Electronic Visit Verification (EVV) Compliance Plan

Transcription

1 Electronic Visit Verification (EVV) Compliance Plan CCHP EVV Compliance Plan Page 1

2 DEFINITIONS Electronic Visit Verification Documentation and verification of service delivery through an HHS approved EVV system. EVV System A telephone or computer-based system that allows confirmation services were provided to an eligible recipient according to an approved prior authorization. EVV Transaction One of the following transactions in an EVV system (1) call-in when service delivery begins; and (2) call-out when service delivery ends. Payment will not be made for any visit that is verified through visit maintenance. EVV is optional for CDS employers and FMSAs and are exempt from the HHSC EVV Provider Compliance Plan. Exceptions Visits that do not auto verify and require the use of one or more reason codes to clear in the EVV system. Grace Period A timeframe during which provider agencies must use an EVV system and may, for billing support purposes only, use paper timesheets as backup documentation. Provider agencies that are in a grace period are not subject to liquidated damages, contract actions, or corrective action plan requirements for failing to achieve a compliance plan score of at least 90%. However, claims may still be subject to denial or recoupment. Review Period A period of time consisting of three consecutive calendar months prior to the review month that occurs at least once within a calendar year or more frequent as determined by the reviewer. Compliance Plan Score A percentage that indicates how often visits are verified through auto-verification and/or using preferred reason codes for visits that are eligible to be billed during a particular period of time. Refer to page 5 for an explanation of how scores are calculated. Non-Preferred Reason Code A reason code that documents a change to an EVV visit record that is caused by a situation in which the provider agency staff did not document services in accordance with program and policy requirements. Preferred Reason Code A reason code that documents a change to an EVV visit record that is caused by a situation in which the provider agency staff documents services in accordance with program and policy requirements. A copy of the Reason Code List as of 06/09/2016 is attached as Attachment A. CCHP must use the list of reason codes found at Provider/Provider Agency Service provider that are under contract and are providing covered CCHP EVV Compliance Plan Page 2

3 Reason Code A standardized, HHSC-approved three-digit number and description used during visit maintenance to explain the specific reason for a change that was made to an EVV visit record. A copy of the Reason Code List as of 06/09/2016 is attached as Attachment A. CCHP must use the list of reason codes found at Visit Maintenance The process by which provider agencies can make adjustments in an EVV system to electronically document service delivery visit information as required by HHSC. 1. Provider agencies must complete visit maintenance within 60 calendar days of the date of service for each visit. The 60 calendar days begins on the date of service. Visits Verified The number of visits that have no exceptions or for which all exceptions have been resolved through visit maintenance in the EVV system. Visits that have been verified are eligible for billing. Visits verified = number of visits auto-verified + Number of visits verified preferred + Number of visits verified non-preferred Visits Auto-Verified The number of visits that have no exceptions and for which no visit maintenance was required. Visit Maintenance Lockout The inability for a provider to complete visit maintenance in an EVV system due to required accurate and complete information not entered into the EVV system. Visits Verified Preferred The number of visits that have exceptions that were verified through visit maintenance using only preferred reason codes. Visits Verified Non-Preferred The number of visits that have exceptions that were verified through visit maintenance using at least one non-preferred reason code. CCHP EVV Compliance Plan Page 3

4 Cook Children s Health Plan (CCHP) is committed to working together with our providers, members and attendants with the implementation of the EVV program for Long Term Services and Support (LTSS) services. Our approach to EVV compliance will follow the Health and Human Services Commission (HHSC) s Provider Compliance Plan for EVV. Services Requiring Verification Personal Care Services (PCS) provided in the home and in the community and by an attendant In-home Respite Services provided by an attendant Flexible Family Support Services provided by an attendant. Community First Choice (CFC) Services: Habilitation and PCS Grace Period Provider agencies with new contracts may only receive a single grace period. The grace period ends on the last day of the third calendar month from the date the contract became effective. A single grace period applies even if the provider agency switches EVV vendors. Provider agencies may no longer use paper timesheets to document service delivery beginning the first day after the grace period. If paper timesheets are used after the grace period ends the claims may be subject to recoupment. Training Provider Agencies must train: All staff who provide services for which EVV is required and comply with all processes required to verify service delivery through the use of EVV. Attendants on the use of the EVV system to document the time at which service delivery begins and ends. Office and administrative staff members on the use of the EVV system to enter all of the required data elements, enter schedules (as applicable), and verify service delivery through visit maintenance and the use of reason codes. Their employees to use the EVV system in a manner that is prescribed by HHSC, It is mandatory for all attendants to complete training before they begin to provide services to members. The provider agency is responsible for keeping track of the details of the training for all of their staff. Provider EVV Compliance Standards Provider agencies that are subject to EVV requirements must use an EVV system to document services provided in the home or community. The EVV record must be completed, including any visit maintenance, prior to submitting a claim. Claims not supported by an EVV entry in the EVV system may be denied or subject to recoupment. CCHP EVV Compliance Plan Page 4

5 Provider agencies must achieve and maintain a compliance score of at least 75% until March 31, 2017 at which time the compliance score will change to 90 % per review period. The review period consists of three consecutive calendar months prior to the review month that occurs at least once within a calendar year. Reason codes must be used each time a change is made to an EVV visit record in the EVV system. Use of non-preferred reason codes will lower the provider agency compliance score. Misuse of reason codes may result in contractual remedies. Provider Compliance Requirements CCHP must ensure that all Providers using the EVV system maintain compliance with the following HHSC minimum standard requirements. The Provider must enter Member information, Provider information, and service delivery schedules (scheduled or non-scheduled) into the EVV system for validation either through an automated system or a manual system. The Provider must ensure that attendants providing services applicable to EVV are trained and comply with all processes required to verify service delivery through the use of EVV. Nurses are not required to use EVV. Providers must notify CCHP of any ongoing issues with EVV contractors or unresolved issues with EVV systems. Providers have 48 hours to notify their payor if the provider has not heard back from the EVV vendors or the issues are ongoing. Providers must notify a Member's service coordinator if the Member refuses to allow home health attendants access to the Member's landline telephone to document when services begin and end. Providers must maintain service delivery visits verified in accordance with program requirements of at least 90 percent per quarter. Providers must ensure all data elements required by HHSC are uploaded or entered into the EVV system completely, accurately, and before billing for services delivered. Providers must ensure that the Provider s attendant uses the EVV system in a manner prescribed by HHSC to call-in when service delivery begins and call-out when service delivery is completed each time services subject to EVV are delivered to a Member. Equipment provided by an EVV contractor to a Provider, if applicable, must be returned in good condition. If equipment is lost, stolen, marked, altered or damaged by the Provider, the Provider may be required to pay the replacement cost of the equipment. CCHP EVV Compliance Plan Page 5

6 Compliance Plan Scoring/Report The Compliance Plan Score percentage indicates how often visits are verified through auto-verification and/or using only preferred reason codes for visits that are eligible to be billed during the review period. Scores are calculated by: Adding the number of visits auto-verified to the number of visits verified preferred for a particular period of time; Dividing the sum by the total number of visits verified for the same period of time; and Rounding the resulting number to the nearest whole percent. Compliance Plan Score = (Number of total visits auto-verified +Number of total visits verified preferred) (Number of total visits verified) rounded to the nearest whole percent. Compliance will be measured quarterly according to the following: Q1 = April/May/June Q2 = July/August/September Q3 = October/November/December Q4 = January/February/March Failure to achieve and maintain a provider compliance score of 90% for each review period may result in a corrective action plan process, liquidated damages, and/or the imposition of contract actions. An EVV Provider Compliance Report Card is included as Attachment B. The report card will be shared with the EVV providers. Reports CCHP will use to monitor compliance 1-EVV Visit Log 2-Units of Service Summary 3-Attendant Providing Svcs This report is used to verify the hours of services delivered by whom and to whom as well as to verify that all visits were complete and accurate prior to the submission of a visit for billing. This report displays authorization information. This report is used to verify which attendants/nurses/other provider staff provided services to a particular individual for a requested date range. CCHP EVV Compliance Plan Page 6

7 4-Provider Agency_FMSA List 5-Contracts List 6-CDS Employee List 7-Alternate Device Order Status 8-EVV Compliance Summary 9-EVV Compl Daily(CSV DADS&MCO) 10A-EVV Compl Daily (MCO Print) 10B-EVV Compl Sum (MCO Print) 11-Reason Code Text 12-Reason Code Usage This report is used to gather provider information and to determine the last time a provider interacted with the EVV system. This report is used to show which provider contracts are in the EVV system. This report is used to verify which Attendants/CDS Employees are associated with which CDS Employer/Individual. This report is used to verify that Alternate Devices have been ordered and to track the status of those orders. This report contains compliance information and statistics vs. program expectations aggregated by CONTRACT NUMBER over a specific 3-month (quarterly) time frame. This report contains compliance information and statistics vs. program expectations aggregated by CONTRACT and then by DATE for DADS and by NPI and then by DATE for MCO's; over a specific 3-month (quarterly) time frame. This report contains compliance information and statistics vs. program expectations aggregated by TAX ID and NPI (MCOs) and over a selected date range for the 3-month (quarterly) time frame. This report contains compliance information and statistics vs. program expectations aggregated by TAX ID and NPI (MCOs) and over a selected date range for the 3-month (quarterly) time frame. This report is used to review a provider's use of reason codes and to ensure all required free text entries were made. This report can also be used by compliance staff to review potential misuse of preferred reason codes. This report shows which reason codes were used, how often, and in what percentage of verified visits, and offers a comparison to overall usage of those reason codes during the specified timeframe. It can be used by DADS compliance staff to look for potential misuse of preferred reason codes. CCHP EVV Compliance Plan Page 7

8 Other Reports MCO Reports These additional other provider reports available on an adhoc basis. These are additional reports MCOs may request from EVV vendors. Corrective Action Plans CCHP may develop a corrective action plan request to ask that the provider agencies specify: The reason the provider agency was not able to meet the compliance requirements for the quarter; The actions the provider agencies will take to ensure they meet the compliance requirements in the future; and The estimated date for completing those actions. The provider agency will have ten (10) calendar days from the date of receipt to respond to the request for a corrective action plan: If a response is received, CCHP will review the response and develop a formal corrective action plan to submit to the provider agency. If no response is received, CCHP may assess liquidated damages or terminate the Provider Network Participation Agreement. CCHP will follow the liquidated damages as developed by DADS: Liquidated damages are assessed at a rate of $3 per visit verified Non Preferred on a day below program expectations threshold. Liquidated damages are subject to a minimum assessment of $10 to a maximum of $500 per day below program expectations threshold. The chart below shows an example of the calculations. Day **Daily Compliance % # of Non- Preferred Visits Calculation 5/1 89% 2 2 x $3 = $6 $10 5/6 80% x $3 = $30 $30 6/5 75% x $3 = $45 $45 6/8 52% x $3 = $594 $500 Total: 585 **less than 90% is a day below program expectations threshold Assessed Liquidated Damage CCHP EVV Compliance Plan Page 8

9 Informal Review The provider agency may request an informal review if the provider agency seeks to demonstrate that the quarterly compliance score was due to a failure of the EVV system. The informal review request must: Be sent in the form of a letter; Be received by CCHP within 10 calendar days of the date on which provider agency received the quarterly compliance review findings; Describe the specific EVV system failures that caused the non-compliance; and Include all of the documentation that supports the provider position. Date system issue was reported to the vendor and CCHP. A request for an informal review that does not meet the above requirements will not be granted. The CCHP will notify the provider agency in writing of the results of the informal review. CCHP s response will determine if the findings were substantiated, unsubstantiated or reduced based on the assessed corrective action plan and/or liquidated damages. Provider agencies that request an informal review may still request a formal administrative review. Administrative Appeal Provider agencies have the right to a formal appeal if the EVV compliance plan review results in liquidated damages. The request must be in writing and must state the basis of the appeal. The request should be received at the following address within 15 calendar days of the provider agency s receipt of the notice: Cook Children s Health Plan Attn: Compliance EVV Appeal P.O. Box 2488 Fort Worth, TX On the first day following the grace period, the provider agency must achieve and maintain a compliance plan score of 90%. Provider agencies under a grace period cannot request a vendor change until the end of the grace period. Claims Provider agencies must ensure claims for services are supported by service delivery records that have been verified by the provider agency and fully documented in an EVV system that has been approved by HHSC. Denial or recoupment is possible if claims are submitted before all the required visit maintenance has been completed in the EVV system or if they are not supported by the EVV system. CCHP EVV Compliance Plan Page 9

10 CCHP processes may include the follow analysis: Prepayment analysis of submitted claims against EVV transactions before payment so that unverified billed services can be identified and denied. A retrospective analysis of submitted claims against completed EVV transactions after payment so that unverified billed services can be identified and denied. An alternate method for the prospective analysis of upfront claim denials that occur during processing when the EVV data is not present and validated. If the billed units exceed the completed EVV transactional units have been verified by the EVV System, the claim is subject to denial or partial payment for the units billed. EVV Reporting Requirements CCHP must require EVV contractors to complete and submit a monthly EVV Summary Report using the template and instructions in Uniform Managed Care Manual Chapter 8.8. CCHP must submit the monthly EVV Summary Report it receives from each EVV contractor to HHSC within five business days of receipt by CCHP. On the first day of each month, CCHP must submit an EVV Contractor Compliance Report to HHSC detailing any action taken in the previous month for noncompliance by any EVV contractor, including a list of corrective action plans submitted by an EVV contractor and the status of each plan and any liquidated damages assessed against an EVV provider. In addition to the monthly EVV Summary Report and the monthly EVV Contractor Compliance Report, HHSC reserves the right to request ad-hoc reports from CCHP for EVV information not included in the monthly EVV Summary Report, as needed. CCHP EVV Compliance Plan Page 10

11 Attachment A EVV Reason Codes This is not a complete listing. For a complete listing of the current Reason Codes, please go to: CCHP EVV Compliance Plan Page 11

12 Attachment B EVV Compliance Report Card Quarterly Reporting Period Month 1 Month 2 Month 3 Number of Actual Visits Number of Visits Auto Verified and Visits Verified Preferred Compliance Score (requires 90% or above) Visit Maintenance # of Actual Visits # of visits auto-verified # of visits auto-verified preferred # of visits verified non preferred Compliance Plan Score = (Number of total visits auto-verified +Number of total visits verified preferred) (Number of total visits verified) rounded to the nearest whole percent. CCHP EVV Compliance Plan Page 12

13 Informational Resources 1 TAC (EVV System) 40 TAC (EVV System) (Reason Codes) (Vendor System Selection Form) (SAD Device Order Form) RFP # (EVV Services RFP) UMCM Chapter 8.7 (Medicaid Managed Care EVV Manual) UMCM Chapter 8.8 (EVV Summary Report) (to be posted soon) UMCM Chapter 8.9 (to be posted soon) CCHP EVV Compliance Plan Page 13