Newsletter August 2024
Quality, Compliance & Customer Service
Kim Zimmerman, MBA-HC, LBSW, CHC
Chief Compliance and Quality Officer
Revised Delegated Managed Care Review Process
The Mid-State Health Network (MSHN) Delegated Managed Care (DMC) review process was revised to increase efficiency, reduce redundancies and address feedback and concerns received from the Community Mental Health Service Participants (CMHSPs). The DMC review includes evaluating provider compliance with delegated functions, clinical performance and documentation, contract requirements and the Medicaid Event Verification (MEV) review. The MEV is a review of a sample of claims to verify them against established attributes developed by the State. MSHN developed a DMC review cycle that spans over 3 years, versus the previous 2-year cycle, that includes consolidating MSHN reviews with external reviews (when possible). The feedback received from the CMHSPs was obtained via surveys, discussions, and the Quality Improvement Council. The following identifies the feedback from the CMHSPs as well as how MSHN is addressing the concerns.
CMHSP Feedback: There is duplication across reviews. MSHN reviews waiver charts and policies one year, the Michigan Department of Health and Human Services (MDHHS) reviews the same policies the next year. This causes the CMHSP to have several corrective action plans at once for the same findings. Additionally, there is a follow-up corrective action plan implementation review by MSHN and then an additional one completed by MDHHS.
MSHN Solution: MSHN now conducts the waiver review at the same time as the MDHHS waiver review and utilizes the MDHHS record sample to eliminate duplication and administrative burden. MSHN also will coordinate a corrective action plan with the CMHSPs for the findings from the MSHN review and the MDHHS review to eliminate the need for CMHSPs to submit two separate corrective action plans for similar findings.
CMHSP Feedback: The size of the MSHN review is overwhelming leading to many staff from the CMHSP having to devote both time and resources to providing documentation for the reviews and making themselves available to answer questions. The MDHHS review also contains a large number of standards that take many staff hours to provide information and supply requested documentation. In addition, the findings are viewed as having minimal impact on quality and the recommendations provided are getting lost in the volume of standards being reviewed.
MSHN Solution: The new review cycle will be more manageable by spreading out the review process over 3 years. This process will also allow for more MSHN/CMHSP reviewer discussion, interaction and understanding of the findings and expectations of the recommendations.
CMHSP Feedback: Can MSHN have a depository for current documents such as policies, procedures, forms, and handbooks, etc., that the CMHSP regularly submits so that this is not requested each time a review is completed?
MSHN Solution: MSHN is establishing a policy/procedure attestation process that will require additional review only if there has been a change since the previous review. For documents such as annual compliance plans, Utilization Management (UM) plans, Quality Assessment Performance Improvement Plan (QAPIP), etc. MSHN will develop a process that will accommodate this request.
As part of the feedback process, the CMHSPs were clear that anything MSHN can do to reduce the scope of auditing, or audit less frequently, would assist with the administrative burden that is caused by the reviews. While MSHN is required to monitor programs and delegated functions, there is some flexibility in the process. By establishing a 3-year cycle, this is creating a less burdensome process for CMHSPs by spreading out the standards being reviewed over a 3-year period and combining our reviews, when possible, with external reviews.
MSHN began implementing this process during Fiscal Year 2024 and coordinated the review with the MDHHS waiver review. Going forward, MSHN will utilize the fiscal year time frame for the scope of the audit, rather than the calendar year. This will allow consistency in providing summary information on the DMC reviews as part of our fiscal year reports.
MSHN will be evaluating this process and getting feedback from the provider network to determine if the new process is meeting the intended purpose of decreasing administrative burden, decreasing duplication of reviews, while maintaining compliance with State, Federal and contract requirements.
For further information or questions, please contact Kim @ Kim.Zimmerman@midstatehealthnetwork.org.