LACDMH CPTT Meeting, July 15, 2008

Here are my notes from the CPTT/MHSA meeting today! My notes are only as good as the speed to which I can take them and my comprehension of the topic. Please be sure to double check and validate your understanding on this topic.

LACDMH MHSA Plan

• LACDMH recently released its final draft of their 3-Year Program and Expenditure Plan / Proposal to be submitted to the State.
• Karen Bollow confirmed that all contract providers’ initial plans were received; she called those who did not submit one. A few providers have decided to pass on this first phase of funding requests.
• On July 29th the LACDMH MHSA Tech. Workgroup will begin meetings to develop the County’s contract provider process and forms for MHSA project approvals; by October/November they hope to have a process developed and accept applications; the workgroup will also work with DMH contracting and finance depts. LA County has revised the state forms for their own submission and these forms can be seen in their Plan, but the MHSA Tech. Workgroup will determine the final format that providers must use.
• DMH should know in August if additional funds are available for MHSA, these will be prioritized for contract providers.
• Contract providers’ new MHSA contract model is being drafted; these must be signed before funds will be disbursed.
• Although the plan indicates providers’ reimbursement requests will be accepted monthly or quarterly, there is no indication for the timing of reimbursements.
• The plan did not reflect the $% which will be available for up front payments, this will be determined by the MHSA Tech. Workgroup.
• The IBHIS RFP has not been released, the plan shows it will be available in mid-August but this was not confirmed by Karen. The plan also reflects IBHIS production beginning in mid 2011.
• The Plan states that EDI projects will be given a priority, which Karen explained to mean that any agency that did not include EDI in their MHSA project proposal and is not in the EDI certification process yet, has been and will be encouraged to modify their project proposal to include EDI as a priority.
• Providers requested about 99% of the available contract provider MHSA funds, their total project budgets show MHSA to cover only 47%.

EDI Day-to-Day Presentations

Brad Hudson & Karlyn Beck - Children’s Hospital (Exym)

• Children’s Hospital is a nonprofit hospital with about 70% of their clients being indigent / underserved. They have a LACDMH $10M contract and are in Service Area 4.
• They are a training facility and have over 40 trainees, and thus high staff turn over of about 30-40%; They have about 125 full time equivalents/employees, 1/3 are trainees.
• Mental Health is provided in 2 outpatient facilities, not at the hospital; 1/3 of clients are under age of 5, also provide ADPA, Adolescent programs, etc.
• Brad pointed out that he has learned to modify his PowerPoint presentations to be more effective using the PowerPoint rule: "10/20/30 rule". I.e. 10 slides, 20 minutes, 30 pt. font
• The Mental Health services are use Exym/ATS for their EHR-S, which was developed at the hospital before Exym, went commercial. The hospital developed their own custom EHR-S for inpatient services some time ago and is now developing outpatient records as well; The two systems are not integrated. Per Keely: in 2007 the Los Angeles Children's Hospital’s custom EHR-S, according to a study of stand-alone children's hospitals by Utah-based Klas Enterprises, tied for third in their use of paperless records.

Training:

• The large number of trainees and high staff turn-over present training and record quality challenges with any EHR-S.
• Exym also does twice per year training and regular web based trainings.
• Super users were developed in-house for staff support.
• Training is integrated into clinical Supervision workflow.
• The Supervision automation/note review and signing workflow is a key feature for the mental health providers.

Changes brought about with EDI:

• No more LACDMH IS manual data entry (DDE) for billing
• Exym is doing all their report writing and DBA work.
• Clinicians have to enter the clinical entries with the same date as the billing, e.g. Dx and enrollment. Per Keely: The Dx will have a start and end date, of sorts, associated with it in an EHR-S, the date it was assigned to the client and the date it was replaced with a new Dx for the client, for example. Since the claim pulls the current Dx and you will be processing claims for past dates, the system needs to pull the Dx with a date that matches the service date. If there was no Dx assigned to the client for the service date, then the claim will not be valid. This issue may not be an issue in all EHR-S’ as it depends on how this is treated by the particular system. For example, if your system, which sounds like the way Exym works, assigns the Dx date based on the date you are entering the Dx, rather than asking you for a Dx start date/expiration date, then I can see how the person entering Dx and the person entering service recordings need to be in synch to avoid claim issues.
• Data quality concentration, staff must be aware of how the system records certain data elements being entered (e.g Dx, see above) and the impact this may have on billing.
• Policy changes, such as where we allow the EHR-S can be accessed, e.g. not at a Starbucks on a public network; also what is still maintained in hardcopy and e-signature policies.

Audits

• Recently had a State audit with 2 auditors, each with a different approach. One wanted hardcopy which was challenging for them and us (collating, etc.), the other audited electronically; in the end they both agreed the e-audit was preferred.
• Client signatures are still hardcopy, so the CCCP and consents are maintained in hardcopy, but they are planning to move these to e-signatures too.
• Provider signatures are now digitized, as the auditor did require us to digitize each providers’ signature electronically and print these on the screens. Per Keely: this is supposed to be a nice to have according to the California State e-signature regulation draft which has been presented to us two years in a row and acknowledged by the State Auditor Controller at CIMH this year! You should push back on this and print out the regulation draft for your auditors!

Reconciliation:

• They are using IS reports, SIFT, and EDI Status reports to reconcile Exym to DMH. Since with the Exym product, Exym staff do the actual claims processing for their customers, no “billing/claims processing” staff are necessary; however staff to work reconciliation, exceptions, errors and denials are required, these are called Financial Counselors by the Children’s Hospital;
• Using SIFT data and reports to see claims status.

Challenges:

• Data clean-up took a long time. Per Keely: review your SIFT data and reports to assure your data is accurate and clean prior to investing in data conversion. Train your data entry staff now to enter data accurately and consistently to assist your conversion efforts down the road. Be clear with your vendor who is responsible for the clean-up that will be necessary at time of conversion.
• Took 1 year of EDI testing, went fully EDI live in July 2007.
• Harder to work group denials, harder to void claims, clinicians need to monitor ‘when’ they enter data (e.g. Dx); tracking billings in batches is harder than tracking individual claims;

Benefits of EDI:

• Weekly billings, volume not an issue to process.
• Data is entered at one location, and were able to eliminate 1.5 FTE’s.
• Clinicians and staff can both view status of claims.
• Fewer input errors.
• When IS is slow, not an issue for us anymore, J
• Less repetitive tasks, e.g. eligibility is batched monthly.
• Productivity tracking is easier.

Advice:

• Start with a small provider/program first.
• Develop an EDI checklist for the items that need to be in the record to develop each EDI transaction. This was very helpful. Per Keely: your vendor can do this for you, or you can develop your own using the LACDMH companion guides. Use the check list to assure all the necessary data for each transaction type is being entered in your EHR-S and is available at the time of the claim, also to see if the EHR-S can prevent the claim, or ideally warn at time of service recording, and /or scheduling that this data element is missing and the service cannot be billed.
• Make system accessible where needed, e.g. for field staff
• Safeguards in place to prevent errors, e.g. Exym has a 24 hour hold window where Progress Notes are completed and held out of billing queue for last minute edits.
• Run reports and compare to IS.
• Assure a good and responsive change management agreement with vendor, to make form/report updates, etc. E.g. NPI
• Easy access to help system for all users.
• Include clinicians in development of product/features and configuration/set-up.

Stirling Behavioral Health Institute, Greg Levine, Billing (Clinivate)

• Stirling services about 450 outpatient clients; and has about 20-25 providers on staff
• The Clinitrak product was signed in Feb 2007 and in production within 60 days; Per Keely: for a basic product (no scheduled etc.) and only 25 clinicians, this is not surprising.
• EDI production in July 07; EHR-S produces service logs for DDE until EDI is up and running.
• Greg batches up all claims when over 100 are pending. Very low denial rate, about 1.7% (no indication of rate prior to EDI)
• He is using the IS reports, but not using the SIFT data; Used SIFT data for conversion;

Training:

• Supervisors are doing the new hire training, but due to training quality inconsistencies they are developing standard training.

Staffing:

• Staff that was doing IS DDE for claims did not have the time to work pending or denied claims prior to EDI, so now they have been freed up to do research and manage exceptions.
• They are dependent on the vendor to develop reports and change reports; product does have some query ability;

Support:

• Finding DMH is harder to get support from, vendor is quicker.
• Steve Terui and Don Lomas are responsive to issues reported. (Someone in the audience voiced concerns about staffing levels at Clinivate). Per Keely: seems the company founders, Steve & Don are doing the claims support themselves, I would definitely look carefully at current and planned staffing levels, as well as track record. Ask for a committed ratio of support to # of customers/users with an ASP of this size.
• Greg and billing staff are happy with the product.

Lessons Learned:

• Should have gone through case load and rendering provider reports first, to assure accuracy prior to data conversion into EHR-S; ended up converting clients that should have been closed out first and required data clean-up effort.
• Typical billing errors include: conflicting dates causing billing denials: e.g. clinician didn’t open the case in the IS (still DDE) before the billing was submitted via EDI. Per Keely: this issue is due to the current need to enter enrollments into the IS manually while EDI claims are automated, so likely the clinical staff are enrolling the clients into the Clinitrak system with a date (on a date) and then the IS DDE staff are printing out a report to enter the enrollments into the IS, and the billing staff are running batches of claims for all services recorded by the clinical staff. So, for example, if the client has not been enrolled into the DMH IS BEFORE the EDI claim is submitted, then it will be rejected; also if the enrollment is done manually into the IS with a date that is after the service date, the claim will be rejected.

by Keely McGeehan, Sahara Management Solutions, Inc.