transformation and quality strategy: template walk-through
TRANSCRIPT
Transformation and Quality Strategy:
Template Walk-through
November 8, 2017
Presented by:
Lisa Bui, Quality Improvement Director
Allison Tonge, Operations and Policy Analyst
Anona Gund, Transformation Analyst
Ann Brown, Operations and Policy Analyst
Paulette Golden, Medicaid Program Integrity Manager
Summer Boslaugh, Transformation Analyst
Lisa Krois, Transformation Analyst
Webinar objectives
• Walk through the Transformation and Quality Strategy (TQS)
template
– Mechanics of entering information into the template
– High-level guidance for template fields
• Review select TQS examples
– Fraud, waste and abuse
– Integration of care
– Value-based payment models
2
Deliverables schedule
CCO contract language:
• Due March 16, 2018
– 2015 – 2017 Transformation Plan Benchmark report (closing report)
– Transformation Quality Strategy (TQS)
• TQS Effective January 2018
• Ongoing
– TQS due annually on March 16 (effective January–December)
– TQS progress report due on September 30 (progress for January–June)
3
Foundational principles
TQS is a means for CCOs to report health transformation and quality work. The
work is determined, developed and implemented by the CCOs with the
direction from the CACs, community and CCO leadership. OHA’s role is to
monitor, spread best practices and provide technical assistance in conjunction
with community and state subject matter experts.
TQS template addresses three key principles:
1. Meets CFR, OAR, 1115 waiver and CCO contractual requirements
2. Pushes health transformation through alignment of quality and innovation
3. Decreases administrative burdens on CCOs
– Template supports OHA processing of information to monitor CCOs’ progress
to benchmarks.
– Template incorporates narrative style and specific/measurement methods.
4
TQS components and subcomponents
• Access
– Access: Availability of Services
– Access: Cultural Considerations
– Access: Quality and
Appropriateness of Care
Furnished to All Members
– Access: Second Opinions
– Access: Timely
• CLAS Standards and Provider
Network
• Grievances and Appeals System
• Fraud, Waste and Abuse
• Health Equity and Data
– Data
– Cultural Competence
• Health Information Technology
– Health Information Exchange
– Analytics
– Patient Engagement
• Integration of Care
• Patient-Centered Primary Care Home
• Severe and Persistent Mental Illness
• Social Determinants of Health*
• Special Health Care Needs
• Utilization Review
• Value-based Payment Models
5
*Pending CMS approval
Template walk-through
6
Program integrity
The Centers for Medicare and Medicaid Services (CMS) is
committed to combating Medicaid provider fraud, waste
and abuse, which diverts dollars that could otherwise be
spent to safeguard the health and welfare of Medicaid
enrollees.
CMS does periodic reviews of State Medicaid programs during which
they focus on Oregon’s managed care and coordinated care
organizations. They will be performing this review in Oregon May 2018.
Program Integrity Audit Unit
7
Fraud, waste and abuse (FWA)
Common fraud, waste and abuse program activities that CMS looks for:
– Policies and procedures relating to FWA prevention and investigation
– CCO audits of contracted providers
– Investigations of suspected provider fraud, waste and abuse
– Documentation that the CCO is identifying and recovering
overpayments
– Case tracking spreadsheets or document that lists provider program
integrity reviews (evaluations, audits, preliminary and full investigations,
etc.) for the past three federal fiscal years
– Documentation on how many cases of suspected provider fraud and
abuse were referred to the state for the past three federal fiscal years by
each CCO.
Program Integrity Audit Unit
8
CMS frequently asked questions
• Do you keep a list of all providers terminated, de-credentialed, dis-
enrolled or whose contract was not renewed for the last three
federal fiscal years?
• What area in your organization is responsible for addressing
complaints and performing provider oversight?
• Do you contract with anyone to conduct program integrity activities?
• What type of data mining do you conduct to look for possible fraud,
waste and abuse activities?
• How you evaluate the effectiveness of your program integrity
operations?
Program Integrity Audit Unit
9
Possible metrics for FWA
• % increase in number of provider audits
• % increase in number of data mining reports, looking for anomalies
in billing
– By provider specialty
– By CPT code
– Billings among peer specialties (for example, comparing cardiologists
against peer cardiologists)
– Looking for duplicate billings
– Use of modifier codes
• % in number of site visits to contracted provider offices
• % in number of referrals to state and/or to the Medicaid Fraud
Control Unit (MFCU)
Program Integrity Audit Unit
10
Integration of Care
11
Value-based payment models
12
Q&A
• Please type your questions and comments into the
“Questions” box on your GoToWebinar control panel.
• We will continue to update our Frequently Asked
Questions document after each webinar in this series.
13
For more information:
• Presenter contacts:
– Lisa Bui: [email protected]
– Anona Gund: [email protected]
– Allison Tonge: [email protected]
– Ann Brown: [email protected]
– Paulette Golden: [email protected]
– Summer Boslaugh: [email protected]
– Lisa Krois: [email protected]
• All TQS resources, including the templates, guidance document, examples
and technical assistance schedule are available on the Transformation
Center website: http://www.oregon.gov/oha/HPA/CSI-
TC/Pages/Transformation-Quality-Strategy.aspx
• The templates and guidance document are also cross-posted on the CCO
Contract Forms page: http://www.oregon.gov/oha/HSD/OHP/Pages/CCO-
Contract-Forms.aspx
14