Arkansas Medicaid Updates

6-20-17 OT, PT and ST Manual changes effective 7-1-17 http://www.arota.org/images/Update_to_Medicaid_Therapy_OT_PT_ST_Effective_7-1-2017.pdf

6-15-17 Update from Melissa Stone, DDS Director regarding continued questions about the 90 minute threshold and the PA Process.

http://www.arota.org/images/Medicaid_Update_6-15-17.pdf

5-26-17

Memo from Melissa Stone, DDS Director regarding Medicaid Changes

http://www.arota.org/images/Therapy_Changes__1_.pdf

5-26-17

Update Large Workgroup Meeting

90-minute soft threshold information:

This is nothing new, but confirming that beginning July 1, all newly evaluated children whom you are requesting >90 minutes per week of OT, will have to undergo a PA/EOB process for the amount greater than 90 minutes. You can begin seeing them for the 90 once you get your DMS 640 back, but you will have to wait until the PA/EOB process is complete to get the additional amount of minutes.

AFMC is aware that we are requesting a 3 business day turn around on these, so hopefully, you won’t have to wait long before you can begin treating for the additional time.

We do not know what exactly this process will look like yet. DDS is doing a 1-year bridge contract with AFMC to do these PA/EOBs. Again, we have no information on this yet. Melissa Stone and AFMC are still meeting to discuss this process.

Regarding “Grandfathering,” all children for whom you currently have a valid DMS 640 and are receiving more than 90 minutes per week of OT, can still receive more than 90 minutes until their DMS 640 expires. AFMC will do a manual edit in their system or “over ride” the 90 minute restriction for these children. They are asking that if you see a child for >90 minutes per week and have a valid DMS 640, that you fax it to AFMC beginning July 1st. Do not fax them yet. You may need to start getting them ready, but they will want them beginning the first week of July. There is no cover sheet or anything. You do not send the eval either. Just fax the DMS 640 by itself. This is not a medical review, it will just be a simple process in order to let AFMC know which kids to allow greater than 90.

As I mentioned in an update below, please do not get caught up in the language of PA and EOB. Moving forward, Melissa said everything will be referred to as PA/EOB.

They are still working on trying to get the DDTCS and CHMS manuals to “mirror” one another….a hybrid as Melissa Stone calls it. I have no news on this.

The company that won the screener for children who go to centers is Optum. They will be using the Battelle Screener. They have committed to going to the families…therefore; the families do not have to make an additional trip somewhere. We have very little other information on this, but they have agreed to get the screening done within 10 business days from referral from the MD. Melissa Stone said these will not likely begin until October or November of 2017. As it stands now, I also believe all children will be screened annually in order to continue attending centers.

The process will look something like this—parent goes to MD to get referral to a center, MD refers child to Optum for the screen, Optum has 10 business days and then sends the info back to MD, MD can then make the referral to the center WITHOUT THE CHILD HAVING TO COME BACK FOR AN ADDITIONAL APPOINTMENT.

Treatment completed prior to June 30, 2017 will still be billed under OLD system.

 

4-12-17
Update from Yesterday’s meeting with Melissa Stone. This is a meeting that was cancelled and rescheduled and got cancelled again. Originally, it was to meet to discuss what (if any) of the workgroup’s recommendations would be accepted in regards to the RFP (request for proposal) for whatever company wins the contract to perform the EOB/PA for minutes requested over 90.

We were not able to discuss much in regards to the RFP because it has not been awarded yet, or it has, but is being contested? At any rate, we know nothing more other than what I have posted below in a previous update. The workgroup asked for several things, but do not know if any of the recommendations will be accepted because Melissa is not allowed to publicly discuss the RFP yet.

 What we did discuss was:

 

  1. Many providers have a bad taste in their mouths at the mention of “Extension of Benefits” (EOB) because historically, they are NEVER approved. It should be noted that you will see the term EOB and PA used interchangeably with this new PA process. The reason is because (behind the scenes) essentially when submitting for minutes greater than 90, you may not know it, but you get a PA in order to get an EOB for more units. Melissa said we are going to have to quit thinking of EOB in the past. In the contract for the company that wins the bid to do the PAs, she has written it everywhere as PA/EOB. She was very adamant to not get caught up in the old EOB when you see/hear/read it moving forward.
  2. There are some issues regarding language in the manuals. The CHMS and DDTCS manuals will mirror one another—although the new draft does not reflect that. There is also an issue with the manuals because the therapy regs will go into effect July 1 and the other regs will be in place August 1, 2017. I cannot answer any questions regarding this because I do not understand this myself, but several were upset.
  3. There is a possible issue regarding “grandfathering” children because some clinics are trying to evaluate all of their children before July 1 and just eat the cost in order to circumvent the PA process. Melissa cannot give details on this, but as I have mentioned before DO NOT EVALUATE ALL OF YOUR CHILDREN BEFORE JULY 1, 2017 IF THEY ARE NOT DUE. What until the appropriate time.
  4. Retrospective review for children receiving 90 will likely be done away with.
  5. New MMIS implementation has been delayed. No date given.
  6. In order for a child to be referred to a CHMS or DDTCS program, the physician must send them to a third party screener—that part we already knew, but two new things on this…first, we were discussing a list of diagnoses that would be excluded…meaning, if a child had a specific diagnosis, they would not have to undergo the screening process. This is still true, but there is NO ACTUAL LIST of diagnoses. It will be up to the physician. If the physician feels the child would benefit, they will send a document (the document has not been developed yet) to the third party letting them know that this child can be bypassed. Secondly, in addition to having to undergo a screening on the front end to get into DDTCS and CHMS facilities, these children will also under go annual screenings by the third party as well.

 

4-10-17 DDS Transformation Efforts
http://www.arota.org/images/DDS_Transformation_Efforts.pdf

 

2-13-17 Large Workgroup Meetings Update:
*It is difficult to provide an update after each work group meeting (we slowed down for the holidays, but there have been three more since my last update) because we are discussing and tossing around ideas most of the time and nothing will be set in stone until presenting to Melissa Stone (we just presented our recommendations on 2-10-17). She will take the suggestions back to her team and decide what they will and will not accept. She will meet with the small group of work group representatives on 2-27-17 and let us know what they have decided from our suggestions. It should also be noted that in an attempt to NOT put out erroneous information, it is difficult to provide constant updates because things change quickly and sometimes even in the group, we are not operating with correct information or we have to clarify or find out further information. Please remember, the large work group meetings are open to the public. They are advertised on our website and Facebook page. There is also an option to Zoom (video) in for those living out of the area. In the meetings, there is great care taken by the moderator(s) –usually Stephanie Smith and Janie Sexton--to ensure a majority before they put any suggestion into a document.

 

As it stands now, the 90 MPW issue is a done deal. This will come into effect beginning July 1, 2017. Here’s what this means:

If you have an existing child that is receiving over 90 MPW of OT, continue doing whatever you are doing until that child is up for re-eval. Here goes me putting something out there that may or may not come to pass---so take note—the next sentence has been suggested, but has not been approved or agreed upon by Medicaid. There has been some talk and a suggestion made that for those children who are receiving OVER 180 minutes per week, perhaps they would have to go through the PA process BEFORE their current RX is up. The date of 9-1-17 has been suggested (**Suggested only. No decision has been made).

***DO NOT EVALUATE EVERY CHILD ON YOUR CASELOAD IN JUNE IN AN ATTEMPT TO BYPASS THE PA PROCESS—you will be flagged. Wait until the appropriate time to re-evaluate please.

Some of the other cost saving suggestions (in addition to the 90 MPW soft threshold) have been (again, nothing is for sure regarding what Medicaid will accept—these were just some suggestions made by the work group):

1. An independent assessment will be performed on children before being referred to a DDTCS or CHMS center for evaluation. Estimated cost savings is TBD.

Existing children would be grandfathered in. Who will do the independent assessment? There is either currently or will be an RFP out (request for proposal) for a 3rd party vendor to manage this. We do not know who this will be or what his/her qualifications will be. We do not know if the screening person will go to the home, MD office or if the parent will have to take the child to an independent facility. We do not know what assessment they will use. The Ages and Stages has been tossed around, but again, this will be up to whomever wins this contract. We have had little input on the qualifications or the assessment instrument. The large work group has, however, made recommendations for the qualifications of the people who would be approving the PAs for minutes greater than 90--which will be discussed later. There is some discussion (again, nothing set in stone) regarding whether a physician could complete his/her own screen (or use the screening the 3rd party plans to use) and refer directly to the center. Again, we do not know yet what Medicaid will decide. The work group has also made a list of suggested diagnoses of children that would be allowed to bypass this independent screening/assessment and go straight to the center for eval. I could list them all here, but again, these were just suggested and we do not know what Medicaid will and will not accept. I will provide more details as we know what Medicaid will accept. Developmental Delay is NOT on the list. It does not mean that a child with a diagnosis such as developmental delay could not go to a center. It means they would be subject to the independent assessment first. The list of diagnoses that could by pass the independent screening included diagnoses such as CP, Autism, Neurological impairments, genetic disorders, spinal cord injuries, blindness, deafness etc.

The workgroup has requested a 10 business day turn around for the independent assessment/screenings.

 

  1. DDTCS—currently DDTCS centers currently evaluate for eligibility for day hab every 3 years. A cost saving suggestion was that they must provide a comprehensive, annual evaluation to determine eligibility for their dayhab services. The estimated cost savings is between 3-5 million.

 

  1. Regarding the PA process, QUALIFICATIONS OF REVIEWERS---The workgroup has made the following recommendations: reviewers must be licensed in the sate of Arkansas with 10 years peds experience (5 being clinical); adequate work force; available specialists within each discipline (feeding etc.); No conflict of interest-reviewer cannot review for clinics for which they currently or in the last 12 months have received payment; Appeals must go to a different reviewer; Representatives from the reviewing agency will participate in meetings with the therapy advisory council at least quarterly, but more frequently if necessary. TURNAROUND TIME: The workgroup is asking for a 72 hour (3 business day) turn around time from the receipt of the PA request to time of reviewer approval or denial. EXCLUSIONS: It has been noted that children who have undergone acute trauma, surgeries, burns, wounds etc. Can begin receiving their treatment immediately to receive up to 180 minutes 3-5 days a week. The PA will be retroactive to the start date of the therapy per the attending physician. There will be a list of ICD-10 codes. I do not have the codes at this time. COMMUNICATION: workgroup has suggested electronic submission and communication of PA approval/denial. The reviewer must be able to access all PRIOR PAs for a child in order to coordinate the issuance of PAs for children receiving therapy from two providers of the same discipline (school based, clinic based etc.). The reviewer must answer yes or no to the request of minutes greater than 90. If the reviewer answers No, they must provide clinical reason for denial. If no, the submitting therapist will have the opportunity to have an appeal ONE time. The reconsideration must be submitted within 35 days of the receipt of denial. A different reviewer must process the reconsideration within 72 hours of receipt. The provider and or beneficiary may appeal the reconsideration denial as provided for in Section 160.000 of the Medicaid manual. If the prior authorization is not processed within 72 hours, a provisional prior authorization will be issued for the recommended minutes until the prior authorization process is completed. Unless the request for Prior authorization specifically identifies the period for which the request is being made, it will be assumed that the PA is for the period covered by the evaluation submitted with the request. DOCUMENTATION REQUIRED WITH PA SUBMISSION: Comprehensive evaluation with appropriate tests, clinical opinion, progress to date, identify all known services currently received, evidence based support for recommendation If available and expected outcomes. The DMS 640 signed by PCP or referring specialist; PA request for therapy cover form (promulgated and # like all Medicaid forms). A PA request can be submitted at any time during the evaluation year. Separate PA would be issued if a child receives services from more than one provider of the same discipline.

Possible change to the DMS-640—May state, “ Therapy prescribed for more than 90 minutes per week per discipline must be prior authorized according to Medicaid regulations. Therapy can be provided up to 90 minutes per week per discipline until prior authorization is received. If therapy above 90 minutes is not approved the reviewer will send copy of denial to PCP” (this is the current practice in retrospective reviews).

For children who are transferring to a different clinic: The receiving clinic/therapist accepts the previous therapist’s evaluation. In order for PA to be transferrable, the following must occur: Signed release of health information specifically requesting approved PA document which can be submitted electronically, a New DSM 640 issued to the new treating clinic/therapist with the same recommendations as in evaluation ad prior authorized and a form for submitting request to reviewer to transfer the approved PA to the new provider.

REPORTING: No quotas for denials will be established or implied in any document or verbal discussion between DNS and the 3rd party reviewing entity. Quarterly reporting will be published on the Ark Medicaid website that will include at a minimum the following: by de-identified reviewer, the number of PA requests approved, denied and appealed, the number of appeals approved and the number of appeals denied. In total by discipline, the number of PA requests reviewed, the number approved, denied, appealed, number of those appeals that were approved and denied. An annual analysis that shows paid expenditures and number of overall recipients per discipline in a fiscal year providing a 5 year comparison and ongoing evaluation of savings.

**There will need to be revisions made to the Medicaid Manuals regarding implementation of these suggestions.

**To assist the PA process reviewers, a guideline regarding dosing considerations has been suggested based upon the World Health Organization’s (WHO) International Classification of Functioning, Disability and health (ICF). The guideline takes into consideration the child’s diagnosis/health conditions, prognosis, body structure and function, limitations of activity, participation, personal factors & environmental Factors. Evidence Based research should also be included if applicable regarding how the recommendation will impact the above factors.

Minutes December 16, 2016 Meeting

BH-DD Provider-Led Coalition

A meeting was held at the offices of the Mental Health Council of Arkansas (MHCA). Doug Stadter, President of MHCA, chaired the meeting, while David Ivers of Mitchell Blackstock Ivers & Sneddon facilitated. Mr. Stadter informed the group of the previous meeting that took place on December 2, 2016. The goal of the meeting today is to get organized and get the work groups together. David Ivers discussed the December 2nd minutes. Those in attendance are reflected on the attached sheet.

Suggested approach for formation of Steering Committee-
Doug Stadter presented the handout “Exhibit A” regarding the formation of a Steering Commmittee. This group is responsible for the overall leadership and development moving forward.
There is a limit of three representatives from each association to be members of the Steering Committee. The list of Committee Members sent from organizations’ leaders needs to be submitted to Mr. Stadter by 12/30/16. This Committee will also hear from each of the subcommittees/work groups that will be formed. Both the Steering Committee and workgroups will be meeting often.
The Steering Committee doesn’t equate to Board membership or control of entity.

Mike McCreight discussed communication with DHS. Discussion points include:
There is an opportunity to come up with new communication with DHS. This may be something both providers and DHS and others get together to come up with a product. There is extreme eagerness for something at DHS level. The two main concerns are financing and data. They can’t create data programmatically. It is important that we work with them to get data.

Suggestions on initial Subcommittees- Mike McCreight
Subcommittee information can be found on the handout titled “Exhibit B”. The attachment was discussed in detail. The main points include:

# Insurance Regs
#2 PASSE Governance/Interview MCOs/ASO --The goal is to get a better idea from MCO’s and ASOs what they want to propose, lessons learned, etc and develop criteria of what we’re interested in, and then have a more formal selection process.
#3 PASSE Certification Requirements- It hasn’t been said that hospitals can’t submit for this. This option- look at something appropriate for the population we serve, any individual can select from among PASSEs.
#4 Statutory Changes/Legislative Approach- This is another issue. People with a legislative background are needed.
#5 Data Bank- Finance is important and DHS does not have the capability to do this without our help. A good, basic set of data is needed before MCOs come into the picture with their data analytics.
#6 Population/Settings- This is a big issue. What does the population need to be? What do the tiers need to be?
#7 Care coordination/ACEs/Health Homes – Mr. Ivers suggested this one be added to the list based on recent feedback from DHS. This is an extremely important component and one that presents several different options.

 

The subcommittees will meet to make recommendations to the Steering Committee, which will bring recommendations back to the broad stakeholder group for input and to make adjustments. Other subcommittees may have to be created as we go along.
David Ivers: consultation with DHS- Most of the subcommittees were based on discussion with DHS on where they would like to concentrate first, though we added data and population.

Mr. Stadter will get copies of the DHS presentation from a few weeks ago of the proposed model as they saw it. It’s the format that will be looked at going forward. DHS is open to how we want it to be designed.

CMS regulations have to be met, and so does the definition of ACEs. Teleconference abilities are important for these meetings.

Suggestions on process for inviting presentations by MCO/ACOs discussion points include:
Mr. Ivers- Various persons and groups have been meeting with some of the MCOs, which is their right, but it’s important that we get feedback to the Steering Committee and that we are all on the same page to the extent possible. The current ad hoc approach has been confusing. Mr. Ivers will work on a list of organizations that have indicated they want to meet with us.

MCO/ASO- The State views this model: MCO partner 49% and provider led side 51%. Each one has to be willing to take some risk (small at first, maybe 2.5% on each side, gradually increasing). Some ASOs are not willing to take risk, so they may fit into the model helping in some other way as a partnership with an MCO or something. Not trying to exclude ASOs. There is other criteria that will have to be figured out too.

Mr. Stadter- provider led 51% ownership can be looked at different than equity. DHS is open to looking at model to bring all providers together for minimal investment. This piece has not been worked out. Other types of equity will be counted.

Governance side- it can correlate with percent of ownership, but sometimes it doesn’t. The issue of any one provider having too much control can be dealt with by setting a maximum ownership percentage. They can require people to invest time and effort. No conversation has taken place about the financial aspect.

Bonds- how affects equity? This is regarding a comment from the last meeting - Can ask for investment from outside parties. There are different ways to look at that. We need to find financial investments. A common way this has been dealt with in past has been through a managed care company holding 51% control of provider partnership. That’s not necessary now. Clarification on the last meeting the topic of bonds- This came up in concept on how you handle the actual insurance side of the network reserves issue. DHS has started negotiations with insurance on those types of issues; they want to bring us in on that.

Mr. Stadter- these are issues/questions to ask when doing the interviews with the companies. Ask what model use in other state/what they would propose. This is where a subcommittee could come in. They could be part of the initial screening of who may be candidates then the Steering Committee can chose and then go back to the subcommittee to work on negotiation with whatever one(s) that is/are chosen. There first needs to be some mechanism to develop parameters to screen candidates so the Steering

 

Committee can chose and go back and negotiate. After some discussion from various members, the plan was to invite the MCOs and ASOs to make initial presentations to the wider stakeholder group, then the subcommittee would develop screening criteria and begin interviews in order to narrow down the list and make recommendations to the Steering Committee. Mr. Stadter added that if anyone has organizations they have met with or organizations that they know might be interested; let him, David Ivers, or Mike McCreight know. They can get that information to the subcommittee.

Mr. Stadter informed the group that hospitals or BCBS being disqualified is still up for discussion. They want this to be entirely provider, community-based. The population is developmental disabilities, mental health, and substance abuse, but this includes the entire span for clients so that means all costs is the part that has to be managed.

Mr. Stadter- before selecting an entity there needs to be governance in place. It is important to have an initial meeting so there is understanding. There has to be buy in. Eliminating some entities is concerning because resource are not evenly distributed through the state.

Mr. Stadter added that DHS has a role in this (drafting legislation for certification for a PASSE). Legislation will be introduced in February. That being said, Mr. McCreight stressed that we first have general presentations by MCO/ASOs before trying to develop parameters. Then development of criteria can begin.

Feedback is needed from providers in Indiana, Colorado, Oregon, and Pennsylvania.

Mike Grundy asked how the coalition would compensate Mr. Ivers, who said he would get back with the group with a proposal from his firm.

DHS has said legislation will be worked on in January. We can come up with ownership, rules, governance, etc. for this PASSE. The State is working on minimum requirements for a PASSE. Specify at least 51% provider owned. Governance is for us to decide for this specific PASSE we develop. Other PASSEs may have governance differently. The possibility of PASSE/ACE complications and overlap was discussed. Forming a PASSE and getting governance is all that needs to be focused on right now. Then the issue of how ACE and PASSE will fit can be addressed. An issue with multiple PASSEs and how many ACEs and PASSEs would be established was discussed.

Correct substance abuse data is needed. Missed population data was discussed. Subcommittee will work on parameters with Medicaid.

Communications: How to manage communication flow-
There is a lot of moving parts, special interests, etc. There is also a lot of contact with the legislature and DHS personnel. How to define contact with them and how to organize that is the topic of discussion for this agenda item. Mr. Stadter reminded the group that the message needs to remain clear. The Steering Committee has to get information from the subcommittees. Members must communicate with their respective associations. There will be a standard message sent from the Steering Committee.

Role of DHS- They’re in process of developing their own team for legislation and they asked us to be involved. DHS- Subject committees to meet and overall Project Team. Project Team leader for DHS?

 

Mr. Stadter- It is important to funnel things up to the Steering Committee (questions, concerns, what you’re hearing out in the community). The Steering Committee can then get that information back to everyone. That information can be emailed to David (divers@mitchelblackstock.com) then he will get it to Mr. Stadter, Mr. McCreight, and the Steering Committee.

Organizations to schedule meetings: BHO, Magellan, Noridian, BCBS, AFMC, Anthem, venture capitalists, and more.

Next Meetings- Steering Committee and Stakeholders meetings
Steering Committee: MHCA or Easter Seals Training Room January 6
th at 1:00 p.m.
Stakeholders Meetings: Every other Friday or as called. January 13th (AARP) and January 27
th (Easter Seals Training Room).
Meeting reminders with addresses will be sent out.

Other Business- No other business was discussed. Meeting was adjourned at 2:51 p.m.

 

12-12-16

After receiving feedback from our lobbyist (Capitol Partners) and our members, AROTA’s executive board made the decision to sign the following letter.

 

“December 12, 2016

 

Governor Asa Hutchinson

500 Woodlane Street, Suite 250

Little Rock, AR 72201

 

Re: DHS/DDS Proposed Therapy Rule

 

Dear Governor Hutchinson:

 

As part of your call for Medicaid reform efforts across all divisions, the following organizations support the DHS/DDS recommendation of prior authorization of speech, physical, and occupational therapy recommendations exceeding 90 minutes per week per discipline that is estimated to generate a gross savings of $16 million annually. This support is contingent upon the development, implementation, and on-going evaluation, in collaboration with DHS, of a prior authorization process that encompasses appropriate clinical criteria and clinical reviewers (experienced, licensed pediatric therapists), a responsive timeline that minimizes a delay in services, and an appeal process to ensure no child is deprived of medically necessary services. This support is also contingent upon this recommendation being a component of any managed care model the state of Arkansas may adopt.

 

 

Arkansas Occupational Therapy Association

 

Arkansas Physical Therapy Association

 

Arkansas Speech and Hearing Association

 

Child Health Management Services Association

 

Developmental Disability Provider Association

 

Kidsource Therapy

 

Rehabilitation Network Association

 

Sensational Kids Pediatric Therapy Program

 

The Learning Center of NEA”

 

The statement from our Lobbyist (Capitol Partners) reads as follows:

 

“As I understand it, your members biggest concern is the lack of structure to the new Prior Authorization requirement.  Yesterday, DHS reminded the group that they have made verbal commitments with regard to prior authorizations - pediatric clinicians will be making the assessments (with PCPs remaining the ultimate authority on the child's plan of care), and there will be a 72 hour time limit for approvals, to name a couple. I was also told that the child would be immediately approved for 90 minutes and will begin therapy as they await the approval for more minutes.  (If you have the complete list of what they have promised, please share it with us so we know what we need to hold them accountable for.)   

 

Given these promises by DHS, we recommend AROTA sign the letter as written after the meeting yesterday.  We understand how vulnerable your members must feel, both in central Arkansas but more so in the rest of the state, and it is disconcerting to not have these promises in writing; however, we are here to hold DHS accountable and to ensure that AROTA is part of any and all conversations affecting your industry.

 

The fact is, changes are coming.  Cuts have to be made in the Medicaid program, one way or another, and these changes must take effect July 1, 2017. It may not seem like it, but DHS is doing the industry a big favor by trying to keep these budget decisions in-house.  If their changes are not approved before legislative session begins in January, the legislature will take it upon itself to make their own Medicaid cuts. Trust us when we say that having these changes come through rules and regs from DHS ensures that y'all will have more of a voice in what these changes look like.  

 

Possible talking points for your board:

 

- Changes are coming by July 1, 2017, one way or another.  We want DHS to remain in control of the new rules and regulations as it will give us more of a voice and opportunity to be heard.

- DHS has promised to work with us on the rules surrounding PAs.

- DHS has promised to stay accountable with regard to actual savings stemming from the 90 minute restriction, giving updates as requested.  And if this plan does not yield savings, they will gladly work with us to come up with something better.

- Melissa indicated yesterday that unless all disciplines sign the letter, she will not present it to the Governor, which means our fate will be left in the hands of the legislature. 

- If she decides to turn in the letter without AROTA's signature, we could be seen as not being a team player and may be left out of future conversations.

- This is truly the best option for AROTA right now.  Sign this letter, and Capitol Partners will all stay diligent in ensuring DHS is held accountable to their promises and their projected savings.”    

 

Feedback from AROTA members regarding AROTA signing the letter in support of the 90MPW Threshold

(Please note, I am not putting names, but I have all the email correspondence from members regarding this issue. )

 

  1. “Yes please sign.”
  2. “I spoke with Melissa (Stone) and it sounds like AROTA should endorse the proposal.”
  3. “I vote we sign the letter.”
  4. “I definitely think we should sign the letter.”
  5. “I say you have to sign it, the what if’s of not signing it are way more concerning and unknown.”
  6. “Go for it. I support signing this document. Play nice with this one, But…we can raise hell if/when they try to establish managed care (3rd party assessments for all referrals) in AR down the road. I am glad we have these guys on our team. It’s reassuring. Thank you for asking for input.”
  7. “I don’t mind signing the letter, but is there a certain place we are to send this letter…?” I clarified that it was for us as a unit/organization to sign, not individuals to sign and mail in.
  8. “I suggest we sign it. Thanks for asking.”
  9. “Thank you for your work. I hope the majority agree to sign!”
  10. “I will remain neutral but cannot put my personal signature on it.”
  11. “I agree with the suggestions of the work group to sign the letter in support of the 90 minute threshold.”
  12. “I am in full support of AROTA signing this letter in support of the 90 mpw soft cap and PA process. The is the best option for children with disabilities in Arkansas and I am grateful to the work group for their efforts to ensure services continue for children who need them.”
  13. “The letter looks great!”
  14. “I’ll sign it!”
  15. “I am in agreement with signing the letter regarding Medicaid.”
  16. “I am writing in response to the email regarding AROTA’s signing of the letter to Governor Hutchinson in support of the 90 mpw threshold with the contingency of continued involvement and development of the PA process. I have had the opportunity to be part of many discussions regarding this process, as well as work on subgroup committees for the PA process over the past few months as part of the large workgroup and Representatives of the Workgroup of pediatric health professions. This Wednesday the representatives of the workgroup, along with members of ARKSha and APTA, met with Melissa Stone to discuss this letter, and made further amendments with each disciplines input. While the letter is not “optimal” it is best that it is going to get right now, understanding that the PA process is still under construction and there are many unknown factors; however, I believe this has been stated and clarified in the letter. Having been a part of this process and understanding the pro’s, con’s as well as contingency’s of this letter, I vote/recommend that AEOA sign the letter to Governor Hutchinson as it currently stands on 12-9-16 and pending any further changes that may alter it’s stance. As you states, if AROTA is the only state association without our signature on the letter, the consequences could include excluding AROTA from many important discussions regarding cost-containment and decision-making, which could shape the future of the profession of occupational therapy and healthcare. I appreciate the time you took to send this letter out to AROTA membership and allowing for comment. I hope that AROTA will strongly consider signing the letter and following suit with the other disciplines in the state.
  17. “AROTA should sign the letter.”
  18. “I agree to sign the letter.”

♦DDS/Medicaid public comment feedback/responses regarding the 90 MPW threshold can be found here: https://www.medicaid.state.ar.us/Download/general/comment/Therapy-1-16Responses.doc

♦Large Workgroup Notes:
11-18-16
The workgroup and therapy advisory council (TAC) are not the same. The TAC has been meeting for 18 years at least 2x a year (sometimes quarterly). The TAC makes recommendations to add/remove tests and AFMC brings to the table telephone calls they have received or questions that they have received regarding tests etc. when they need help answering certain questions that keep coming up.
TAC is not part of thte workgroup, but it happened to be the conduit for DHS/DDS letting workgroup know that they were going to go ahead and push this out without the PA in place.

****New eval codes won't be in effect unitl the new Medicaid system goes up (not sure when that is).

Retrospective review will still be there which WILL result in a "double review" for those getting a PA for more than 90 MPW.

Gabe Freyaldenhoven (works in out pt ortho with pediatrics) expressed concerns regarding his population--due to the severity and acuity--have some sort of "modifier" that would allow these situations to not require a PA (also, with burns at Children's etc.). The workgroup was in agreement and looking to make this type of group exempt from the PA.

Credentials for reviewers:

licensed in the state of Arkansas (OT, PT, ST with c's)
10 years peds exp (professors can be reviewers, but must have at least 50% of at least 10 years with peds) we are insisting on an adequate work force (must have enough reviewers)
we are requesting specialists in areas be utilized when appropriate (feeding etc.)
no conflict of interest (looking at a way to make it anonymous--remove company letterhead and therapist name etc.)
upon appeal, it will go to a different reviewer

Timeline for PA process:

72 hours (3 business days)
PA process would begin for evaluations that expire after 7-1-17
electronic submission
Adequate workforce

Documentation requirements:

Evaluation cnsistent with requirements in Medicaid manual as well as:
comprehensive medical history
clinical opinnion that supports recommendations and expected outcomes of therapy
narrative of previous therapy treatments and progress to date
appropriate evaluation tests that followed testing protocols
identification of evidence-based support for recommendations and expected outcomes
DMS 640 signed by PCP
PA cover form (promulgated and # like all Medicaid forms)
identify all services currently received by recipient (cernter based, school, ST, OT, PT etc.)
De-identification of clinic/therapist prior to completion of document review
Can submit PA any time during evaluation year????? (uncertain)
Separate PA would be issued if child receives services from more than one provider of the same disipline (school, out patient etc.

We need to be able to get Rx's (640s) back faster from MDs...we would like to recommend 10 business days

If a recepient transfers to another clinic/provider etc. do we have to re-submit if their PA was already approved? (I believe we said we could use it since it was already approved).

There is a template/Rubric being developed for the reviewers to use. Cheri Woodson of NWA has been working on this.

All PAs are good for one year (still need to make sure they will be transferrable)

If the reviewer determines the documentation does not support greater than 90 MPW, the reviewer must enter into the system the detailed rationale for denial.

Providers may request administrative reconsideration of an adverse decision or the provider and /or beneficiary may appeal as provided in section 160.000 of the manual (this would be like forgetting to submit something. But if the denial is due to the reviewer not feeling the child demonstrated medical necessity, it would go to another reviewer.

There needs to be further discussion in cases where there are dual providers.

♦Large Workgroup Notes:
11-4-16
The majority of the meeting was regarding setting up a PA process.
At the beginning of the meeting, there were a lot of questions regarding numbers by members in the audience…how did they (DHS and the work group) come up with this amount of savings? DHS’ numbers do not match the work group’s numbers. The work group has asked for DHS to provide their numbers. The numbers will have to be “vetted” before anything can move forward. DHS is not unwilling to provide how they came up with the numbers--it just takes a long time to get anything from them. Apparently, DHS’ savings number is a lot higher than the work group’s numbers and the savings DHS calculated goes beyond what was even requested. IF DHS’ numbers are correct, then there may be a savings surplus and the possibility of making additional requests (120 MPW for 0-3 population etc.) may be possible. We will know nothing until we get the numbers from DHS. It is unclear when they may provide them, but again, they must be “vetted” before anything can happen. The work group has calculated a savings of approximately $13 Million. DHS’ calculations for the same plan are reported to be approximately $56 million.

 The group agreed on the following regarding a PA process:

-The reviewers must be licensed in the state of Arkansas

-The reviewers must have 10 years of pediatric experience (at least 50% of that being clinical)

-Reviews must be discipline specific (an OT reviews OT reports etc.)

-We are insisting on an adequate workforce to do the reviews

-We would like electronic submission to keep it timely

-The reviewers cannot review for somewhere that they work (there must be no conflict)

-We re-worded turn around time from 72 hours to “2-3 business days”

If we receive a 2-3 day turn around time, since we can begin treating at 90 MPW, ideally, this would only add 3 days to our inability to see the client for the time over 90 MPW.

We also discussed what documents a therapist would be required to submit for review:

You would send The evaluation, treatment plan and prescription, but also the idea of a universal “Coversheet” was discussed. The coversheet would go on top of the other documents you are submitting. It would have a checkbox at the top indicating if the child receives services at a center, school, private clinic (Center Based versus non Center Based). The discussion behind this was regarding some of the rationale for seeing children for more time that are not in centers is because they do not have the advantage of instructional classroom time/day hab etc. which is definitely a consideration.

Pages of the PA form must be numbered and promulgated (so they cannot be changed)

-we would like a “reconsideration” period where if you are denied on your first attempt, it can go back through and be re-assessed by another reviewer (no details on this process yet)

-Separate PAs would be required if the child receives therapy in more than one place (Feeding clinic and Sensory Clinic etc.)

-We would like a transferable PA (if the child changes clinics or centers)…meaning, if they are already approved for >90 once, you should be able to continue.

 Other items of interest that were discussed:

Schools are likely going to annual evals if they bill Medicaid

Schools and clinics/providers will have to practice “coordinated care” if the child receives outside therapy services in regards to use of minutes.

To help identify children who get evaluated and do not qualify and the parent takes them somewhere else (who WILL), put some sort of flag or qualifier associated with their Medicaid number to help eliminate this issue.

You must do an eval to treat. Apparently, there are people going into daycares and doing evaluations for free and treating? I am uncertain of how this is possible, but it is apparently being done.

It has been suggested to Medicaid that they recoup the entire evaluation period if the child is found to not actually require services instead of just the previous 3 months.

 The other items that were included on the agenda, but were NOT discussed involved “Independent Assessment” and “Evaluate the DDTCS and CHMS eligibility and programming requirements for developmental therapy/habilitation services to generate cost savings.” I am going to type what is on the agenda regarding these topics. Again, we did not discuss either—we ran out of time trying to outline the PA process-- Therefore, I am unable to answer specific questions regarding either of these topics. “2. Independent Assessment: Ages and States screening for all children suspected of having a developmental delay/disability. PCP/PCMH would refer/accept/review completed Ages and Stages screening from provider or family or complete the screening in the office by the PCP or PCP staff. Based on the results of the screening the PCP would refer family with prescription for evaluation(s). The PCP would provide family choice of providers for evaluation(s). Based on the results of the evaluation(s), the PCP would refer family with prescription for services. This initiative is consistent with the mission of the AAP and CDC to address early identification of children with developmental delays and /or disabilities in order to obtain optimal child development in both the pediatrician’s office and within a family-centered systems network of community based services.

  1. Annual evaluation to qualify for developmental therapy/habilitation services. Projected savings of 5.5 million annually based on at least 5% of children testing out annually but adjusted to 2.5% for the enrollment of new children identified and qualifying for the service.
  2. Class sizes and ratios
  3. Starring education requirements/credentials for developmental therapy/habilitation services
  4. Governing division within DHS for therapy (all), DDTCS and CHMS

If the above can be done it would also address the dual licensure issue. This will also need to be developed at the same time as the case to increase state general revenue to fund quality child care services is addressed either through increased in day care voucher, ABC funding, Early Head Start or Head Start.

4. As a result of generating savings in the children’s program areas, we would request that a minimum of 50% of the generated savings be directed to the HCBS waiting list.”

We are not done with the outlining the PA process. The PA process requires more work and we did not even discuss the other two pressing issues. We have set another meeting date for 11-11-16 at 1:30. It will be held at Easter Seals. The address is: 3920 Woodland Heights Rd. Little Rock, AR 72212.

I am assuming if you could not come today, but want to come to the next meeting, you would still need to send an email to sssmith@eastersealsar.com for headcount purposes.

 

♦10-27-16 RFP for Initial assessment has been released. Public comments can be made to stephen.mckinght@dhs.arkansas.gov and are only open until tomorrow at midnight unless it is extended. The document can be viewed at http://humanservices.arkansas.gov/Pages/procurementDetails.aspx?show=512

♦10-25-16 Notes from the Therapy Advisory Council Open Meeting

Please note that Lainey Moore Morrow, from the Medicaid Saves Lives Facebook page, had a live stream during most, if not all, of the meeting. It can be viewed at https://www.facebook.com/search/str/Medicaid+saves+lives/keywords_top

1. Timely Filing has been turned off. You can now submit billing back to 10-1-2013. This opened on 10-17-16 and will remain open until April 15, 2017. It costs 10 cents to check to see if a child is eligible. There is a webinar on the AFMC website explaining this. It can be viewed at https://afmc.org/health-care-professionals/arkansas-medicaid-providers/policy-and-education/timely-filing-webinar/

2. If you would like to view the live stream from yesterday's meeting, it can be viewed on Representative David Meek's Twitter feed. Several times during today's meeting, people were referred to watch this in order to help answer questions https://twitter.com/davidmeeks

3. PA Process: When the RFP (request for proposal) for the PA process goes out, there will be stipulations that require a 72 hour turn around and PT, OT and STs are the ones doing the reviewing. The workgroup will be involved in helping develop the RFP. The state is aware that historically PAs can take a long time. Since a third party will be under contract to provide this service, they will be legally obligated to the terms of the contract. This issue is a separate issue and it will have it's own public comment period etc.

4. There is some confusion regarding the use of the terms PA and Extension of Benefits. This is being looked into and the appropriate wording will be utilized.

5. When the MD signs your initial RX for more than 90, he/she will know that if the RX is for more than 90, it will have to go to a PA process. You may begin treating at 90 until your PA returns. If you want to take a gamble, or feel certain you will get your PA, you can go ahead and treat at the greater amount keeping in mind, you cannot bill for it until your PA is returned.

6. If you see children in your clinic who also receive therapy in public school, there may be some issues regarding going over minutes. It was recommended that you practice "Coordinated Care" in which you know and are aware of how much time they are receiving in school and if Medicaid is being billed. Also, you may decide if one or the other agency is going to submit the PA or may agree that the excess time will be covered by educational funds if the PA is denied.

7. The 90 MPW threshold does not pertain to children in acute care hospitals--only those receiving DD services.

8. Regarding the "Independent Assessment"-it will also have it's own timeline and public comment dates. This was described as being more of a "Developmental Screening" versus an actual PT/OT or ST evaluation. It would only pertain to DDTCS and CHMS centers versus independent provider clinics. If a child/family is unable to get to the clinic doing the screening, the person doing the screening must go to them.

9. The 90 MPW threshold public comments are open until 11-13-16, BUT it will go in front of the Public Health Committee on 10-31-16. From there, it would be voted on in December to go into effect on July 1, 2017.

10. There is a new IEP process/paperwork that is being piloted in some areas. More information on this (including a powerpoint and webinar) can be found at https://arksped.k12.ar.us/index.html

11. Many of you want to be involved in the workgroup or feel out of the loop. Anyone can attend the large workgroup meetings, but only a few representatives from that large group actually go and present what is discussed in the large group. If you are interested in attending the large workgroup meetings, I will get the information from our Medicaid Representative and begin posting them here. We are also going to start town hall type meetings in various areas of the state. I am really excited about this and looking forward to it. Please stay tuned to this page and our facebook page for more information.

12. Will the time be increased to 120? The way the current proposal is written, it is written as a 90 MPW threshold. If the wording of the document changes, the process must begin over again with a different public comment period etc. Again, the public comment period on the 90 MPW threshold is still open. This still has to go in front of the Health Care Committee and it must eventually be voted on before it would eventually take effect on July 1, 2017.

13. Do the members of the workgroup get paid or get a kickback for money saved etc.? None of the workgroup receive any money from our organization or DDS/Medicaid as an incentive to make decisions or serve on the workgroup.

14. *****UNRELATED to the 90 MPW issue, REGARDING PREMATURITY ADJUSTMENT---this will be outlined in the new Medicaid Manual, but therapists need to adjust for prematurity BASED ON WHAT THE TEST INDICATES. For example, currently in the Medicaid manual it states to adjust for prematurity until the child is 1 year of age, but some tests say to adjust until the child is 2 years of age (the PDMS-2).

15. ******UNRELATED to the 90 MPW issue, REGARDING TESTS AND PROTOCOLS---if a new edition of an existing approved test comes out, it is automatically accepted. You may continue to use old editions of tests AS LONG AS CURRENT PROTOCOLS ARE STILL IN PRINT AND CAN BE PURCHASED FROM THE PUBLISHING COMPANY.

16. Many had complaints about this all coming out of nowhere, feeling in the dark etc. I can only speak for AROTA, but I make information available as soon as I receive it. Your membership is appreciated, but not mandatory to read this page or our facebook page. That being said, please consider renewing/joining today! Our fight is not over and many believe we have a long road ahead of us. I am still hoping to get a lobbyist for us in the near future. We are the only assocation that currrently has no one representing our interests. We are relying on the lobbyists of the other organizations. For now, we may all be fighting for the same thing, but when other important issues arise, we need someone looking out for our interests as well.

♦10-19-16 Public Comment from Melissa Stone, DDS Director

Subject: Public Comment

Good afternoon,
I wanted to let you all know that we are extending the public comment period on the speech, occupational and physical therapy rule until Nov. 13. As you probably know, we have had a tremendous response to the proposed rule change already. I am personally reviewing the responses along with a team from DHS, and these comments will be considered seriously before we make decisions about whether the proposed rule needs to be changed. I’ve already talked with dozens of families and therapists and read hundreds of comments, and understand people have real concerns about the impact of this rule.
Please let interested therapists and others who are watching this rule know that the comment period has been extended.

Thanks,
Melissa Stone, DDS Director

♦10-18-16 Public Comment time frame regarding the 90 MPW Medicaid proposal has been extended to 11-13-16. Please visit https://www.medicaid.state.ar.us/general/comment/comment.aspx
Comments may be made to becky.murphy@dhs.arkansas.gov

♦10-17-16 AROTA has a new Legislative Representative! Dr. M. Tracy Morrison
We are excited to have someone with her background and knowledge serving in this position. Her bio and contact information can be found at https://www.astate.edu/college/conhp/departments/occupational-therapy/people-details.dot?pid=042357af-1643-4475-9eb1-d6a13430a15e

♦10-6-16 From our Medicaid Representative, Angela Traweek regarding the proposed changes:

Prepared by the Workgroup of Pediatric Health Professions:

The Arkansas Department of Human Services (DHS)-Division of Developmental Disabilities Services is currently developing recommendations to present to the Health Reform Legislative Task Force to meet the cost saving goals set by Governor Hutchinson. In an effort to be proactive in developing cost saving recommendations that would not jeopardize access to or decrease the quality of services for children and adults with special needs, a Workgroup of Pediatric Health Professions was formed to work collaboratively with DDS. This Workgroup consists of representatives from ARPTA, AROTA, ArkSHA, CHMS, DDTCS, DDPA, and Early Intervention Providers.

If DHS-DDS is unable to develop sound cost saving recommendations, it is very likely that the state will move to managed care for the oversight and management of therapy for children and adults with special needs.

The Notice of Rule Making issued on September 15, 2016, refers to one of the recommendations made by the Workgroup in collaboration with DHS-DDS.

The following details the components of the recommendation in an effort to answer a number of questions and concerns that have been raised by therapists and families throughout the state:

  • The effective date of this recommendation is July 1, 2017.
  • Prior authorization would be required only for therapy recommended above 90 minutes per week per discipline (ST, PT, OT).
  • Recommendation of any therapy at, below or above the 90 minutes per week per discipline would still have to be justified by the results of the evaluation and the therapist’s clinical opinion as defined by Medicaid in the respective therapy provider manuals, which is current practice.
  • The physician would still be required to review the evaluation report and recommendations for therapy and complete the DMS 640 (prescription for therapy services), which is current practice.
  • A pending prior authorization for therapy above 90 minutes per week would not prevent the therapist from beginning treatment at the 90 minutes per week level as long as the therapist had the signed DMS 640 from the physician.
  • The prior authorization process will be performed by a 3rd party vendor selected through the state’s RFP process.
  • It is not expected that any additional documents will be required for the prior authorization process except a cover form submitted with the signed DMS 640 from the physician and the evaluation report supporting the recommendation for therapy at a level above 90 minutes per week.
  • It is expected that the reviewers for prior authorization will be credentialed pediatric therapists with experience both in years and in specialty areas.
  • It is expected that the timeline for the reviewers to complete the prior authorization process will be quick so as not to create a delay in services.
  • An appeal process will be in place with respect to prior authorization denials.

The Workgroup believes that this recommendation is responsive to the request of both the Governor and the Health Reform Legislative Task Force in providing cost saving measures that are not detrimental to providing access to and delivery of quality services for children and adults with special needs.

♦9-23-16 Medicaid Proposed Changes from our Medicaid Representative, Angela Traweek:
Notification of Public Comment Period for Proposed Changes to the Medicaid Regulations related to provision of PT, OT and ST services.

As many of you are aware, our state is currently undergoing Medicaid payment reform. This is due to the steady rise in utilization of Medicaid dollars. Initially, the state considered a rate reduction of 3-6% across the board. Association representatives came together to discuss other options that could be brought to the table for consideration. After much discussion and analysis on ways to approach savings to Medicaid spending without imposing reimbursement rate reductions, the therapy associations along with the CHMS and DDPA proposed that the state consider placing a 90 minute per week, per discipline cap on therapy with the option of requesting prior authorization for any treatments recommended to exceed the cap.
The Therapy Advisory Council met on September 14th with the intent of discussing the details of how the prior authorization process would work. It was at the beginning of this meeting that the therapy association representatives learned that Medicaid has written the 90 minute cap into proposed regulations and the notice for public comment period had already been issued that very day.
The intention was and still is for therapists to have the option to submit for prior authorization any therapy recommendation exceeding the cap.
In Summary:
On September 14, 2016, Medicaid submitted proposed changes to the manual for therapy. The public comment period on these proposed changes ends on October 14, 2016. Below is an excerpt of the proposed changes from one of the Medicaid provider manuals – this change is repeated in all Medicaid provider manuals that reference PT, OT and ST services.   Please go to the Arkansas Medicaid website at www.medicaid.state.ar.us to review the proposed changes and the process for public comment. The state has set a public hearing regarding this matter along with several proposed changes to other industries on September 30th at 11:00 AM at the DHS Building downtown Little Rock. The public hearing will be held in Conference Room B. The DHS building is located at 7th and Main Streets in Little Rock.

Occupational, physical and speech therapy services are available to beneficiaries in the ARKids First-B program and must be performed by a qualified, Medicaid participating Occupational, Physical or Speech Therapist. A referral for an occupational, physical or speech therapy evaluation and prescribed treatment must be made by the beneficiary’s PCP or attending physician if exempt from the PCP program. All therapy services for ARKids First–B beneficiaries require referrals and prescriptions be made utilizing the “Occupational, Physical and Speech Therapy for Medicaid Eligible Recipients Under Age 21” form DMS-640. View or print form DMS-640.

Occupational, physical and speech therapy referrals and covered services are further defined in the Physicians and in the Occupational, Physical and Speech Therapy Provider Manuals. Physicians and therapists must refer to those manuals for additional rules and regulations that apply to occupational, physical or speech therapy services for ARKids First–B beneficiaries.

Arkansas Medicaid applies the following daily therapy benefits to occupational, physical and speech therapy services in this program:

  1. Medicaid will reimburse up to four (4) occupational, physical and speech therapy evaluation units (1 unit = 30 minutes) per state fiscal year (July 1 through June 30) without authorization. Additional evaluation units will require an extended therapy request.
  2. Medicaid will reimburse up to six (6) occupational, physical and speech therapy units (1 unit = 15 minutes) weekly, per discipline, without authorization. Additional therapy units will require an extended therapy request.
  3. All requests for extended therapy services must comply with the guidelines located within the Occupational, Physical and Speech Therapy Provider Manual.

 

7-7-16: An update from our Medicaid Chariperson, Angela Traweek, is as follows:
"Recently, Medicaid updated the approved lists of standardized assessments that will be acceptable for establishing OT eligibility for services.  The official notice went out to providers in June with an effective date of May 1, 2016.  Many therapists have expressed concerns about being penalized for the use of the PDMS 1 during the months of May and June, 2016.
I have spoken to Medicaid regarding this concern and the response is as follows:

  1. AFMC is aware of the time lapse in notification to providers and will accommodate the retrospective reviews for evaluations conducted in the months of May and June utilizing the PDMS 1.
  2. Therapists are encouraged to purchase and use the newest versions of assessments/tests.  Older tests should only be used as long as original protocols for those tests are available for purchase.
  3. AFMC historically utilizes the MMY to validate whether a newer version of a test provides the same or close to the same results as the original and the therapy advisory counsel takes this into account when adding newer versions or new tests to the approved evaluation list.
  4. Medicaid does have a policy that indicates if tests are used that are not on the list, then reliability and validity of that test must be documented in the evaluation report."