KHCA / kcal OCTOBER 30, 2015

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Pamela Leonard
5 years ago
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1 KHCA / kcal OCTOBER 30, 2015

2 RFP Highlights Contract years two and three: Six measures have been selected by KanCare as Pay for Performance (P4P) indicators for LTC. To incentivize high performance and quality health outcomes, 5% of each MCO s total PMPM payments will be held back each year for the purpose of incentive payments. If the MCO meets quality benchmarks established in their KanCare agreements for each of the 5 selected P4P indicators, the MCO will receive the 5% back in full.

3 RFP Highlights (cont) Six quality measures will be weighted at.83% of the 5% capitation withhold timely claims processing encounter data submission credentialing process grievances appeals customer service A MCO failing to meet all the required standards for an incentive payment in a given area will not receive.83% of their capitation payments back for each area in which it fails to meet the benchmark standard in full or in part.

4 RFP Highlights (cont) Five Quality Measures have been established for LTC % of Medicaid NF claims denied by MCOs - For 2014, 5% less than Future rates to be determined by the State. % of Medicaid NF residents who had a fall with major injury - 5% improvement from 2012 or maintain high performance as designated in reporting template details. % of members discharged from a NF who had a hospital admission within 30 days % improvement or maintain high performance as designated in reporting template details. Rate of NF days per eligible member % improvement or maintain high performance as designated in reporting template details. Increase in number of Person-Centered Care Home (as recognized by PEAK) in Network (combined MCOs) count increase in # of PEAK homes annually

5 MCO Reports to KanCare 2013 Annual Report - Report_to_CMS_DY_ending_12_31_13_FINAL.pdf 2014 Annual Report Report_to_CMS_Final_for_2014_WITH_Attachments.pd f 2015 Latest Quarterly Report - _Report_to_CMS_QE_ pdf

6 Is KanCare Meeting its objectives? Annual reports suggest that the fiscal, eligibility, access to care, Health Homes, quality metrics, member services, provider services, grievance and appeals programs, processes and goals are being met are being implemented or are in development. The number of member/patient complaints that are not addressed by the MCOs is minimal. The number of provider complaints that are not addressed by the MCOs is minimal. While apples to apples statistics are not available, it would seem that the MCOs are providing a more member and provider responsive level of service at a lower cost that the State administered system.

7 What s Not Working? Are all member and provider grievances reported: Yes: MCO s have systems to track and report grievances They can track by category They can track by resolution status Create Complimentary Service Lines to deepen brand and leverage continuum of care Leverage Core Competencies No: provide a complete Managed Care Contracting service, including but not limited to: Providers may address many (or most?) member issues that never get reported to the plan Providers may make ROI decisions about the cost/benefit of addressing grievances Contract solicitation selling the value proposition Contract language review and negotiation Reimbursement / fee schedule analysis and negotiation The Bottom line is that MCOs are accountable under KanCare and trends are easily identified and performance can be benchmarked.

8 Is there an upside for Providers? So What s in it for KHCA/KCAL members? Is there an upside for Providers? Can providers do better under KanCare and MCO contracts? How do post acute providers know what MCOs expect? Are MCO s willing to reward performance and share savings? Is KanCare something to invest in or avoid? Can provider really success or will the rules get changed once we figure it out?.

9 Understanding the MCO Perspective MCO Panel Q&A What are some of the big Lessons learned to date? What are the major Goals/objectives your MCO needs to accomplish to succeed in KanCare? How can providers help MCO meet the MCO deliverables under KanCare? Are there current deficiencies or is your MCO losing withhold? Are there opportunities for providers to develop subnetworks or get involved in care management/care coordination, Health Homes? Are there MCO education, training or other resources that providers and/or members are underutilizing? What are some of the good things about KanCare that are not part of other State programs? What could Kansas incorporate into KanCare that other states are doing? Are you developing Value Based or pay-for-performance reimbursement methodologies for SNF, AL, HH? Are you open to KHCA members proposing bundled payment, per episode or care management programming services? Question from AmeriGroup Question from Sunflower Question from UHC. Question from NCAL Question from KHCA Question from rural KHCA member Question from urban KHCA member Question from KHCA system member Question from KHCA Independent owner

10 Now that you understand the MCO perspective

The Four Knows and Tips of Contracting with Managed Care Organizations October 7, 2012

The Four Knows and Tips of Contracting with Managed Care Organizations October 7, 2012 The Four Knows of Contracting 1. Know the Rules 2. Know What the MCOs Need/Want? 3. Provider Know Thyself 4. Know