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Community HealthChoices: Recap Third Thursday Webinar (April 18, 2019)

May 02, 2019
Reimbursement By Jennifer Matoushek, Senior Consultant

On April 18, 2019, during the Department of Human Services' (DHS) "Third Thursday Webinar," DHS discussed the CHC monitoring report updates and information about the implementations during Phase 3. Below is an overview of the discussion. 

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As CHC prepares and continues their implementation of Phase 3, they will be hosting provider summits in the Lehigh/Capital Zone, Northwest Zone and Northeast Zone through the months of May and June. These summits are educational conferences that are geared towards providers learning more about CHC. To find dates and more information, click here

Plans in Phase 3- Electronic Visit Verification (EVV)

  • The DHS Electronic Visit Verification (EVV) system will go live between September and October 2019, however Pennsylvania will be implementing EVV in full by January 2020.
  • DHS will offer training to providers choosing to use the EVV system,  starting in August 2019 and will continue to be offered through full implementation.
  • OLTL waiver services included in the initial implementation will include Personal Assistance Services, Participant-Directed Community Supports and Respite. 
  • Implementation will be required in home health services by January 1,  2023.

Southwest  and Southeast Report Updates

QMUM 7 Denial Log: Home and Community- Based Services

This monthly report identifies denials of medical necessity, terminations, reductions and changes for covered services. 

Southwest: January 2019

  • The HCBS Authorization Denials report reported that AHC had 1 denial, PHW had 7 denials and the University of Pittsburgh Medical Center (UPMC) had 16 denials. 
  • The Physical Health Denial Rate report reported AHC had 53 denials, PHW had 88 denials and UPMC had 12 denials. 
  • The Pharmacy Denial Rate report reported that AHC had 53 denials, PHW had 54 denials and UPMC had 97 denials.
  • The Dental Denial Rate report reported that only UPMC had 1 denial. 
  • The Home Modification Denial Rate report reports that only UPMC had 1 denial. 

Southeast: January 2019

  • The HCBS Authorization Denial Rate report reported only UPMC having 2 denials.
  • The Physical Health Prior Authorization Denial Rate report reported only UPMC with 2 denials. 
  • The Pharmacy Denial Rate report reported AHC had 692 denials, PHW had 17 denials and UPMC had 228 denials. 
  • The Dental Denial Rate report reported that AHC had 380 denials, PHW had 162 and UPMC had 25 denials. 
  • The Home Modification Denial Rate report reported that there were no denials. 

Missed Services

This monthly report identifies all services that were not delivered for participants who utilize home health skilled care, home health aide services and personal assistance services and identifies all non-delivered or late trips for medical, non-emergency and non-medical transportation services. 

Southwest: January 2019

  • The percentage of hours the agency could not staff was reported as the following: AHC-0.18%, PHW- 0.17% and UPMC-0.02 %.
  • The percentage of hours the participants refused services was reported as the following: AHC-0.32%, PHW-0.25% and UPMC-0.05%.
  • The percentage of hours the participant had unplanned hospitalization was reported as the following: AHC-0.25%, PHW-0.27% and UPMC-0.03%.
  • The percentage of trips missed was reported as the following: AHC-0.7%, PHW-0.9% and UPMC-0.8%.
  • The percentage of late trips was reported as the following: AHC-3.6%, PHW-2.2% and UPMC-5.6%.
    The percentage of trips that participants refused was reported as the following: AHC-6.6%, PHW-0% and UPMC- 22.1%.

Southeast: January 2019

  • The percentage of hours the agency could not staff was reported as the following: KF- 0%, PHW-0.02% and UPMC-0.04%.
  • The percentage of hours the participants refused services was reported as the following: KF-0.01%, PHW-0.12% and UPMC-0.16%.
  • The percentage of hours the participant had unplanned hospitalization was reported as the following: KF-0.01%, PHW-0.15% and UPMC-0.05%.
  • The percentage of trips missed was reported as the following: KF-2.1%, PHW-0% and UPMC-3.6%.
  • The percentage of late trips was reported as the following: KF-0%, PHW-0.04% and UPMC-7.7%.
  • The percentage of trips that participants refused was reported as the following: KF-13.9%, PHW-0%, UPMC-25.8%.

Southwest Report Updates

Person Centered Service Plan Changes

This monthly report identifies changes—including increases and decreases— to PCSPs.

Southwest: January 2019

  • The percentage of PCSPs with an increase include AHC-2%, PHW-0% and UPMC-1%. 
  • The percentage of PCSPs with a decrease include AHC-0.1%, PHW-0% and UPMC-0.2%.
  • The percentage of  PCSPs decreased due to MCO decision to reduce services following a reassessment only include AHC with 0.2%
  • The total number of PAS hours reduced due to MCO decision to reduce services following a reassessment only include UPMC with -1220 hours. 
  • The number of participants with a reduction to services due to an MCO decision following a reassessment only included UPMC with 11 participants.  
  • The average number of hours reduced for participants with a reduction to services due to an MCO decision following a reassessment only included UPMC with -111 hours. 

Southwest: Monitoring report for Complaints & Grievances

This quarterly report provides the reasons for why a participant filed a complaint or grievance. 

  • AHC top non-long-term services and supports (LTSS) Grievance Categories were pharmacy, outpatient medical service, dental, PAS, dentures. Top non-LTSS complaint categories were non-covered physical health, other physical health issues, MCO Administration, MCO Courteous Services.
  • PHW top non-LTSS Grievance Categories were Pharmacy, dental-dentures, other physical health. Top non-LTSS Complaint Categories were on emergency medical transportation, courteous provider office staff, courteous service by MCO.
  • UPMC top non-LTSS Grievance Categories were home health, other physical health, pharmacy, dental-other (includes denials of dental services other than braces or dentures). Top non-LTSS Complaint Categories were MCO Administration, courteous office staff, non-covered physical health, MCO courteous service, quality of clinical care. 

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