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PERM: Does MEQC affect states?

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As a senior consultant in the BerryDunn Government Consulting Group, Christy has valuable expertise in both Medicaid and the private insurance sector. Her experience and background with the Payment Error Rate Measurement (PERM) program has developed a passion for assisting states in identifying the need to prioritize the activities and resulting outcomes of a PERM cycle as well as offering and assisting with implementation of recommendations to mitigate known areas of concern that may otherwise result in PERM errors.

She has provided valuable contributions while working closely with states to evaluate and implement new processes and procedures to ensure federal compliance measures are in place before PERM reviews begin. Christy has a profound understanding of state and federal policies as they apply to PERM reviews and a broad experience working in and understanding the operation and limitation of many state eligibility systems.

Christy Schilling
07.22.19

Read this if you are a state Medicaid Director, State Medicaid Chief Information Officer, State Medicaid Project Manager, State Procurement Officer, or work in a State Medicaid Program Integrity Unit.

The Centers for Medicare & Medicaid Services (CMS) issued a Payment Error Rate Measurement (PERM) Final Rule on July 5, 2017, that made several changes to the PERM requirements. One important change was the updates to the Medicaid Eligibility Quality Control (MEQC) requirement. 

The Final Rule restructures the MEQC program into a pilot program that requires states to conduct eligibility reviews during the two years between PERM cycles. CMS has also introduced the potential for imposing disallowances or reductions in federal funding percentage (FFP) as a result of PERM eligibility error rates that do not meet the national standard. One measure states can use to lessen the chance of this happening is by successfully carrying out the requirements of the MEQC pilot. 

What states should know―important points to keep in mind regarding MEQC reviews:

  • Each state must have a team in place to conduct MEQC reviews. The individuals responsible for the MEQC reviews and associated activities must be separate from the state agencies and personnel responsible for Medicaid and Children’s Health Insurance Program (CHIP) policy and operations, including eligibility determinations.
  • States can apply for federal funding to help cover the costs of the MEQC activities. CMS encourages states to partner with a contractor in conducting the MEQC reviews.
  • The deadline to submit the state planning document to CMS is November 1 following the end of your state’s PERM cycle. If you are a Cycle 2 state, your MEQC planning document is due by November 1, 2019. 
  • If you are a Cycle 1 state, you are (or should be) currently undergoing the MEQC reviews.
  • There are minimum sample size requirements for the MEQC review period: 400 negative cases and 400 active cases (consisting of both Medicaid and CHIP cases) over a period of 12 months.
  • Upon conclusion of all MEQC reviews, states must submit a final findings report along with a corrective action plan that addresses all error findings identified during the MEQC review period.

CMS encourages states to utilize federal funding to carry out and fulfill MEQC requirements. BerryDunn has staff with experience in preparing Advanced Planning Documents (APD) and can assist your state in submitting an APD request to CMS for these MEQC activities. 

Check out the previously released blog, “PERM: Prepared or Not Prepared?” and stay tuned for upcoming blogs about specific PERM topics, including the financial impacts of PERM, and how each review phase will affect your state.   

For questions or to find out more, contact the team

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Read this if you are a state Medicaid or CHIP agency.

The Centers for Medicare & Medicaid Services (CMS) has temporarily suspended all Payment Error Rate Measurement (PERM) improper payment-related engagement/communication and data requests to providers and state agencies as a result of the COVID-19 nationwide public health emergency declaration. 

CMS has also adopted a temporary policy of relaxed enforcement regarding activities related to Medicaid Eligibility Quality Control (MEQC) until further notice.

CMS continues to provide state Medicaid and Children’s Health Insurance Program (CHIP) agencies with a number of methods to assist in each state’s approach and response to the COVID-19 pandemic. Some flexibilities offered to state Medicaid and CHIP agencies include:

  • Eligibility and enrollment 
  • Benefits 
  • Cost-sharing 
  • Financing 
  • Managed care 

While this has been communicated with state Medicaid and CHIP agencies, you should take some important steps to manage these flexibilities to ensure you don’t encounter issues when PERM and MEQC review activities resume. Reviews are conducted according to state and federal policies and regulations in force at the time of service on the sampled claims under review. 

CMS has issued guidance to identify whether or not each of the flexibilities requires an approved state plan amendment (SPA), waiver, or whether simply providing documentation in the individual case file will provide the required support when PERM and MEQC activities resume. 

Additionally, it is equally important to ensure the “pre-COVID” processes and procedures resume immediately upon expiration of the public health emergency declaration in order to remain in compliance with state and federal regulations. 

Here are a few key considerations to help reduce the number of errors identified once PERM resumes:

  • Management of new state-specific policies and procedures in effect during the COVID-19 pandemic is critical. You need to ensure all processes requiring CMS approval or notification have been enacted and that these temporary processes revert back to pre-COVID processes immediately upon termination of the public health emergency.
  • Continued training and guidance to Medicaid and CHIP staff during this time to ensure understanding of expectations and adherence to new processes. Applying and understanding eligibility and enrollment flexibilities for both members and providers is vital to meet all expectations and documentation requirements.

New updates continue to be announced by CMS to ensure Americans have access to the care they need during this time. This requires remaining diligent to the expectations of these flexibilities and preparing for the impact of PERM and MEQC outcomes when these activities resume. This is key to reducing improper payment error rates. 

For additional detailed information regarding the identified flexibilities above, please refer to the PERM cycle preparation tool we have prepared.

If you have questions regarding relaxed requirements or you would like to have an in-depth conversation with our PERM experts, please contact the team.
 

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PERM is suspended―key considerations during COVID-19 

Federal contractors with the Centers for Medicare & Medicaid Services (CMS) have begun performing Payment Error Rate Measurement (PERM) reviews under the Final Rule issued in July 2017—a rule that many states may not realize could negatively impact their Medicaid budgets.

PERM is a complex process—states must focus on several activities over a recurring three-year period of time—and states may not have the resources needed to make PERM requirements a priority. However, with the Final Rule, this PERM eligibility review could have financial implications. 

After freezing the eligibility measurement for four years while undergoing pilot review, CMS has established new requirements for the eligibility review component and made significant changes to the data processing and medical record review components. As part of the Final Rule, CMS may implement reductions in the amount of federal funding provided to a state’s Medicaid and Children’s Health Insurance Program (CHIP) programs based on the error rates identified from the eligibility reviews. 

Since the issuance of the Final Rule in July 2017, Cycle 1 states are the first group of states to undergo a PERM cycle, including reviews of the data processing, medical record, and eligibility components. These states are wrapping up the final review activities, and Cycle 2 states are in the early stages of their PERM reviews.

How can your state prepare?

Whether your state is a Cycle 1, Cycle 2, or Cycle 3 state, there are multiple activities your Medicaid departments should engage in throughout each three-year period of time during and between PERM cycles: 

  • Analyzing prior errors cited or known issues, along with the root cause of the error
  • Identifying remedies to reduce future errors
  • Preparing and submitting required questionnaires and documents to the federal contractors for an upcoming review cycle
  • Assisting federal contractors with current reviews and findings
  • Preparing for and undergoing Medicaid Eligibility Quality Control (MEQC) planning and required reviews
  • Corrective action planning

Is your state ready?

We’ve compiled a few basic questions to gauge your state’s readiness for the PERM review cycle:

  • Do you have measures in place to ensure all eligibility factors under review are identifiable and that all federal and state regulations are being met? The eligibility review contractor (ERC) will reestablish eligibility for all beneficiaries sampled for review. This process involves confirming all verification requirements are in the case file, income requirements are met, placement in an accurate eligibility category has taken place, and the timeframe for processing all determinations meets federal and state regulations. 
  • Do you have up-to-date policy and procedures in place for determining and processing Medicaid or CHIP eligibility of an individual? Ensuring eligibility policies and procedures meet federal requirements is just as important as ensuring the processing of applications, including both system and manual actions, meet the regulations. 
  • Do you have up-to-date policy, procedures, and system requirements in place to ensure accurate processing of all Medicaid/CHIP claims? Reviewers will confirm the accuracy of all claim payments based on state and federal regulations. Errors are often cited due to the claims processing system allowing claims to pay that do not meet regulations.
  • Do you have a dedicated team in place to address all PERM requirements to ensure a successful review cycle? This includes staff to answer questions, address review findings, and respond to requests for additional information. During a review cycle, the federal contractors will cite errors based on their best understanding of policies and/or ability to locate required documentation. Responding to requests for information or reviewing and responding to findings in a timely manner should be a priority to ensure accurate findings. 
  • Have you communicated all PERM requirements and updates to policy changes to all Medicaid/CHIP providers? Providers play two integral roles in the success of a PERM review cycle. Providers must understand all claims submission requirements in order to accurately submit claims. Additionally, the medical record review component relies on providers responding to the request for the medical records on a sampled claim. Failure to respond will result in an error. Therefore, states must maintain communication with providers to stress the importance of responding to these requests.
  • Have you begun planning for the MEQC requirement? Following basic requirements identified by CMS during your state’s MEQC period, your state must submit a case planning document to CMS for approval prior to the MEQC review period. After the MEQC review, your state should be prepared to issue findings reports, including a corrective action plan as it relates to MEQC findings.

Need help piloting your state’s PERM review process?

BerryDunn has subject matter experts experienced in conducting PERM reviews, including a thorough understanding of all three PERM review components—eligibility, data processing, and medical record reviews. 

We would love to work with your state to see that measures are in place that will help ensure the lowest possible improper payment error rate. Stay tuned for upcoming blogs where we will discuss other PERM topics, including MEQC requirements, the financial impacts of PERM, and additional details related to each phase of PERM. For questions or to find out more, please email me
 

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PERM: Prepared or not prepared?

Read this if you are a State Medicaid Director, State Medicaid Chief Information Officer, State Medicaid Project Manager, or State Procurement Officer—or if you work on a State Medicaid Enterprise System (MES) certification or modernization efforts.

You can listen to the companion podcast to this article now:


Over the last two years, the Centers for Medicare and Medicaid Services (CMS) has undertaken an effort to streamline Medicaid Enterprise System (MES) certification. During this time, we have been fortunate enough to have been a trusted partner in several states working to evolve the certification process. Through this collaboration with CMS and state partners, we have been in front of recent certification trends. 

What is outcomes-based certification (OBC)? 

OBC (or streamlined modular certification) is a fascinating evolution in MES certification. OBC represents a fundamental rethinking of certification and how we measure the success of system implementation and modernization efforts. The prior certification approach, as many know it, is centrally focused on technical capability, answering the question, “Can the system perform the required functions?” 

OBC represents a shift away from this technical certification and toward business process improvement, instead answering the question, “How is this new technology enhancing the Medicaid program?” Or, put differently, “Is this new technology helping my Medicaid program achieve its desired outcomes?” 

What are the key differences between the MECT and OBC? 

To understand the differences, we have to first talk about what isn’t changing. Technical criteria still exist, but only so far as CMS is confirming compliance with core regulatory and statutory requirements—including CMS’ Standards and Conditions. That’s about the extent of the similarities. In addition to pivoting to business process improvement, we understand that CMS is looking to generalize certification under this new approach, meaning that we wouldn’t see the same Medicaid Information Technology Architecture (MITA)-tied checklists like Provider Management, or Decision Support Systems. Instead, we might expect more generalized guidance that would allow for a more tailored certification. 

Additionally, OBC introduces outcomes statements which serve as the guiding principles for certification. Everything, including the technical criteria, roll-up into an outcome statement. This type of roll up might actually feel familiar, as we see a similar structure in how Medicaid Enterprise Certification Toolkit (MECT) criteria rolled up into critical success factors. 

The biggest difference, and the one states need to understand above all else, is the use of key performance indicators (KPIs). These KPIs aren’t just point-in-time certification measures, they are expected to be reported against regularly—say, quarterly—in order to maintain enhanced funding. Additionally, it’s likely that each criterion will have an associated KPI, meaning that states will continue to be accountable to these criteria long after the Certification Final Review. 

How are KPIs developed? 

We’ve seen KPIs developed in two ways. For more strategic, high level KPIs, CMS develops a baseline set of KPIs heading into collaborating with a state on an OBC effort. In these instances, CMS has historically sought input on whether those KPIs are reasonable and can be easily reported against. CMS articulates what it wants to measure conceptually, and works with a state to ensure that the KPI achieves that within the scope of a state’s program.  

For KPIs specific to a state’s Medicaid program, CMS engages with states to draft new KPIs. In these instances, we’ve seen CMS partner with states to understand the business need for the new system, how it fits into the Medicaid enterprise, and what the desired outcome of the particular approach is. 

What should states consider as they plan for MES procurements? 

While there might be many considerations pertaining to OBC and procurements, two are integral to success. First—as CMS noted in the virtual MESC session earlier this month—engage CMS at the idea stage of a project. Experience tells us that CMS is ready and willing to collaborate with—and incorporate the needs of—states that engage at this idea stage. That early collaboration will help shape the certification path. 

Second, consider program outcomes when conceptualizing the procurement. Keep these outcomes central to base procurement language, requirements, and service level agreements. We’re likely to see the need for states to incorporate these outcomes into contracts. 

What does this mean for MES modularity and scalability? 

Based on our current understanding of the generalization of certification, states, and subsequently the industry at large, will continue to refine what modularity means based on Medicaid program needs. Scalability represents an interesting question, as we’ve seen OBC scaled horizontally across smaller, discrete business areas like pharmacy or provider management. Now we’re seeing the beginnings of vertical scaling of a more streamlined certification approach to larger components of the enterprise, such as financial management and claims processing. 

The certification landscape is seemingly changing weekly as states wait eagerly for CMS’ next guidance issuances. Please continue to check back for in-depth analyses and OBC success stories. Additionally, if you are considering an OBC effort and have questions, please contact our Medicaid Consulting team

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Considerations for outcomes-based certification

Read this if you or your government agency may be interested in project management or a project management office.

You may think that PMO stands for Project Management Office, Program Management Office, or Portfolio Management Office, and you would be correct. However, when establishing your PMO priorities, think:
1.    P – Planning and Processes
2.    M – Motivation
3.    O – Operations

Determining where your organization will focus your efforts is fundamental to the successful functioning of the PMO, whether the PMO is well established or just getting started. With multiple competing projects and initiatives, spending some time planning and developing your PMO priorities in the short term will save you time and effort moving forward. 

According to the Project Management Institute’s (PMI’s) research, they reported that "aligning projects and strategic objectives has the greatest potential to add value to an organization.” 

The “value” here must be determined by each organization, but through establishing your PMO priorities early, you promote a culture of project management in order to gain greater experience in project management practices and personnel. This allows for more efficient processes, more focused and flexible project managers, greater scope, schedule, and budgetary control, and ultimately more successful projects implemented.

Planning and processes

The first step in establishing the priorities for your PMO requires planning and evaluating existing processes. Identifying all projects for the upcoming year is an excellent place to start. For each project or initiative, you will want to pull together information that will assist you in the prioritization process. This may include items such as type of project, expected outcomes, aligned strategic objective(s), targeted length of the project, targeted start date, funding sources, types of approvals needed, resource capacity, and risk versus reward analysis. Each organization can make the determination of what kind of information is necessary in this step to make prioritization more streamlined and specific to their current structure and processes.

As new team members enter and exit project work, there is a risk that knowledge transfer of the PMO processes get lost, or deviations in processes begin to occur. PMI notes “high-performing organizations succeed through a strategic focus on people, processes, and outcomes” and 74% of these high-performing organizations are supported by a PMO. Taking the opportunity for continuous process improvement―to review and share the PMO processes and templates with the organization on a reoccurring basis―helps to ensure consistency across programs within the organization. With consistency comes efficiency, allowing your project teams to focus on the work at hand, and not recreate processes. Consistency and efficiency will help streamline administrative activities, improve resource estimates, and increase the likelihood that projects will come in on time and on budget.

Motivation 

The second step in establishing PMO priorities is motivation. Having a working knowledge of your organization will help in this step―knowing what excites or drives them to succeed. Motivating factors may vary for different organizations. For example, if you’re a government entity, the deciding factor in priority may be a legislative mandate. Early identification of your organization’s motivating factors allows you to expedite the prioritization efforts and increase planning time for high-priority projects, including aligning resources sooner. Here are a few ideas to consider when thinking about finding what motivates people in your organization:

  • Durations/meeting timeframes
  • Legislation/mandates
  • Strategic plans and goals
  • Recognition
  • Policy
  • Outcomes/potential impacts
  • Level of risk
  • Return on Investment (ROI)

Operations

The third step in establishing PMO priorities is operations. By outlining operational aspects of the projects before establishing your PMO priorities, you can see the big picture and organizational strategy. Per PMI, organizations which “align their PMO to strategy report 38% more projects meet the original goals and business intent, while 33% fewer projects are deemed as failures.” This allows you to understand dependencies between projects, identify possible duplication or gaps, and plan for resources earlier. Below are a few examples to consider with this step:

  • High-level strategy (will the work be delivered in phases or at the end of the project)
  • Approximate Full-Time Equivalents (FTEs) required
  • Skill level needed for the resources
  • Organizational charts and reporting relationships
  • Approximate cost for the project/initiative

Now that you are aware of the three steps―planning and processes, motivation, and operations, you are ready to begin establishing your PMO priorities. Evaluating all three steps helps ensure you’ve considered everything before prioritizing the work, although some items may clearly have more weight than others. There is no magic formula for establishing PMO priorities, and given the same projects, different organizations would have different priorities. One organization may define and identify project work as high, medium, or low, while another PMO may number projects, with number one being the first project to start. Either way is right. 

The important take-away is for your PMO to develop a consistent methodology as you are establishing priorities now and in the future. 

Does your organization need help establishing your PMO processes, prioritizing, or developing strategic plans? Contact our Medicaid Consulting team for more information on how we can help.

Resources cited

Project Management Institute. PMI’s Pulse of the Profession: The High Cost of Low Performance. PMI.org. Accessed July 8, 2020. https://www.pmi.org/-/media/pmi/documents/public/pdf/learning/thought-leadership/pulse/pulse-of-the-profession-2014.pdf?v=eb9b1ac0-8cad-457f-81ec-b09dbb969a38 
Project Management Institute. PMI’s Pulse of the Profession – 9th Global Project Management Survey: Success Rates Rise – Transforming the High Cost of Low Performance. PMI.org. Accessed July 8, 2020. https://www.pmi.org/-/media/pmi/documents/public/pdf/learning/thought-leadership/pulse/pulse-of-the-profession-2017.pdf 

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The 1, 2, 3s of establishing your PMO priorities

Read this if you are a member of a State Medicaid Agency’s leadership team.

Monday’s NESCSO-hosted conversation was a breath of fresh air in our COVID-19 work-from-home experience. Seeing familiar faces presenting from their home offices reminded me that, yes, we are truly all in this together—working remotely, and focused on how best to foster an efficient and effective Medicaid program for our state clients and members. Over the past several years I have written a “Reflections” blog, summarizing the week-long MESC event while flying home. Today, I am posting my reflections on the first forum NESCSO sponsored in lieu of their August conference that was cancelled this year due to the global pandemic. Following are my major takeaways.

The main speakers were Karen Shields, Deputy Director from the Center for Medicaid and CHIP Services, and Julie Boughn, Director, Data Systems Group also for the Center for Medicaid and CHIP Services. There were several other guests that joined in this two-hour forum, some from the Data Systems Group, and some from the states.

Crisis as a learning tool

Karen Shields reinforced that we will be better and stronger as a result of the crisis that faces us, and encourages us to use the current crisis as a learning tool. She stressed the importance of how we are leveraging our creativity and innovation to keep moving forward. She said to start with the end in mind, be a team player, and keep in mind these three important points of focus for CMS:

  1. Share what works, share what doesn’t. Prioritize.
  2. Systems development needs to be agile. Partnership is critical. States needs to be “elbow deep” with others. Everyone is allowed to speak. 
  3. Re-usability is key! Push back on those who say we cannot reuse.

During the Q&A session, Karen discussed how to maintain consistency by turning to action and using lessons learned. Resist the urge to “fall back.” Let’s keep moving forward. She underscored how they will continue the all-state calls as there are lots of topics and conversations needed to explore deficits of need. 

Support systems and policies

Julie Boughn opened by stressing what an important layer of support systems provide policies. She said COVID is not a system issue—the systems supporting the approach to address the virus are working and a big part of contributing to helping alleviate the issues the pandemic presents. She noted an appropriate quip that “Without systems, policies are just interesting ideas on pieces of paper.”

She underscored that healthcare and all that goes with supporting it is never static. The Medicaid arena is in a world of increasing change, requiring the supporting systems to adapt to make payments correctly and facilitate the provision of benefits to the right people. CMS has been focused on, and continues to bring our focus to outcomes, especially in the IT investments being made. Promote sharing and re-use of those investments.

During the Q&A, Julie reinforced the priority on outcomes and spoke to outcomes-based certification (OBC). There was a question on “What happens to modularity in the context of OBC?” She said that they are completely compatible and naturally modular, and to think about how a house can be built but not be completely done. Build the house in chunks of work, and know what you’re achieving with each “chunk”. Outcomes are behind everything we do.

Engage with your federal partners

In the next presentation, CMS modeled a dialogue that demonstrated how states can engage with their federal partners. CMS wants to continue changing the relationship they have with states. They also reminded the audience of what CMS is looking for; as Ed Dolly, the Director for the Division of State Systems within the Data and Systems Group said during the conversation, “Do you understand the problem trying to be solved?” Define your final outcome, and understand that incremental change drives value. In addition to communicating the problem, focus on speed of delivery (timeliness), and engage in back and forth exchange on what best measures can be used, as well as the abilities to capture the measures to report progress. The bottom line?  “When in doubt, reach out!”

The remainder of the forum featured representatives from the State System Technology Advisory Group (S-TAG), Private Sector Technology Group (PSTG), and Human Services Information Technology IT Advisory Group (HSITAG). They discussed a variety of IT topics.

Technology outlook

The S-TAG had representation from an impressive list of states—West Virginia, Washington, Wyoming, Vermont, and Massachusetts. They spoke to how they envision their technology response to changes in policy now and in the next 12-18 months. There was too much to present here, and I recommend reviewing the recording once NESCSO posts it. Initiatives included: Provider enrollment, electronic asset verification, electronic visit verification, integrated eligibility systems, modularity implementations, migration to the cloud, pharmacy systems, system integrator, certification, strategic planning, electronic data interchange upgrades, payment reform, road map activities, case management, care management, T-MSIS, and HITECH.

HSITAG spoke about the view across the health and human services spectrum—Where are we today? Where will we be tomorrow? COVID has tested our IT infrastructure and policy. Is there an ability to quickly scale up? Weaknesses in interoperability became exposed and while it seemed Medicaid was spared in the headlines, the need to modernize is now much more apparent. Modularity showed its value in more timely implementations. There is concern over an upcoming increase in the Medicaid population. Are we equipped for the short term?

For the long-run, where we will be “tomorrow” in the 12-18 month view, there will be a bigger dependency on the interrelations between all programs. Medicaid Enterprise Systems can and should look at whole systems, focusing on social determinants of health. Data and program integrity will be key, as the increased potential of fraud in the midst of challenging state budgets. We will need to respond quickly with limited resources.

Keep relationships strong

PSTG spoke of how when COVID hit, it caused them, like the rest of us, to modify their goals. They spoke about relationships and the importance of maintaining them with clients and colleagues, questions of productivity, what things that we have learned will we carry into the post-pandemic era, will we remain flexible, and how will we “unwind” all the related changes that will not be carried forward. Looking forward, PSTG wants to support the growing of the outcomes-based culture, evolve the state self-assessment (currently an active workgroup), and how to be less prescriptive to allow for more flexibility on “how” vendors get to solutions.

I was grateful to be able to join this event, and hear that we are in this together—we will get through it and we will keep moving forward. I felt this was a good start to what I hope will be the first of many MESC 2020 forums. The session felt like it ended too quickly even though we covered a lot of ground. I am excited about the thought of hearing about new ideas, improving our understanding of upcoming changes CMS is sponsoring, and engaging in the innovative thought that will keep us moving toward a better tomorrow. Thanks to NESCSO for sponsoring this event and bringing us together.

Please contact our Medicaid Consulting team for more information on if you have any questions.

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MESC 2020: Where we are today and where we will be tomorrow

Read this if you use, manage, or procure public safety and corrections technology.

Recently we discussed the benefits of developing a strong, succinct Request for Proposal (RFP) that attracts Offender Management Systems (OMS) vendors through a competitive solicitation. Conversely, we explored the advantages and disadvantages of leading a non-competitive solicitation. Industry standards and best practices serve as the common thread between competitive and non-competitive solicitations for standard implementations. So, how does an agency prepare to navigate the nuances and avoid the “gotchas” of a non-standard implementation in the corrections realm?

Functional areas in the corrections industry exist in an ever-evolving state. The ongoing functional area refinements serve to overcome potential gaps between standardizing organizations (e.g., CTA, APPA) and your agency’s operations. For example, CTA does not distinguish incidents from disciplines as distinct functional areas. While merging workflows for incidents and disciplines may align with one agency’s practice, your agency may not always correlate the two functions (e.g., disciplinary action might not always result from an incident). Moreover, your agency may not have a need for every functional area, such as community corrections, depending on the scale of your operation.

Your agency should view the industry standards as a guide rather than the source of truth, which helps you cultivate a less parochial approach driven solely by standards and follow instead a more pragmatic plan, comprised of your unique operations and best practices. CTA and APPA specifications alone will result in comprehensive solicitation. For that reason, agencies can enhance an OMS modernization initiative by enhancing solicitation requirements to include jurisdictional specifications resulting from interviews with end-users and policy research. 

Upcoming OMS webinar

On Thursday, November 5, our consulting team will host a webinar on navigating a solicitation for a new OMS. During the webinar, our team will revisit the benefits of an independent third-party on your solicitation and review industry standards, and will discuss:

  1. Crafting requirements that address common OMS functions, as well as jurisdiction-specific functions (i.e., those that address the unique statutes of the state). Crafting requirements helps your agency to ensure a replacement system addresses core business functions, provides a modern technical infrastructure, and complies with local, state, and federal regulations.
  2. Thriving with a collaborative approach when acquiring and implementing an OMS system, helping to ensure all stakeholders not only participate in the project but also buy into the critical success factors.

If you have questions about your specific situation with OMS implementations, or would like to receive more information about the webinar, please contact one of our public safety consultants.
 

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Managing non-standard Offender Management System (OMS) implementations

Read this if you are a state Medicaid agency, state managed care office, or managed care organization (MCO). 

The COVID-19 pandemic and resulting economic downturn has led to increased Medicaid member enrollment and has placed a strain on state budgets to support Medicaid and other health and human services programs. It has also impacted traditional Medicaid utilization patterns and has challenged provider reimbursement models, forcing managed care programs and supporting MCOs to:

  • rethink the control of program costs, 
  • seek MCO program flexibilities to expand coverage such as telehealth, and 
  • make operational changes to support their growing member populations.

Managed care opportunities

While COVID-19 has created many challenges, at the same time it has given managed care programs the opportunity to restructure their delivery of services not only during the public health emergency, but for the longer term. Flexibilities sought this year from the Centers of Medicare & Medicaid Services (CMS) put in place through waivers and state plan amendments have helped expand services in areas such as the delivery of COVID-19 testing, medical supplies, and behavioral health services via telehealth. 

These flexibilities have relieved the administrative burden on Medicaid programs, such as performance and reporting requirements outlined under federal law and 42 CFR §438. Although these flexibilities have helped managed care programs expand services during the pandemic, the benefits are temporary and will require MCOs to make programmatic changes to meet the demands of its population during and after the public health emergency.

A recent study by Families USA cited 38 states reporting 7% growth in member enrollment since February. As the Medicaid population continues to grow in 2020 and beyond, managed care programs have numerous opportunities to consider: 

Managing care coordination and establishing efficiencies with home- and community-based services (HCBS)

The increased risk of adverse health outcomes from COVID-19 due to older age and chronic illness, and the demands on providers and medical supplies, has forced Medicaid programs to seek waiver flexibilities to expand HCBS. As part of HCBS delivery, MCOs may focus on the sickest and most costly of their member populations to control costs and preserve quality. 

MCOs will most likely monitor cost drivers such as chronic conditions, catastrophic health events, and frequent visits to primary care providers and hospitals. MCOs have the opportunity to establish efficiencies and improve transitions across different providers and multiple conditions to better manage the over-utilization of services for members in skilled nursing facilities, and for those who receive HCBS and outpatient services.

Adjusting and monitoring Value-Based Payment (VBP) models

With the continued transition to VBP models, Medicaid programs face the challenge of added costs and adapting plan operations and services to address pandemic-related needs, chronic conditions, and comorbidities. 

Building on the latest guidance to state Medicaid directors from CMS on value-based care, Medicaid programs can look at COVID-19 impacts on provider reimbursement prior to the rollout of VBP models. Medicaid programs can continue establishing payment models that improve health outcomes, quality, and member experience. States can adjust contracts and adherence to local and state public health priorities and national quality measures to advance their VBP strategy. Managed care programs may need to consider a phased rollout of their VBP models to build buy-in from providers transitioning from traditional fee-for-services payment models, and to allow for refinements to current VBP models.

Continued stratification and the assessment of risk

By analyzing COVID-19’s impact on the quality of care and member experience, improved outcomes, and member and program costs, managed care programs can improve their population stratification methodologies factoring as population demographic analysis, social determinants of health, and health status. Adjustments to risk stratification during and after the COVID-19 pandemic will inform the development of provider networks, provider payment models, and services. Taking into account new patterns of utilization across its member population, managed care programs may need to refine their risk adjustment models to determine the sickest and most costly of their populations to project costs and improve the delivery of services and coordination of care for Medicaid members.

Telehealth

As providers transition back to their traditional structures, MCOs can continue to expand telehealth to improve service delivery and to control costs. Part of this expansion will require MCOs to balance the mentioned benefits of the telehealth model with the risk of over-utilization of telehealth services that can lead to inefficiencies and increased managed care program costs. In addition, because of the loosening of federal restrictions on telehealth, managed care programs will most likely want to update program integrity safeguards to reduce the risk of fraud, waste, and abuse in areas such as provider credentialing, personal identifiable information (PII), privacy and security protocols, member consent, patient examinations, and remote prescriptions. 

Continued focus on data improvement and encounter data quality

Encounter data quality and data improvement initiatives will be critical to successfully administer a managed care program. As encounter data drives capitation rates for MCOs, a continued focus on encounter data quality will likely enable Medicaid programs to better leverage actuarial services to establish sound and adequate managed care program rates, better aligning financial incentives and payments to their MCOs. 

States have pursued a number of flexibilities to establish a short-term framework to support their managed care programs during the COVID-19 pandemic. However, the current expansion of services and the need for MCOs to rapidly identify additional areas for operational improvements during the pandemic have allowed Medicaid programs to further analyze longer-term needs of the populations they serve. These developments have also helped programs increase their range of services, to expand and manage their provider networks, and to mature their provider payment models. 

If you would like more information or have questions about opportunities for adjustments to your managed care program, please contact MedicaidConsulting@BerryDunn.com. We’re here to help.
 

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COVID-19 and opportunities to reboot managed care

Read this if you are a member of a State Medicaid Agency’s leadership team or Program Integrity (PI) unit. 

In March 2020, the Centers for Medicare and Medicaid Services (CMS) suspended PERM cycle activities in response to Secretary Azar’s public health emergency (PHE) declaration. The suspension of the PERM cycle activities provided states with an opportunity to direct resources to the state’s PHE response. In August 2020, CMS released the suspension of PERM cycle activities to allow CMS and states to complete the PERM cycles that were either in progress or in the process of starting up.

While the PERM cycle suspension was in place, CMS released an updated PERM Manual in May 2020. You can access the updated PERM Manual here. The update primarily consists of the addition of guidelines related to the return of the eligibility reviews to the PERM cycle, as defined in the PERM Final Rule published by CMS in July 2017. The manual updates include adding regulation on the CMS Eligibility Review Contractor (ERC) to perform the eligibility reviews. 

Another topic receiving significant updates in the manual was the sample guidelines. Some of the updates included:

  • Sampling units related to Third-Party Liability (TPL)
  • CMS and its contractors must be granted systems access for the review process
  • Sampling timeframes updated for each cycle

There are more updates in the manual, which states will not want to miss. BerryDunn has prepared a summary of the updates included in CMS’ May 2020 release of the PERM manual. View the summary.

While state resources are busy addressing the current PHE, the states should be tracking and documenting waiver activity, as many of the flexibilities provided by waivers will expire at the end of the PHE or soon after. Provider claims for services rendered during the PHE are eligible for the PERM cycle review, and states will need to give the PERM reviewers the flexibilities honored by the state. 

For questions or to find out more information about the PERM Cycle, contact Dawn Webb

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Keeping the PERM Manual update in focus during the PHE