO. The investigations shall include, as applicable, but
need not be limited to:
1.
2.
TTBH QM PLAN
An interview of the complainant, the person who is the focus
of the complaint and other persons who may have knowledge
of the alleged problem or process and a review of the
applicable laws and regulations which might be relevant to or
provide guidance with respect to the appropriateness or
inappropriateness of the activity in question, to determine
whether or not a problem actually exists.
a.
If the preliminary review results in conclusions or
findings that are permitted under applicable laws,
regulations or policy or that the complained of act
did not occur as alleged or that it does not otherwise
appear to be a problem, the investigation shall be
closed. The CEO, CAO, and the person who is the
focus of the investigation will be notified that the
case has been closed.
b.
If the preliminary investigation concludes that there
is the existence of a serious pattern of conduct in
violation of the compliance plan, improper billing
occurring, that practices are occurring which are
contrary to applicable law, inaccurate claims are
being submitted, or that additional evidence is
necessary, the investigation shall proceed to the
next step—a full formal investigation. If a full
formal investigation is required, the CEO, CAO and
the appropriate Program Director shall be notified a
formal investigation will be required.
The identification and review of representative bills or claims
submitted to the Medicare/Medicaid programs to determine
the nature of the problem, the scope of the problem, the
frequency of the problem, the duration of the problem, and
the potential financial magnitude of the problem.
Page 34
3.
Identifying witnesses, taking written statements, and
interviews of the person or persons in the departments and
institutions who appeared to play a role in the process in
which the problems exists. The purpose of the interview will
be to determine the facts related to the complained of
activity, and may include, but shall not be limited to:
a.
b.
c.
d.
e.
f.
g.
h.
TTBH QM PLAN
Individual understanding of the Medicare and
Medicaid laws, rules and regulations.
Collecting documentary and demonstrative
evidence such as medical records, financial
records, Human Resource files and records,
copies of contracts or agreements with employees,
agents, vendors an external contractors which
describe business relationships;
The identification of persons with supervisory or
managerial responsibility in the process;
The adequacy of the training of the individuals
performing the functions within the process;
The extent to which any person knowingly or with
reckless disregard or intentional indifference acted
contrary to the Medicare or Medicaid laws, rules
or regulations;
The nature and extent of potential civil or criminal
liability of individuals or TTBH; and
Drawing conclusions and reporting investigative
findings and preparation of a summary report
which (1) defines the nature of the problem (2)
summarizes the investigation process, (3)
identifies any person whom the investigator
believes to have either acted deliberately or with
reckless disregard or intentional indifference
toward the Medicare/Medicaid laws, rules and
policies, (4) if possible, estimates the nature and
extent of the resulting overpayment by the
government, if any.
When an investigation is concluded, and a case
has been confirmed, the Compliance Officer will
notify the CEO, CAO, Human Resource
Supervisor and the appropriate Program Director
of the findings. The Federal False Claims Act
requires that persons holding management
positions be held responsible for awareness and
practices of their staff. Persons in management
positions may be held accountable for the
Page 35
i.
j.
D.
foreseeable failure of staff to adhere to standards,
policies, regulations and laws whether there is
actual knowledge, deliberate ignorance or reckless
disregard on the part of the management staff.
When an investigation is concluded and a case has
been found to be unconfirmed, inconclusive or
unfounded, the Compliance Officer will notify the
CEO, CAO, and the appropriate Program Director
of the findings. The person who is the focus of the
investigation will be notified that the case has
been closed.
Investigation reports will have one of the four
findings:
i.
Confirmed—An
allegation
that
is
supported by evidence collected during an
investigation.
ii.
Unconfirmed—Evidence collected during
the investigation proved that the allegation
did not occur.
iii. Inconclusive—Evidence collected during
the investigation led to no conclusion or
definite result due to lack of witness or
other relevant evidence.
iv.
Unfounded—Allegation is determined not
to be true prior to any investigation.
ORGANIZATIONAL RESPONSE
1.
Criminal Activity. In the event TTBH uncovers what appears to be
criminal activity on the part of any employees, volunteers and contract
providers or program component, it shall undertake the following steps.
a.
b.
c.
TTBH QM PLAN
Immediately stop all billing related to the problem in the unit(s)
where the problem exists until such time as the offending
practices are corrected.
Initiate appropriate disciplinary action against the person or
persons whose conduct appears to have been intentional,
willfully indifferent or with reckless disregard for the Medicare
and Medicaid laws. Appropriate disciplinary action shall include,
at a minimum, the removal of the person from any position with
oversight for or impact upon the claims submission or billing
process and may include, in addition, suspension, demotion and
discharge.
Make reports to governmental authorities and to law enforcement
officials as appropriate.
Page 36
2.
Non-Criminal Activity. In the event the investigation reveals billing or
other problems, which do not appear to be the result of conduct, which is
intentional, willfully indifferent, or with reckless disregard for the
Medicare and Medicaid laws, TTBH shall nevertheless undertake the
following steps.
a.
Improper Payments: In the event the problem results in
duplicate payments by Medicare or Medicaid, or payments for
services not rendered or provided other than as claimed, it shall:
1. Correct the defective practice or procedure as quickly as
possible;
2. Calculate and repay to the appropriate governmental entity
duplicate payments for improper payments resulting from the
act or omission;
3. Initiate such disciplinary action, if any, as may be appropriate
given the facts and circumstances. Appropriate disciplinary
action may include, but is not limited to, reprimand,
demotion, suspension and discharge.
4. Promptly undertake a program of education at the appropriate
business unit to prevent future similar problems.
b.
No improper Payment: In the event the problem has or does not
result in an overpayment by the Medicare or Medicaid program,
TTBH:
1. Correct the defective practice or procedure as quickly as
possible.
2. Initiate such disciplinary action, if any, as may be appropriate
given the facts and circumstances. Appropriate disciplinary
action may include, but is not limited to, reprimand,
demotion, suspension and discharge.
3. Promptly undertake a program of education at the appropriate
business unit to prevent future similar problems.
E.
STAFF DISCIPLINE
Employees, volunteers and contract providers may be subject to adverse
personnel action for failing to participate in organizational compliance efforts,
including but not limited to:
1.
The failure of an employee, volunteer or contract provider to comply with
TTBH policy and procedure and/or perform any obligation required of the
employees, volunteers or contract providers relating to compliance with
the program or applicable laws or regulations;
2.
The failure to report suspected violations of compliance programs laws or
applicable laws or regulations to an appropriate person; and
TTBH QM PLAN
Page 37
3.
The failure on the part of a supervisory or managerial employee, volunteer
and contract provider to implement and maintain policies and procedures
reasonably necessary to ensure compliance with the terms of the program
or applicable laws and regulations.
Adverse personnel action will follow TTBH’s existing employee, volunteer and
contract provider’s Human Resources polices and procedures.
XII.
CORRECTIVE ACTION PLANS
A.
Whenever a compliance issue has been identified, the Compliance Officer has the
responsibility and authority to take or direct appropriate action to address the
issue. The corrective action will be set forth in writing. In developing the
corrective action plan, the Compliance Officer should obtain advice and guidance
from others as necessary, such as the CEO, CAO, the appropriate Program
Director, the Human Resource Supervisor and TTBH’s legal counsel if needed.
Information about corrective action plans shall be provided to the TTBH
Compliance Committee and the CEO.
B.
Corrective Action shall be pre-approved by, at a minimum, the CEO and CAO.
Corrective action should be designed to ensure not only that the specific issue at
hand is addressed, but also systems are placed in operation, which would prohibit
the repeat of similar problems. Corrective actions may require certain functions be
reassigned, training take place, restrictions on personnel take place, reassignment
of duties, terminating contractual relationships, that repayment be made, or that
the matter be disclosed externally. Corrective action may include
recommendations that a sanction or disciplinary action be imposed. Moreover, if
the Compliance Officer believes that any non-compliance has been willful, that
belief and the basis for it, shall be reported to the CEO, CAO and to the
Compliance Committee. TTBH employees, volunteers and contract providers who
have engaged in willful billing and claims misconduct will be subject to the
disciplinary action up to and including termination and criminal prosecution.
XIII. ANNUAL COMPLIANCE REVIEW
On or before the end of each fiscal year, the Compliance Officer will arrange for a review
of TTBH’s current compliance and regulatory operations. The purpose of the review,
which shall include probe samples, as the Compliance Officer considers advisable, is to
ascertain whether the compliance operations of TTBH are within standards. A written
report describing the results of the audit shall be prepared on or before September 1 of
each year.
XIV. ANNUAL REPORT AND WORK PLAN
TTBH QM PLAN
Page 38
A.
XV.
On or before September 1, the Compliance Officer shall prepare and distribute to
the CEO and to TTBH’s governing board a report describing the compliance
efforts during the preceding fiscal year and a proposed work plan for next fiscal
year. The report shall include the following elements:
1.
A summary of the general compliance activities undertaken during the
preceding fiscal year, including any changes made to the Compliance
Plan;
2.
A summary of the Hotline log for the preceding fiscal year;
3.
A summary of the preceding fiscal year’s Compliance Review;
4.
A description of actions taken to ensure the effectiveness of the training
and education efforts;
5.
A summary of actions to ensure compliance with TTBH’s policy on
dealing with excluded persons;
6.
Recommendations and result of recommendations for changes in the Plan
that might improve the effectiveness of TTBH’s compliance effort; and
7.
A copy of the proposed work plan for the next year.
8.
Any other information specifically requested by the CEO and the Board of
Trustees.
REVISIONS TO THE INTEGRITY PLAN
This Compliance Plan is intended to be flexible and readily adaptable to changes in
regulatory requirements and in the health care system as a whole. The Plan shall be
regularly reviewed to assess whether it is working and effective. TTBH’s CEO shall have
the authority to amend the plan at any time.
XVI. EXCLUDED PERSONS
A.
TTBH complies with 42 U.S.C. 1320a-7a(a)(6), which imposes penalties for
“arranging (by employment or otherwise) with an individual or entity that the
person knows or should know is excluded from participation in a Federal health
care program for the provision of items or services for which payment may be
made under such a program”. Accordingly, prior to employing or contracting
with any provider for whom TTBH intends to submit bills to a Federal health
program, TTBH confirms the provider has not been excluded from participation
in federally funded programs. Those steps will include checking the provider’s
name against the HHS/OIG Cumulative Sanctions list and the GSA Debarred
Bidders List. TTBH’s Compliance Officer will assure TTBH staff responsible for
credentialing has addressed this with each new hire. TTBH will neither use nor
hire a provider who is barred from participation in a federally funded program. If
TTBH learns that any of its current providers (either as employees, volunteers or
contract providers) has been proposed for exclusion or excluded, it will remove
such persons from any involvement in or responsibility for Federal health
insurance programs until such time that TTBH has confirmed the matter has been
resolved.
TTBH QM PLAN
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XVII. REFERENCES
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
The Deficit Reduction Act-2005
The Federal Anti-Kickback Statute
The Stark Law
The Texas Illegal Remuneration Statute
Civil Money Penalties Statute
The Federal False Claims Act
The Medicaid Fraud Prevention Act
Center for Medicare and Medicaid Services
Office of the Attorney General
U.S. Department of Justice / Federal Bureau of Investigation
TTBH QM PLAN
Page 40
UTILIZATION MANAGEMENT PLAN
I. PURPOSE:
A.
B.
C.
D.
E.
F.
To monitor and improve the effective and efficient utilization of Tropical Texas
Behavioral Health’s (TTBH) clinical resources.
To assist in the relentless pursuit of a higher quality of care through the
analysis, review, and evaluation of clinical practices and systems within
TTBH.
To address any instances of under-utilization, over-utilization, or inefficient
utilization of TTBH’s resources.
To better define who is eligible for services, what services will be provided,
the price that will be paid and the expected outcomes for people and the
system.
To ensure that people receive the services they need and ensure equitable
distribution of available resources.
Strive to achieve a balance between the demand for services, availability of
resources, and the needs and well being of persons in need of mental health
services.
II. OBJECTIVES:
A.
B.
C.
D.
E.
To develop and maintain a Utilization Management (UM) Program which
remains flexible to meet the needs of our clients, facilitating access to care
rather than as a barrier.
To evaluate medical and clinical necessity for behavioral health services
utilizing written and medically objective level of care guidelines, that has been
established by physicians and licensed clinicians.
To establish the process used to review and approve the provision of
professional services, including an appeal system for adverse determinations.
To establish mechanisms to report quantitative and qualitative information on
service activity and outcomes to clients and providers in a timely manner.
To provide a mechanism to identify potential quality issues for review by the
Performance Improvement Committee (PICC), and EMT Executive
Management Team.
TTBH QM PLAN
Page 41
F.
G.
H.
To use data to identify patterns of utilization, work with clinicians to determine
if the patterns and variation are desirable or not; and work with providers to
make needed improvements.
To conduct retrospective reviews in conjunction with quality management,
claims management and data verification to maximize the use of staff
resources.
To integrate utilization data into various functions, including strategic and
local planning.
III. UTILIZATION OVERSIGHT
The statewide UM Committee will provide guidance to TTBH’s utilization management
processes through making recommendations which impact policy, implementation and
oversight processes.
The State will monitor TTBH’s data entered into WebCare and CARE on a routine basis
to determine compliance and performance, to include the outcomes of service delivery.
They will review data that reflects patterns of current service utilization and the
clinical/assessment decisions used by TTBH to make those decisions. When outliers or
trends are detected which reflect unusual or unexpected results, the State will initiate
contact and the causes will be explored. The State and TTBH will collaborate to ensure
that necessary oversight and improvement occurs and management decisions can be
made. The following will be monitored by the State: TRAG (Adult and Child), UM
Clinical Guidelines (Adult and Child), Complaints, Appeals and Overrides, and TTBH’s
UM Plan
IV. UTILIZATION MANAGEMENT PROGRAM
A.
PURPOSE
TTBH uses sound and objective principles for managing both business and clinical
decisions in a manner that ensures that people receive quality, cost effective services in
the most appropriate treatment setting, in a timely manner and TTBH has an effective
mechanism to manage the utilization of clinical resources. UM Staff and the UM
Committee identify and monitor patterns of over utilization and under utilization and
other utilization problems that compromise care or inappropriately utilize resources.
TTBH strives to achieve balance between the demand for services, availability of
resources and the needs and well being of persons in need of mental health services.
B.
OVERVIEW OF UM PROGRAM
Utilization management is a dynamic process that provides timely, accurate and
relevant information to facilitate fact-based decision making by TTBH and results in
positive outcomes for persons receiving services and improved provider practice. UM
Staff and the UM Committee make recommendations, and participate in, interventions
TTBH QM PLAN
Page 42
to make utilization of services more effective, efficient and consistent with contractual
requirements and the local planning process.
UM responsibilities include:
•Developing, implementing and improving TTBH’s UM Program so that it meets the
needs of people receiving services, the community, TTBH and the State;
• Conducting prospective, concurrent and retrospective reviews to authorize services
using the State’s UM Guidelines and ensuring that people are receiving and benefiting
from services;
• Applying objective criteria when making adverse determinations or denials;
• Ensuring notification of adverse determinations to the person requesting or receiving
services and his/her provider, to include information on how to file an appeal;
• Managing appeals in a timely manner according to established procedures;
• Implementing utilization care management for persons with special circumstances to
ensure their access to needed services;
• Collaborating with other TTBH functions such as Quality Management, Financial
Services and Network Management in the use of UM data and with providers in
planning interventions to improve provider practice;
• Coordinating and supporting the activities of the UM Committee; and
• Participation on the state level in the development and improvement of the UM
Guidelines.
C.
UM PROGRAM PLAN
The UM Manager, under the direction of the UM psychiatrist and in consultation with the
UM Committee, assumes the responsibility for execution of the UM Plan. The
procedures, authority, and accountability outlined in the UM Plan are designed to
ensure effective implementation of TTBH’s UM Program and to meet the State’s rules
and contractual requirements. TTBH’s UM Program Plan shall be reviewed and
updated annually or more frequently as indicated. TTBH is responsible for distributing
the UM Plan and for training network providers on relevant aspects of the UM plan.
D.
UM FUNCTIONS
1.
Physician oversight of UM processes. Must be done by a board eligible
psychiatrist who possesses a license to practice medicine in Texas. The
oversight function includes approval of all policies and procedures related to UM,
to include changes based on new technology and availability of resources.
2.
Consistent application of the UM Guidelines and processes. This is
accomplished through ongoing supervision of staff and UM operations
management.
3.
Utilization reviews and authorizations for all service packages as indicated by the
State Utilization Management Guidelines.
TTBH QM PLAN
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4.
Collection, analysis, and documentation of utilization information.
This
information is to be used in ongoing analysis of systemic issues that may support
clinical and management decisions.
5.
Utilization care management. This function exists to accommodate unusual
circumstances where telephonic and documentation review might not be
sufficient to make an appropriate authorization decision. This function includes
coordinating services for persons with special circumstances and needs, and
facilitating authorization where it cannot be effectively conducted through the
usual processes, necessitating direct contact with the provider, client and/or
family members.
6.
Utilization Management Committee: Consists of TTBH Physician, TTBH UM and
quality management staff, mental health professionals, financial and information
management staff, and other TTBH staff. The primary function of the UM
Committee is to monitor utilization of TTBH’s clinical resources to ensure they
are being expended effectively and efficiently. The UM Committee assists the
promotion , maintenance and availability of high quality care through the
evaluation of clinical practices, services and supports delivered by TTBH and its
contracted providers using clinical, encounter and administrative data and
performance measures.
7.
Provider Submission of Documentation and Request for Continued Stay: TTBH
will develop a process for provider submission of clinical information which will
include at minimum telephonic and/or electronic submission and will ensure that
client-specific information gathered for utilization review remains confidential in
accordance with all applicable laws and is shared only with those that have the
need for any authority to receive it.
8.
Adverse Determinations: An adverse determination applies to a person
requesting services that are denied and those persons who are receiving
services, who no longer meet UM criteria for that service(s) and for whom the
provider and client request additional authorization. The initial recommendations
to deny authorization for continued stay is made by the Utilization Manager who
then refers it to the TTBH UM Physician, who will make a decision based on all
available data. The final denial of services based on failure to meet clinical
criteria may only be made by a physician.
9.
Appeal of Adverse Determinations: TTBH will ensure client access to an
objective appeals process when services are denied, limited or terminated.
Clients funded by Medicaid are also afforded access to the Medicaid Fair
Hearing Process. TTBH will ensure that all providers and clients are provided
information about their right to appeal and the process to do so.
TTBH QM PLAN
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10.
TTBH UM Data Submission to the State: TTBH will submit utilization data to the
state according to the state MH BD LMHA Data Reporting Guidelines and the
State’s Performance Contract. If TTBH delegates any UM activities to an
external entity (to include another LMHA or ASO) TTBH will have a written
contract with the UM Contractor that is consistent with all applicable rules and
State Performance Contract requirements. TTBH will maintain its UM Committee
or designate another appropriate committee to:
 review the reports produced by the UM Contractor,
 make improvements in TTBH processes that impact utilization of resources;
and
 evaluate the effectiveness of interventions to improve provider practices.
E.
UTILIZATION REVIEW ACTIVITIES
Evaluating the adequacy, appropriateness and quality of services provided to persons
receiving services is a component of all Utilization Management review processes.
Although specified services are routinely reviewed, all TTBH mental health services are
subject to review when indicated, without regard to payment source. Decision made by
TTBH’s UM staff and UM Committee are based on objective and valid criteria and
standards approved by the State.
Utilization reviews are conducted for the following purposes:
1. Service Package Authorization: retrospective oversight of initial and subsequent
level of care assignments to ensure consistent application of State UM
guidelines.
2. Authorization for Continued Stay: concurrent review to establish need for
continued services or review of automatic authorizations.
3. Outlier Review: retrospective and concurrent review of data to identify outliers
followed by review of individual cases to determine need for change in level of
care assignment or service intensity. May result in referral for peer review or
other oversight activities.
4. Inpatient Admission and Discharge Planning: prospective or concurrent review of
inpatient admissions to ensure most clinically effective and efficient Length of
Stay. Review of discharge plans to ensure timely and appropriate treatment
following an inpatient stay.
5. Administrative Review: review of clinical and administrative documentation for
timeliness and adequacy of UM processes to include reimbursement, corporate
and contract compliance, data verification and rehabilitation plan oversight.
F.
INTER-AGENCY INTERFACE
Utilization Management is committed to not only reviewing practices related to resource
utilization, but also to taking action to modify inappropriate, inefficient or ineffective
utilization. Much of TTBH Utilization Management function overlaps or is reliant on
TTBH QM PLAN
Page 45
coordination with, Quality Management, Provider Relations, Claims/Reimbursement,
Management of Information Services and other service management functions.
Successful interface among the various authority functions of TTBH is essential for
effective and efficient management of resources, identification of gaps in service
delivery and resolution of over-and-underutilization of services/resources. Interface
between Utilization Management and other authority functions occurs through exchange
of data, information and reports, joint participation in a variety of committees and
collaboration in planning, projects and operational initiatives.
G.
UTILIZATION MANAGEMENT REPORTS
Utilization information from various data sources (e.g., CAM, encounter data, CARE,
etc.) is available via Business Objects and other programs. Business Objects reports
are created in an evolving and ongoing process, and variations of the following data
configurations will be available as they are created. Databased information illustrates
numerous aspects of service utilization, and will be shared across TTBH functional
areas, for management decisions.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20
21.
22.
23.
CLIENTS SERVED PREVIOUS TO AN AUTHORIZATION - ADULT
CLIENTS SERVED PREVIOUS TO AN AUTHORIZATION - CHILD
SERVICE AND AUTHORIZATION LAG AT INTAKE - ADULT
SERVICE AND AUTHORIZATION LAG AT INTAKE - CHILD
MEDICAID CLIENTS ON W.L. / W.L. - ADULT
MEDICAID CLIENTS ON W.L. / W.L. - CHILD
UM PERCENT OF SERVICES IN VIVO SUMMARY (HOURS) - ADULT
CLIENTS SERVED BUT NOT ASSESSED – ADULT (Over Served)
CLIENTS SERVED BUT NOT ASSESSED – CHILD (Over Served)
POPULATION BY LEVEL OF CARE MATRIX – ADULT
POPULATION BY LEVEL OF CARE MATRIX – CHILD
DISCHARGE REASON SUMMARY - ADULT
DISCHARGE REASON SUMMARY - CHILD
APPROPRIATENESS OF SERVICE AUTHORIZED CONTRACT MEASURE BY
MONTH - ADULT
APPROPRIATENESS OF SERVICE AUTHORIZED CONTRACT MEASURE BY
MONTH - CHILD
LEVEL OF CARE DEVIATION REASONS – UNDERSERVED - ADULT
LEVEL OF CARE DEVIATION REASONS – UNDERSERVED - CHILD
LEVEL OF CARE DEVIATION REASONS – OVERSERVED - ADULT
LEVEL OF CARE DEVIATION REASONS – OVERSERVED – CHILD
CRISIS SERVICES REPORT - ADULT
CRISIS SERVICES REPORT - CHILD
LOW UTILIZER S/P 2 > 1.99
LOW UTILIZER S/P 3 > 3.49
TTBH QM PLAN
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24.
25..
26.
27.
28.
29.
30.
31.
32.
33.
34.
H.
LOW UTILIZER S/P 4 > 3.99
LOW UTILIZER S/P 1.1 > 1.99
LOW UTILIZER S/P 1.2 > 1.99
LOW UTILIZER S/P 2.2 > 3.99
LOW UTILIZER S/P 2.3 > 3.99
LOW UTILIZER S/P 2.4 > 3.99
REHAB SERVICES
SMHF TRUST FUND UTILIZATION ANALYSIS REPORT
PHARMACY REPORT
APPEALS REPORT
CRISIS / SCREENING REPORT
INTER-RATER RELIABILITY
Consistent application of valid and reliable criteria across all service settings is an
important aspect of the UR process. Scheduled checks of inter-rater reliability assess
how consistently and timely all UM staff apply criteria across all levels of care subject to
UR decisions.
Only a Board certified or eligible psychiatrist can make the determination to deny
authorization of inpatient care. Consistent application of criteria are monitored in the
following manner:







On an annual basis, a random sample of a minimum of five (5) cases of
denials made by each physician are selected by the UM Manager or
designee for review by another physician not involved in the case.
All physicians reviewing appeals of adverse determinations or making
denial decisions will have a sample of their decisions audited by another
physician, but physicians will not audit their own cases. Audits for interrater reliability will be assigned equitably to all participating physicians,
depending on caseloads and other duties.
For each case selected for inter-rater reliability testing, the auditing
physician or UM staff will review the same documentation available to the
physician or UM staff who made the initial denial or authorization decision,
applying clinical criteria and guidelines established by TTBH.
The UM Manager or designee will calculate scores for presentation to the
UM Committee and UM Physician.
A benchmark of 80% inter-rater reliability is set.
Scores falling below 80% will be required to participate in biannual tests
until his/her score achieves 80% or higher.
Physicians’ scores falling below 80% inter-rater reliability during an annual
or biannual test will be addressed by the Physician, and these scores for
UM staff will be addressed by the UM Manager or designee.
TTBH QM PLAN
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

I.
The UM Manager, if available, will maintain all individual and group
scores, corrective action plans, and resolution. The UM Committee will
review this information also.
The UM Manager, if available, will include a Summary of Actions and
Improvements for inter-rater reliability testing of all UM reviewers,
including physicians, in the annual evaluation of the UM program.
PROVIDER PROFILING
One means of assessing utilization is through the use of provider utilization profiles.
Profiling may be defined as “gathering data and using relevant methodology, for the
purpose of describing and evaluating a provider’s mental health practice performance in
relation to the use of resources.” Proper utilization of mental health resources is also an
important aspect of quality assessment.
Use of Provider Utilization Profiles:
The primary objective of profiling should be to encourage high-quality service delivery,
which includes appropriate utilization of resources and results in improved client
satisfaction and outcome. Although some measures used for provider profiling may
lack precision, profiling has educational validity for TTBH and providers. Depending on
the degree of reliability of measures, provider utilization profiles may also be used for
calculating payment and making contract decisions. The profiling report must consider
factors that influence utilization rates and outcomes in order to enable providers to
educate themselves and allow TTBH a fair basis for payment or termination decisions.
Providers who advocate for necessary and appropriate mental health care and services
for clients must be protected from retaliation by TTBH. TTBH must not terminate,
demote, or refuse to compensate a provider because the provider advocates in good
faith for a client, seeks reconsideration of a decision denying a service, or reports a
violation of law to an appropriate authority.
The following should be considered in using provider profiles for various
purposes:
 Provider education – A provider may be cost-effective in one aspect of his/her
practice and not in another. Data on a provider should be classified by TTBH in
order to evaluate and educate a provider, in terms of services provided, referral
practices, etc.
Profiles should inform the provider about cost effective
management of client sub-populations. Data can illustrate a provider’s cost
effectiveness in managing specific types of clients. The provider knows precisely
where improvement may be needed.
 Basis for compensation – TTBH may elect to provide higher reimbursement to
those providers who care for more acute or more complex clients.
 Retention of providers – A contract termination decision should never be based
exclusively on a provider’s profile unless:
1. problem is ongoing;
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2. the provider has been informed of the problem and given sufficient time to
correct the behavior;
3. with respect to termination for over-utilization, the provider’s client
population has been carefully considered and appropriately risk adjusted
(evaluation of case mix).

Credentialing and re-credentialing – Provider profiles may be considered but
should not be determining factors in credentialing decisions.

Improving practice patterns & the profiling process – Quality management
processes may be used to identify best practices, ineffective practices,
productivity, or to develop a better profile instrument.
Provider Data, Which May Be Used For Profiling:
Certain aspects of providers’ practices can be profiled reliably, but others cannot.
Provider attributes for which validated objective measures are nonexistent, should not
be profiled or used.
Attributes that can be objectively quantified and reliably measured may include:
1. length of stay (LOS);
2. readmission or recidivism rates to identified services;
3. number of requests for special or support services;
4. prescription charges;
5. # days inpatient;
6. # days outpatient;
7. use of crisis services & emergency room visits;
8. lab tests; and
9. individual achievement of clinical outcomes;
10. # of adverse determinations
11. # of appeals
Sources of Data:
TTBH will ensure their data sources are accurate, and have an awareness of the
limitations of certain data sources as follows:
 Claim Forms may be insufficient to determine performance results because they
do not capture clinical characteristics about clients; outcome of the care provided
or detailed information on the severity of the client’s condition.
 Coding may hamper data accuracy and reliability related to unclear definitions of
diagnosis, condition or treatment or inaccurate coding.
 Medical Records may be incomplete or imprecise. Providers may err in their
documentation not directly related to reimbursement.
Potential Profile Focus:
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Provider – Tracking fidelity to treatment models, outcomes and costs by diagnosis and
treatment.
Hospital or facility – Track recidivism rate, length and duration of services provide
comparisons to hospitals with similar demographics, track short and long-term
outcomes and charges.
Client – Comparisons of normative data prior and post treatment. Measures medical
interventions for cost and outcomes.
Methods of Profiling:
A profile that is constructed to answer specific questions and uses appropriate statistical
methods may differentiate providers with a degree of reliability. Before providers are
profiled, however, TTBH should involve them in selection of measures and to identify
complicating factors such as case mix.
The provider utilization profile must be designed to answer a concise question and be
clearly interpretable. Data sources for utilization profiles range from claims databases
maintained by TTBH to individual client records kept in providers’ offices and at service
sites.
A profile should be based on a scientifically drawn sample of eligible subjects or on a
complete census. TTBH should not formulate a profile until enough data are acquired
to render the profile statistically useful. To attain statistical validity, adequate amounts
of data need to be collected over a sufficient time period or data may need to be pooled
with other sources.
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