Page 2 of 26
Inside This Issue (click to go directly to the article):
1. Big Changes Afoot! DMH Introduces Provider Reimbursement Changes
2. ACHSA Monitors Development of Probation Group Home Monitoring Process
3. ACHSA Meets with DMH and CEO to Get A Better Understanding of County Budget Process and the Development and Tracking of the County DMH Budget -- Part 3 of 3 Parts
4. Wraparound Expansion Workgroups Raise More Questions than Answers
5. "Whatever" is the Watchword as DMH MHSA Workforce Education and Training (WET) Advisory Committee Begins to Shape Upcoming County WET Plan for FY 09-10 and Beyond
6. SOWhat’s up with the Statement of Work? ACHSA Continues Discussions with DCFS Regarding Outstanding Issues in the Wraparound SOW
7. DMH Stakeholder Delegates Meet to Discuss PEI and MHSA Innovations
8. DCFS Updates ACHSA on Family Preservation Program
9. May the Workforce Be With You – Report Details Findings of the California Consumer Employment Summit
10. Probation Restructuring Steering Committee Steers Clear of Placement Practice Model and Focuses on Practical Changes
11. Mental Health Odds & Ends
12. Child Welfare Nuts & Bolts
13. ACHSA News
14. Conferences Events
15. In the News
16. Upcoming ACHSA Meetings
KEY ISSUES- Big Changes Afoot! DMH Introduces Provider Reimbursement Changes
At a February 20th, 2009 contract providers meeting at St. Anne’s, Los Angeles County Department of Mental Health officials shared updates on the budget and transformation, as well as new changes to the Department's Financial Responsibility Requirements and provider contract Financial Exhibit. Welcoming providers to the meeting, Deputy Director Robin Kay said, “The Department is committed to transparency, partnership, and collaboration in developing protocol, policies and procedures.”
Certified Public Expenditures, Reimbursement of Providers, and Changes in the Financial Exhibit
The highlight of the meeting was a presentation by Administrative Deputy Lyn Wallensak on provider reimbursement changes being proposed by the Department to meet necessary legal requirements related to Certified Public Expenditures. Until February 2008, DMH had always forwarded claims for Medi-Cal services to the State prior to paying contractors. The claims were accompanied by a State certification form that had two separate elements: 1) confirmation that medically necessary services had been provided to eligible beneficiaries; and 2) confirmation that the county had sufficient local match for FFP drawdown. However, in early 2008, the federal Centers for Medicare and Medicaid Services (CMS) notified the State that this certification did not meet federal regulations to draw down FFP, and the State notified County DMH. It was determined that federal regulations require that the public agency make the expenditures prior to claiming FFP, and the timing of County payments to contractors and State claiming of FFP was non-compliant.
To temporarily mitigate the problem, State and DMH negotiated a ‘bifurcated process’ that accommodated both federal regulations and DMH legal entity contract language, which states that DMH pays providers on “approved claims.” Under the bifurcated system, DMH has submitted claims to the State with the first certification (medical necessity, eligibility) and then after paying providers, DMH has submitted a second certification asserting that it has made the “certified public expenditure,” or CPE.
The bifurcated process has had several flaws. For example, the State requires DMH to certify the entire EOB file, and the EOB files contain multiple providers and multiple fiscal years. So if one contractor were to require a contract amendment to either increase a type of funding or increase the maximum contract amount, DMH would be delayed from making the CPE for the entire EOB file until those contract issues were resolved, affecting all contractors. During Fiscal Year 2008-09, DMH was unable to make CPE on all claims until very recently, due to several providers who needed contract amendments for FY 07-08 services, delaying the County’s receipt of $164 million in Federal revenue.
After the State's upcoming implementation of SD/MC Phase II, the bifurcated process will no longer be an option, so the financial provisions of the legal entity agreement must undergo significant changes to ensure compliance with CPE beginning July 1, 2009. DMH will also need to significantly change its internal processes to accommodate revisions, including how and when payments are made to contractors, how dollars are allocated in contracts, strict enforcement of maximum contract amounts, and the anticipated phasing out of cash flow advances. All providers must enter into new contracts starting July 1st, 2009 with one, two, or three year terms.
In order to make these new changes, DMH intends to simplify accounting of funded programs by implementing IT solutions to help facilitate payment processes, allow contractors and the county to more accurately gauge the status of contractors in relation to maximum contract amounts, and reduce the number of contract amendments. These changes should also result in more timely receipt of FFP for the County and more timely payments to contractors for all funded programs.
Major Changes in Payments
§ Most significantly, these changes mean that starting July 1st, 2009, DMH will pay providers every two weeks, with 26 payments a year.
§ All services will be paid on claims submitted to the IS system if they clear IS edits and are within contract amounts. Contractors will be paid sooner for Medi-Cal services; Medi-Cal, Healthy Families, and MAA claims that are subsequently denied or disallowed by the State will be “recouped” against the next payment.
§ Contractors will have no more than 5 months after the month of service to submit a claim without a valid late code; and no more than 11 months after the month of service to submit a claim with a valid late code. Payments to providers prior to adjudication will result in additional “lag time” between the contractors’ entry of a claim into the IS and submission to the State.
§ DMH will not automatically shift denied claims to another funded program. Contractors will need to positively resubmit denied claims to Medi-Cal or other funded programs depending on the reason for denial.
§ For more information on payments, please view the Flowchart for Revised Payment Procedures for Contractors.
Major Changes in Funding
Contract amounts and the Financial Summary will be based on gross program dollars. This will eliminate barriers and simplify financial tracking and payments; however, as a result, contractors will no longer have the option to shift CGF funds. DMH will need to increase staff, but their goal to have a 1:1 relationship between IS Plans and “Funded Programs” will allow DMH to utilize IT solutions to facilitate payment and keep the number of staff needed in the Provider Reimbursement Unit from snowballing.
Major Changes to the Maximum Contact Amounts (MCA)
Maximum Contract Amounts and Funded Program Amounts will be strictly enforced. Contractors will not be allowed to exceed contract amounts during the year or at settlement. Contractors will need to establish provisional rates that closely approximate actual costs. They may ask DMH to consider contract amendments to adjust funding among programs. They will need to monitor claims against maximum contract amounts and funded programs and notify the county once they reach 75% of their contract amount.
DMH will institute additional contract monitoring by program, fiscal, and contract staff. Issues with the timing of denied/voided claims versus new approvals will have to be accommodated, depending in part on State adjudication timelines under SD/MC-II. Providers and DMH may also face issues with cost report settlement and Medi-Cal adjudication.
Cash Flow Advances Eliminated
Cash flow advances will be eliminated after 2009-10, and the repayment period of unearned 2009-10 CFA will be extended. CFAs interfere with DMH’s ability to monitor contract levels for individual programs and funding sources. The belief is that more timely and frequent payments will eliminate future need for CFAs, although this is certainly an open issue and of major potential concern for contract agencies.
Public Comment Period on DMH Legal Entity Agreement – Attachment II – Financial Exhibit A
Lyn distributed the new February 20th, 2009 draft of Financial Exhibit A (Financial Provisions) of the LEA which incorporates the proposed provider reimbursement changes referenced above. Public comments are officially due by March 13th, 2009 at 5 P.M., although ACHSA has already received a commitment from DMH to provide an extension as necessary.
Next Steps
At ACHSA's request, Robin Kay has agreed to establish a joint ACHSA/DMH workgroup to identify and attempt to resolve operational issues that need to be addressed as a result of the proposed changes to the Financial Summary. The workgroup met last Friday, and is scheduled to meet again on March 5th, when the proposed contract language changes will be reviewed. We will provide an update on these meetings in our next newsletter.
If you have any questions, please contact Bruce or Marissa.
- ACHSA Monitors Development of Probation Group Home Monitoring Process
Since the beginning of this year, ACHSA has been working diligently to clarify and refine the monitoring/quality assurance (QA) process for Probation group home providers. This article summarizes ACHSA’s discussions with Probation to eventually reach agreement on a monitoring process for the first year of visits.
First, in January, Probation announced its intention to begin unannounced group home monitoring visits. Upon ACHSA’s objection to unannounced visits, Probation then agreed to contact providers beforehand in order to schedule any visits. Probation expressed its intention to begin monitoring visits in February and March. Probation distributed draft questionnaires for one youth and parent and a draft monitoring tool to be used during its visits. ACHSA created a workgroup to review the questionnaires and tools and submitted feedback to Probation.
At the January 30th Probation Provider Subcommittee Meeting, ACHSA later learned that Probation intended to conduct quarterly monitoring visits. At the meeting, Probation shared eight-page Quarterly and Annual Inspection Checklists which it intended to use to conduct these inspections. Upon learning of the quarterly visits and new inspection checklists, ACHSA asked Probation to delay all monitoring visits in order to give ACHSA time to review the new tools and develop recommendations as to both the tool and process. ACHSA convened a workgroup that ultimately concluded that the process was more problematic than the tool itself. ACHSA forwarded the following concerns to Probation:
1. ACHSA objected to quarterly inspection visits, especially for providers that have only a handful of probation youth. In comparison, we pointed out that DCFS and the Auditor-Controller (A-C) have agreed to only conduct a SINGLE,ANNUAL combinedmonitoring visit for DCFS youth.
2. ACHSA requested that Probation defer to DCFS to monitor agencies whose primary population is DCFS children.
3. ACHSA objected to Probation’s plan to begin monitoring without an inspection manual in place to clarify and guide the inspection visits, although we agreed that Probation could continue to hold its “meet and greet” sessions with providers,that didn’t involve monitoring, until an inspection manual and protocol was agreed upon.
4. ACHSA requested that Probation meet with the A-C, DCFS, and ACHSA to jointly review the monitoring tools so as to eliminate duplicative audits. ACHSA emphasized that it had previously approached the Board of Supervisors regarding this issue for DCFS providers and the Board supported ACHSA’s position that the A-C and DCFS should not conduct multiple, duplicative audits.
On February 18th, immediately following the Probation Steering Committee Meeting, ACHSA met with Probation in order to discuss our above concerns regarding the tool and process. The meeting included several provider and Probation representatives, as well as California Community Care Licensing (CCL).
Lisa Campbell, Director of Placement Permanency/Quality Assurance (PPQA), explained the two purposes of the monitoring visits: 1) to get to know group homes better by visiting the sites and becoming familiar with the programs; and 2) to foster a collaborative relationship between Probation and providers to avoid problems getting out of hand and to fix any problems with Probation as quickly as possible.
In order to attempt to support the Department’s plans for quarterly visits, Lisa reviewed the Group Home Contract which states that group homes shall monitor quarterly for compliance with Title 22. ACHSA pointed out that a group home’s responsibility for its own quarterly internal monitoring does not support quarterly visits by Probation. Lisa then referred to Title 22 to support Probation’s monitoring plans. ACHSA further clarified that Probation does not have inspection authority under the Title 22 Regulations that apply only to CCL, which was confirmed by the CCL representative at the meeting. Lisa pointed out her belief that Probation monitoring is also supported by the Adoption and Safe Families Act and Title IV-E funding regulations. The providers clarified their recognition that Probation is entitled to conduct monitoring visits, while further explaining their concern with the process, rather than the authority, of the Department.
ACHSA pointed out that many agencies are already monitored by the A-C, DCFS, and DMH. Providers reiterated that Probation’s primary concern should be outcomes and whether children are being served properly, questioning the need to monitor agencies that are fully compliant on a quarterly basis. Lisa continued to insist that Probation do quarterly visits during the first year, and she emphasized that “monitoring” is a soft term that did not have to amount to an audit or inspection. Providers, however, expressed concern with the checklists that heavily relied on inspections of the agency’s physical plant, emphasizing that several monitoring agencies inspect their physical plant but no agency reviews their programs and services. Accordingly, the group decided on the process below for QA visits during the first year of monitoring.
The first visit, to be conducted between February 2009 and April 2009, will be a “walk through” visit where the monitor will tour the facility. The monitor may bring the annual inspection checklist to take notes and to familiarize himself/herself with the facility. The visit will last between 30 to 90 minutes.
The second visit, to be conducted between May 2009 and July 2009, will be a Quality Assurance visit that will focus on the provider’s program. The monitor will interview one child that has been placed at the agency for less than one month, the child’s parent, and group home staff that are familiar with the child, using a one-page questionnaire that has been jointly developed by Probation and providers. During the visit, the provider will give Probation a list of three children from which Probation will choose one to interview. The visit will address such questions as what is and is not working with the agency’s program and whether the provider needs any additional technical assistance from Probation. The visit will last between one to two hours.