Provider Monitoring Process Overview Training. Updated August Course#: C Music Only No Narration

Transcription

1 Music Only No Narration Course#: C

2 This webcast includes spoken narration. To adjust the volume, use the controls at the bottom of the screen. While viewing this webcast, there is a pause and reverse button that can be used throughout the presentation. The written version of the narration appears to the right of the screen. Course#: C

3 My name is TaWanda Jackson. I am the ODP Lead for Provider Monitoring. Welcome to the Provider Monitoring Process Overview training webcast. This training is one of several updated webcasts that are being provided to assist in preparations for each stage of the Provider Monitoring Process. These presentations are specifically targeted to the provider and Administrative Entity (AE) administrative staff responsible for completing the monitoring process for licensed and unlicensed providers, including direct vendors of Intellectual Disability Waiver funded services. The mission of the Office of Developmental Programs (ODP) is to support Pennsylvanians with developmental disabilities to achieve greater independence, choice and opportunity in their lives. ODP s vision is to continuously improve an effective system of accessible services and supports that are flexible, innovative and person centered. Provider Monitoring is one of the monitoring processes that ODP uses to evaluate our current system and identify ways to improve it for all individuals. Course#: C

4 During this webcast we will provide an overview of: * The need and intended purpose of this process * Each stage of this process with general timeframes and expectations * Long term view of the process for both providers and Administrative Entities (AEs) In this and future webcasts, we will also provide suggestions of what agencies can do to prepare for and successfully complete each stage of the process. Course#: C

5 Fiscal year marked the initiation of the ODP Provider Monitoring process. As a result of feedback received by providers, AEs and ODP Regional staff and changing Waiver and regulatory requirements, this process is revised each year. Providers and AE Provider Monitoring Leads should review the revised Provider Monitoring Process each year at the location where you accessed this webcast. Each Regional ODP office has two Provider Monitoring Leads listed here with the exception of the Southeast Region which has one Regional Lead. Any questions regarding the Provider Monitoring Process should be directed to the Provider Monitoring mailbox address shown at the bottom of this slide or to the identified Regional Leads. Course#: C

6 Provider Monitoring utilizes standard process tools and data collection documents, to verify that providers are qualified and services are provided in compliance with regulations, the Waivers and federal and state requirements. Provider Monitoring also ensures that the Office of Developmental Programs policy and procedures and the current ODP Provider Agreement for participation in the Consolidated and P/FDS Waiver are followed. This process was also developed by ODP to support the assurances made to the Centers for Medicare and Medicaid Services (CMS) to develop and implement a statewide monitoring process of all providers and to ensure each organization is providing services in a manner that aligns with the compliance measures set forth in the Waiver regulations, policies and procedures. Course#: C

7 These processes have been developed in accordance with ODP s commitment to Continuous Quality Improvement. The focus of this commitment is to ensure that the quality of the Waiver programs is improved on a continuous and on going basis rather than through a once a year cycle. There are four components to the Continuous Quality Improvement strategy as defined by CMS: Design, Discovery, Remediation and Improvement. * Design: speaks to developing the initial methodology to be used * Discovery: looks at the data to determine areas of concern * Remediation: refers to addressing or correcting the problems identified in a timely manner * Improvement: adjusting the overall process based on new learning Course#: C

8 You may ask, Why Provider Monitoring? Why continue implementation? The statewide Provider Monitoring process was developed to support the Assurances ODP made to CMS. Specifically the assurances that: * The state demonstrates that it has designed and implemented an adequate system of assuring that all Waiver services are provided by qualified providers. * The Medicaid agency retains ultimate administrative authority and responsibility for the operation of the Waiver program by exercising oversight of the performance of Waiver functions by other state and local/regional non state agencies and contracted entities. In addition, ODP must monitor its providers to ensure each organization meets the conditions of the legal agreements set forth by ODP. Furthermore, the statewide implementation of this process will allow ODP to ensure that all providers adhere to important policies and procedures to ensure high quality of care for each individual enrolled in the program. Course#: C

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10 The Provider Monitoring Process is divided into two phases: the Self Reporting phase and the On site Review phase. This slide briefly describes the two phases. During the Self Reporting phase, all providers are required to complete a self assessment annually, regardless of being scheduled for an On site Review during that Fiscal Year. Providers are required to use the standardized ODP Provider Monitoring Tool or Vendor/Transportation Monitoring Tool as applicable along with the Provider Monitoring or Vendor/Transportation Monitoring Guidelines as applicable based on the services enrolled and qualified for in order to complete the annual self assessment of their compliance level across a variety of measures derived from the Waiver requirements, ODP and the Office of Medical Assistance Programs Provider Agreements, waiver regulations and ODP written policies and procedures. Providers who render Agency with Choice (AWC) services along with traditional services will be responsible for following this process along with the AWC Monitoring process. This information allows providers to plan their improvement strategies, enhance the quality of services delivered to the individuals they serve and prepare for their On site Review. The data gathered from this phase also provides ODP with a baseline to track and trend statewide compliance of providers across these measures. During the On site Review phase, AEs validate the provider s self assessment at the provider s corporate location(s) and service location(s) where individuals in the sample who are registered with the Lead and Reviewing AEs receive waiver services. All providers have an Onsite Review completed at least once in a two year cycle. Providers whose MPI number ends with an odd number last digit have an On site Review conducted the first year of the Provider Monitoring cycle. Providers whose MPI number ends with an even digit will have an On site Review conducted during the second year of the Provider Monitoring cycle, unless otherwise determined by ODP. Providers may be assigned to participate in the On site Review phase at a frequency of more than once every two years based upon measured performance and compliance with the Provider Monitoring process and ODP standards. The AE uses the same tool in the On site Review phase that was used by the provider in the Self Reporting phase. Please take a few minutes to review this slide. Then we will look at each of the phases more closely. Course#: C

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12 Every year, providers will complete a self assessment using the same standardized ODP Provider Monitoring Tool or Vendor/Transportation Monitoring Tool as applicable, that will be used by the AE during the On site Review phase. The purpose of the Self Reporting phase is to assist providers with assessing their compliance with ODP requirements and their level of preparedness for the next phase of Provider Monitoring, the On site Review. ODP will identify the sample of individuals to be used in this process. The sample will include 10 individuals in the primary sample plus an additional five alternate individuals as backup. The provider must use the initial 10 individuals as identified by ODP, unless there are extenuating circumstances. ODP will provide the sample to the AE who will then forward this information to the providers, including direct vendors utilizing the standard letter developed by ODP. The provider has 60 days to complete and submit the appropriate Monitoring Tool to ODP. In addition, the provider must use the Provider Monitoring or Vendor/Transportation Monitoring Guidelines as applicable and the MCI or Vendor Claims Tracker as applicable, to gather their information and ensure that the respective tool is completed accurately and appropriately and must also ensure all relevant documentation is collected, maintained and made available during the On site Review and upon request by ODP or the AE. ODP will track this for completeness and timeliness and then forward the information to the AEs. NEW PROVIDERS: A person or entity that wishes to provide Intellectual Disability services through ODP must first complete its initial registration and qualify to provide a service. Once determined qualified, the individual or entity shall review the Provider Monitoring Overview webcast, the Provider Monitoring Process document, the Provider Monitoring or Vendor/Transportation Monitoring Guidelines for New Providers (as applicable) along with all source documents referenced within the guidelines. The individual or entity shall also review and complete the Provider Monitoring Tool for New Providers or Vendor/Transportation Monitoring Tool for New Providers as applicable. This tool contains specific measures from the complete monitoring tool which are applicable to a new provider. A person or entity that becomes qualified as a new provider and completes the Provider Monitoring or Vendor/Transportation Monitoring Tool for New Providers shall participate in the Self Reporting and On site Review phases during the following fiscal year. Course#: C

13 This is a screenshot of what the electronic Monitoring Tool used to complete and submit the information to ODP looks like. Once the submit button at the bottom of the screen on the last page is selected, all responses entered are locked and cannot be changed. ODP recommends that the PDF version of the appropriate Monitoring Tool is used as a working document and that a single person be responsible for data entry and submission of the information to the online document. Course#: C

14 A link to the tool will be ed to the identified primary contact at the beginning of the Self Reporting phase. The primary contact is the individual the provider organization has designated as the contact person for the Provider Monitoring activities within their organization. Providers will be able to save partially completed work and return to complete the tool at a later date once the unique link is accessed and the Save Page and Continue Later button is selected. Providers and AEs are required to update their contact information when or if it changes utilizing the Provider Monitoring Contact Information Form which is posted and available where you have accessed this webcast. Failure to do so may prevent a provider or AE from maintaining compliance with the established ODP Provider Monitoring requirements. Course#: C

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16 During the On site Review phase, providers are assigned to an On site Review based upon the odd/even category of the last digit of their Master Provider Index (MPI) number. Providers with an odd number last digit will have an On site Review conducted during the first year; providers with an even number last digit will have an On site Review conducted in the second year. All new providers will be monitored during the first full fiscal year that begins after the completion of the Provider Monitoring or Vendor/Transportation Monitoring Tool for New Providers. For those providers subject to the an On site Review, the Lead AE will contact the provider to schedule and conduct the On site Review. An Exit Conference shall be conducted with the provider to review their findings if the provider requests the conference. Based on the findings of the On site Review, the Lead AE prepares the AE Review Report which includes a standardized letter and Statement of Findings listed on ODP s standardized CAP template. The provider develops a Corrective Action Plan (CAP) addressing any identified areas of noncompliance on the template received from the Lead AE and submits the CAP to the Lead AE for review and approval. In this slide we introduce the concept of Lead AE and Reviewing AE. Let s take a moment to define these two terms. The Lead AE is designated by ODP based on the AE with which the most individuals served by the provider are registered. In the event the provider is a multi county provider, the Lead AE shall communicate with the appropriate Reviewing AEs in addition to the provider. Effective fiscal year , the Lead AE also functions as the Qualifying AE. If a provider does not have any current service authorizations, the Lead AE will be designated according to where the provider anticipates serving the most individuals. The Reviewing AE is the AE or AEs where Waiver participants of a multi county provider are registered, with whom the total number of Waiver participants is fewer than the Lead AE. Reviewing AEs conduct portions of the provider s On site Review for the selected individuals served in the Reviewing AEs jurisdiction during the On site Review phase. Reviewing AEs schedule On site Reviews with assigned providers to coincide with Lead AE schedules by December 31 st. Course#: C

17 This slide summarizes the On site Review process for providers. Please keep in mind that this presentation is a high level overview of the process. More specific information regarding the On site Reviews will be provided in future webcasts. Course#: C

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19 This slide outlines the timeline for each of the stages of the Monitoring Process for providers. ODP will continue to analyze the results and feedback from the provider self assessments and identify revisions to process, tools, guidelines, sampling methodology, etc. as appropriate and warranted. Providers are required to submit the results of their self assessment electronically to ODP. Providers are required to forward a copy of the confirmation received once the tool has been electronically submitted to the Lead AEs. Lead AEs are required to complete an On site Review with any provider who has not completed a self assessment by November 30 th. Providers are required to correct all noncompliances discovered during the Self Reporting phase within 30 days of discovery. Please take a minute to review this slide. Course#: C

20 Providers who refuse to schedule or participate in the Provider Monitoring Process will be sanctioned by ODP. AEs who are non compliant with the On site Review phase of Provider Monitoring will be issued a DCAP from ODP. Any noncompliance with any part of the Provider Monitoring Process by a provider or an AE can result in a CAP or DCAP. Please take a minute to review this slide. Course#: C

21 While this training is an overview of the process and ODP will be providing more specific training for each phase, there are a number of things organizations can do now to help successfully prepare for this process each year. Make sure your administration and staff: * Are aware of the revised process and any changes * Support the importance of this process * Understand the potential impacts * Meet the requirements Use the pdf version of the current Provider Monitoring or Vendor/Transportation Monitoring Tool, Provider Monitoring and Vendor/Transportation Monitoring Guidelines, as well as the MCI and Vendor Claims Trackers which are available where you have accessed this webcast. The supporting documents referenced in the Provider Monitoring and Vendor Transportation Monitoring Guidelines should be reviewed as well, to ensure agency documents and information meeting the compliance standards established by ODP are available to support the completion of the Self Reporting and On site Review phases. The MCI and Vendor Claims Tracker (as applicable) should be reviewed as well so that all providers are familiar with the Excel spreadsheet and its purpose. Please keep in mind the use of the MCI and Vendor Claims Tracker spreadsheets are required for all providers, Lead AEs and Reviewing AEs. Some examples of this could include making sure: * records are up to date * Agency policies align with Waiver requirements and 55 Pa Code Chapter 51 * Governing structures are up to date Course#: C

22 At this same time, the AE can prepare by: * Ensuring their staff are familiar with the current process and the potential impacts, time and capacity needs to support the process and meet the requirements. * Identifying providers within their AE where they will likely be the Lead AE or Reviewing AE and open communications with the other AEs to build the partnerships necessary to complete this process. This can include ensuring the use of sending secure messages between Reviewing and Lead AEs. * Reviewing the pdf version of the Provider Monitoring or Vendor/Transportation Monitoring Tools, Provider Monitoring and Vendor/Transportation Monitoring Guidelines, as well as the MCI and Vendor Claims Trackers which are available where you have accessed this webcast. AEs should also familiarize themselves with the supporting documents referenced in the applicable Guidelines as well as the use and purpose of the MCI and Vendor Claims Tracker to be sure the requirements are understood. * Once again, the use of the MCI and Vendor Claims Tracker spreadsheets are required for all providers, Lead AEs and Reviewing AEs. Course#: C

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24 The Corrective Action Plan Process or CAP includes but is not limited to the following oversight and monitoring processes: * AE Oversight * SCO Monitoring * Provider Monitoring * ODP required self reviews such as those required with AE Oversight, Provider or SCO Monitoring * Annual Administrative Reviews, if conducted Upon completion of the monitoring, the reviewing entity will use the CAP form to document and communicate the areas of noncompliance or in need of improvement to the monitored entity. The monitored entity will then use the form to document their plan to correct the issues as well as any steps taken to prevent future occurrences. Corrective Action Plans for Licensing reviews are not included as they already have and will continue to use their established CAP process. Course#: C

25 This is what the Statement of Findings, Final Audit Report/Corrective Action Plan form looks like. Within the Provider Monitoring process, the form is issued electronically by the Lead AE within 30 calendar days of the completed On site Review. The monitored provider then completes the unshaded sections and returns the form to the reviewing entity for approval. A separate webcast providing detail of this process is available where this webcast was accessed. Course#: C

26 Again, here is a list of Regional Contact Leads for Provider Monitoring. Please note that questions regarding the Provider Monitoring Process should be directed to the Provider Monitoring mailbox address shown at the bottom of this slide or to the identified Regional Leads. Course#: C

27 If providers are unsure who their primary and secondary contacts are, an agency listing of the organizations currently registered and the primary contacts are available where you have accessed this webcast. Listed here is the link and menu path to the websites that includes the information and resources related to the Provider Monitoring Process. Course#: C

28 Finally, the Self Reporting, On site Review and Corrective Action Plan webcasts will also be available in the same place where you have accessed this webcast. Please be sure to review each webcast. Course#: C

29 Fiscal year marked the initiation of the ODP Provider Monitoring process. As a result of feedback received by providers, AEs and ODP Regional staff and changing Waiver and regulatory requirements, this process is revised each year. Providers and AE Provider Monitoring Leads should review the revised Provider Monitoring Process each year at the location where you accessed this webcast. Each Regional ODP office has two Provider Monitoring Leads listed here with the exception of the Southeast Region which has one Regional Lead. Any questions regarding the Provider Monitoring Process should be directed to the Provider Monitoring mailbox address shown at the bottom of this slide or to the identified Regional Leads. Course#: C

30 This webcast has been developed by the Pennsylvania Department of Human Services, Office of Developmental Programs and produced by The Columbus Organization. Thank you for participating in this lesson. Course#: C