Appendix 1 Readiness Template DLTC

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Nov 7, 2013 (3 years and 7 months ago)

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NOTE: This document is not a definitive checklist of MCO certification requirements. It describes the developmental tasks th
at must be
accomplished before any organization begins to op
erate as a MCO.


1

Appendix 1


Readiness Template

DLTC

Management Planning Tool for LTC Expansion “Readiness Template”


Business
Area

State Performance Indicator

(Certification Requirement)

Detailed MCO Systems

(Including IT)

Strategic
Planning


The 3
-
year MCO business
plan approved prior
to contract effective date, including:



Timeline for providing required risk reserve,
solvency requirements, and working capital
(if not licensed as an HMO).

Organizational design and governance:

Existence of legal (contracting) entity t
hat will
carry the financial risk and be responsible for
quality, including:



Governance board with membership able
to provide appropriate oversight.



Organization chart w qualified and full
-
time
CEO, CFO, and Quality Manager.

Documentation of how MCO will c
oordinate
with adult protective service and counties’
51/55 systems.

Evidence of consumer and other stakeholder
involvement in strategic planning.


Establishment of a separately identifiable restricted investment reserve account in a financial
institution
and Business Solvency Plan, with timeline and financing strategy.

Consumer and Stakeholder Participation:



Identify stakeholders and provide opportunities for consumers and stakeholders to participate
in planning process.



Provide training/support to enhance

meaningful consumer and stakeholder participation.



Create mechanisms for consumers and reps to participate in quality management and
appeals and grievance processes.

Develop policies and procedures for best practices (designing quality into the
organization).

Legal and Operational Platform for Regionalized Governance satisfactory to all planning partners,
including:



Mission and values statements.



Operating and risk sharing agreements.



By
-
laws and business protocols.



Steering and oversight committ
ees, including consumer and stakeholder members.

Organizational needs assessment (strengths, weaknesses, opportunities, barriers) for
administrative, care management, IT and financial management tools and competencies to carry
out managed long
-
term care, i
ncluding:



Strategies to learn management techniques.



Identification of essential IT and competencies.



A claims payment / business system adequate for



Encounter reporting



Service authorization and benefit coordination



Utilization management



Fiscal
monitoring analysis



Managing enrollment



Provider network monitoring and contracting


Information/
Knowledge
Management

An information management plan that supports
each business process’s specific information
management and information technology (IT)
nee
ds.

Identification of essential IT and reporting tools and competencies to carry out managed long
-
term care


Plan for control of data:


NOTE: This document is not a definitive checklist of MCO certification requirements. It describes the developmental tasks th
at must be
accomplished before any organization begins to op
erate as a MCO.


2

Business
Area

State Performance Indicator

(Certification Requirement)

Detailed MCO Systems

(Including IT)





䑡瑡 杯v敲湡湣e



䑯D畭敮瑡tion



䑡瑡 i湴敧r慴i潮⁲畬敳Ⱐ



摡瑡ts散畲ity



䑡瑡⁲整敮tion



P潬ici敳⁡ d⁰牯 敤畲敳⁦潲o
摩s慳瑥爠t散ov敲y.



䍵Cr敮琠t湤⁦畴ure⁈䥐AA/䡉H⁲敱畩r敭敮瑳


B畤来ti湧
慮搠
Pr潪散瑩o湳


䥮Itial″
-
ye慲⁢畤g整ea灰rov敤⁡ ⁰慲琠潦
扵sin敳s⁰ a渮


䥤I湴ific慴a潮 ⁤ 瑡ts潵rces⁡ 搠d桥⁡湡lytic慬整e潤⁵ 敤⁴漠or潪散琠瑨攠e畤g整e

䵡湡杩湧
E湲nllm敮t


A灰rove搠dcc敳s⁐l慮.

A䑒䌠慮d
䥮I潭攠e慩湴nn慮c攠䍯湳潲瑩畭

r敡摩湥ss⁲敱uir敭敮瑳⁡牥⁤ c畭敮瑥t
s数慲慴aly.


P慲瑩ci灡t攠e渠Acc敳s⁐l慮 摥v敬潰m敮琠wit栠hD剃⁡湤
䥮I潭攠eai湴n湡湣攠䍯湳潲瑩畭.

䍍C⁥ rollm敮琠tr潣敳s敳⁩渠灬慣e⁴ 慣c数琠tew
e湲潬lm敮瑳Ⱐ,ssig渠n慲攠瑥慭sⰠmak攠e畲攠
湥敤敤⁳敲vic敳⁡ 攠e渠nl慣攠e渠摡y ⁥ rollm敮琬⁤敶敬o瀠p湩tial⁣慲攠ala渠w/i渠n〠0ays⸠
.䌩

䵡湡杩湧
E湲nllm敮琠
慮搠
䍡灩瑡ti潮


P潬ici敳

慮d⁰牯 敤畲敳⁴ m慮慧攠e湲nllm敮琠
慮搠da灩t慴a潮⁤敶敬潰e搠dri潲⁴漠
im灬敭敮瑡ti潮.


剥R潮cil攠e湲潬lm敮琠牥灯牴s⁡ 搠d慰i瑡瑩o渠naym敮瑳⁷ 瑨tm敭扥r⁥ r潬lm敮琬⁤is敮r潬lm敮琠
慮搠䱏䌠敦f散瑩v攠摡瑥t.

Pr潣敳s⁦潲⁲敳潬vi湧 摩scr数慮ci敳⁢ tw敥渠n桥 S瑡t
e enrollment reports and the MCO’s
敮r潬lm敮琠牥t潲摳.

剥o敲瑩fic慴a潮 灲潣敳s敳⁩n⁰ 慣e⁴ 慩湴ni渠敮roll敥 敬i杩扩lity


f畮c瑩o湡l⁳cr敥湳Ⱐ,湴敲e慣攠
睩瑨t
䥮f潭攠e慩n瑥t慮c攠䍯湳潲瑩畭.

䵡湡来m敮琠tf⁣潳琠t桡r攠r散敩v慢l敳Ⱐ,r潣敳s⁦潲⁩湴敲e敮瑩o湳⁩
f⁣潳琠t桡r攠eaym敮瑳 琠
瑩m敬yⰠ,r潣敳s⁴ ⁲敦敲⁦潲潳s ⁥ igibility if⁩湴敲e敮ti潮s⁡牥潴os畣c敳sf畬
.


Care
Management
and Care
Planning

-----

Service
Authorization

Adequate and trained care management teams
in
place.


Approved Service Authorization Policy (RAD)
in place (dif. for FC / WPP).

Policies and procedures for SDS in place.


Strategy and timeline to achieve employed and/or su
bcontracted care management teams.



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m慮慧敭敮琬⁣慲攠m慮慧em敮琠瑥c桮iq略s⁩湣l畤in朠潵瑣潭攠ess敳sm敮琬⁲tsk
m慮慧敭敮琠t湤敧潴i慴i潮⁳kills.



Tr慩湩湧 灬a渠n敶敬潰
e搠dn搠dn⁰ 慣攮

Pr潣敳s⁦潲⁰oi潲⁡畴桯riz慴i潮 ⁳敲eic敳Ⱐ,l敲楣al⁳異灯r琠tn搠d湴n杲慴g潮 睩t栠hisc慬⁳ys瑥ts.


NOTE: This document is not a definitive checklist of MCO certification requirements. It describes the developmental tasks th
at must be
accomplished before any organization begins to op
erate as a MCO.


3

Business
Area

State Performance Indicator

(Certification Requirement)

Detailed MCO Systems

(Including IT)

-----

Utilization
Management



Appropriate interdisciplinary plans for benefit
package provided are in place.

Member
Grievances
and Appeals
Process

Policies and procedures and MCO structure in
place.


Service
Provision

-----

Provider
Network

-----

Contract
Management

-----

Provider
Relations


State review and certification of adequacy of
service capacity prior to implementation.

Process for determining future provider
network needs is in place.

Have negotiated and executed cost
-
effective
provider contracts.


Identification of service needs among potential enrollees, assessment of the capacity of the local
provider pool to meet these needs (gap analysis); planning with potential providers to achi
eve a
satisfactory workforce and provider pool in regard to capacity, quality and options for consumers;
and establishment of minimum provider competencies.

This planning must address the needs of consumers who are interested in self
-
directed supports.

Dev
elop contracts and put in place (contract language must be approved by
DHS
).

Train providers in philosophy of managed LTC, claims processes, etc.

Process to ensure an adequate number of personnel with the appropriate skills to meet the
scope of services, i
ncluding policies to ensure services do not decline during personnel
shortages due to operational contingencies or changes in staffing structure or mix.

Provider capacity monitoring and management.

Claims
Processing


Demonstrated ability to submit acceptable
encounter data. An encounter data worksheet
is posted on
http://DHS.wisconsin.gov/LTCare/encounter

Pr
oposers that receive a letter of intent to
award a con
tract from the Department must
complete this worksheet within 5 business days
of receipt of the letter.

The requirement to complete the encounter
data worksheet applies to any new
organization that has not submitted data using
the encounter application; a
ny existing
organization that is adding new programs or
expanding their line of business; and any

Acquire or develop claims processi
ng capacity. Considerations include:



䍵C瑯t敲⁓ervic攠e畮cti潮sⰠ



䍵C瑯tiz敤⁃桥ck⽅OB⁰物湴nng



䍯Cm畮ic慴a潮s 睩瑨tmem扥rs



剥灯rti湧⁲敱uir敭敮瑳Ⱐ



QA⽡/摩琬



䡩杨⁣潳琠t⁣l慩m⁰牯 敤畲敳Ⱐ



䍯C琠t潮瑡i湭敮琠tr潣e摵r敳Ⱐ



䍯潲Ci湡tio渠nf⁢ n敦i瑳



Pr潣敳s敳

f潲⁡摪畳tm敮瑳Ⱐ,潲o散瑩潮sⰠ,湤⁣l慩ms⁴ 慴ac慮湯琠te⁡ j畤ic慴ad



剥R潮cilia瑩o渠睩瑨ts敲vic攠慵瑨潲oz慴i潮s



E湣潵湴nr⁳畢missi潮sⰠ,ie
-
潵瑳




NOTE: This document is not a definitive checklist of MCO certification requirements. It describes the developmental tasks th
at must be
accomplished before any organization begins to op
erate as a MCO.


4

Business
Area

State Performance Indicator

(Certification Requirement)

Detailed MCO Systems

(Including IT)

existing organization that has not had their
encounter data audited.

Policies and procedures to handle provider
appeals.


Financial
Management
and
Reporting


Full
-
time, qualified fiscal manager with
appropriate certification, such
as a CPA.

Ability to manage and effectively utilize
sophisticated information systems.

Accounting policies and procedures in place,
including for use of GAAP accrual accounting
practices.

Cost allocation plan.

Ability to implement an IBNR model

Ability to

produce financial statements that tie
out to claims.


Process used to ensure the accurate recording and timely collection of accounts receivable;
including processes for member obligations receivable and capitation receivable.

Cost allocation: Process
used to determine accurate proportion of shared administrative services
and costs (e.g., support staff, fiscal staff, management staff, IT, building costs, and supplies).

Procedures for monitoring consumer cost sharing collections.

Methodology for analyzin
g (fiscal) risk.

Monitor and analyze budget versus actual variances.

Process to identify “outliers” (members whose claims exceed expected costs).

䥂乒整e潤潬ogy;⁰牯 敳s⁴ 潮i瑯爠慣c畲慣y 慮搠d敬i慢ility 潦⁴ 攠e整e潤潬ogy.

mr潣敳s⁵ 敤⁴漠o湳畲攠ehe⁡
cc畲慴攠牥u潲oi湧⁡ 搠dim敬y⁣潬l散瑩潮 潦⁡ c潵湴n⁲散敩v慢l攻e
i湣lu摩湧⁰ 潣敳s敳⁦潲omem扥r li条瑩o湳⁲散敩va扬e⁡ 搠da灩t慴a潮⁲散eiv慢l攮

䵡i湴nn慮c攠潦⁳潬v敮cy 灲潴oc瑩潮s.

mr潣敳s⁵ 敤⁴漠oe瑥牭i湥⁡ c畲慴攠uro灯r瑩潮 潦⁳桡r敤⁡摭i湩s瑲慴av攠e敲
vic敳 慮搠d潳瑳
攮e⸬.
s異灯r琠t瑡tfⰠ,isc慬⁳瑡tfⰠm慮慧敭敮琠t瑡tfⰠ,TⰠ,畩ldin朠g潳瑳Ⱐ,湤⁳異pli敳).


啴rliz慴i潮
剥oiew


䑥a潮s瑲慴a搠dbility⁴ 灲p摵c攠牥e潲瑳⁴ 慴
cl敡rly⁣潭m畮ic慴a⁵ iliz慴i潮 i湦潲o慴a潮⁡ 搠
瑲敮摳⁴ 慬lev敬s 潦⁴ 攠e䍏⸠.

mr潣敳s⁢y 睨wch⁵ iliz慴a潮⁩湦潲o慴a潮 will 扥
s桡r敤 睩瑨tf䑔s⁡ 搠d瑨敲⁰ r瑳 ⁴ 攠䵃MⰠ
慮搠桯w⁉䑔s⁡ 搠d瑨敲e⁷ ll⁢ ⁧ ve渠n敬瀠p渠
慮alyzi湧⁴桡琠i湦潲o慴a潮⸠.


mr潣敳s⁦潲⁲散潮cili慴a潮 a湤⁲数潲瑩n朠g渠n敲eic敳⁡ 瑨triz敤⁶敲e畳⁳敲eic敳⁵ 敤;

s敲eic攠
畴uliz慴i潮⁲数潲瑳.

mr潣敳s⁴ ⁣潭m畮ic慴a⁣桡湧敳⁩n⁰牡 瑩ce⁰ t瑥牮t⁡ 搠桥al瑨⁣慲攠a敬iv敲y id敮瑩fie搠d桲h畧栠
畴uliz慴i潮慮慧敭敮琠牥tiews.

mr潣敳s⁴ ⁲evie眠w湤⁥val畡瑥t桩杨 vol畭攠e⁨ g栠物sk⁩湤ic慴arsⰠ,r慣瑩c攠e畩摥li湥s⁡ 搠
灲潴潣o
lsⰠ畮畳畡l c畲u敮c敳Ⱐ,linic慬 瑣潭敳Ⱐ,n搠d敲eic敳 灲潶id敤⸠.䡯w 慲攠瑨ase
r敶iews⁵ 敤⁴ i湩miz攠物sk?

n畡lity
䵡湡来m敮t


n䴠Mr条湩z慴i潮慬⁳瑲畣t畲攬⁩湣l畤in机g



A⁳敮i潲慮慧敲e睩瑨tr敳o畲ue
-
摥ploym敮琠t畴u潲楴y⁩s 摥si杮慴ad⁡
r敳灯湳ibl攠
f潲⁑䴠灲潧pam.



A⁦畬l 瑩m攠e畡lifi敤⁰牯 敳si潮al⁩s i渠nl慣攠
䑥Di杮⁑䴠Mro杲慭⁴ 慴awill:



Ass畲攠煵慬ity 潦⁢ 瑨⁰牯vi摥搠慮搠灵rc桡se搠d敲eices;



䵯ni瑯爠t敲e潲m慮c攠e湤⁄整ec琠tro扬敭s;



䑥瑥rmi湥⁣慵s敳 ⁰牯 lems;



Pri潲o瑩z攠
煵ality
-
im灲潶敭敮琠tctiviti敳;


NOTE: This document is not a definitive checklist of MCO certification requirements. It describes the developmental tasks th
at must be
accomplished before any organization begins to op
erate as a MCO.


5

Business
Area

State Performance Indicator

(Certification Requirement)

Detailed MCO Systems

(Including IT)

to coordinate the quality program.



Q䴠Mc瑩viti敳⁨慶攠i湤ividu慬s爠 湩瑳 睩瑨t
cl敡rly⁡ si杮e搠牥d灯湳ibility⁦潲⁴o敭.



䵥c桡nisms f潲⁡o瑩v攠灡r瑩ci灡ti潮⁦r潭
c潮s畭敲eⰠ,瑡晦Ⱐ,湤 桥rs.



䵵s琠tave⁣le慲灥r慴a潮ali湫s⁴ ⁡ 搠
s異灯r琠tr潭 桥r⁦畮c瑩潮慬⁡牥慳.


䑈D
-

a灰rov敤⁑畡lity†Pr潧r慭⽐l慮Ⱐ
慤潰瑥t by 杯v⸠扯慲aⰠ,湣l畤i湧:



䥮Il畤敳⁡ 湵al⁧潡ls⁢ se搠d渠nin摩湧s
from⁰牥 i潵s⁑䴠慣瑩viti敳;



䑥Dcri扥sⁱ 慬ity
-
m潮i瑯tin朠gr潣敳se

慮搠慣瑩viti敳;



䑥Dcri扥s⁡ le慳琠tn攠e敲e潲o慮c攠
im灲潶敭敮琠tr潪散琮




䑥瑥rmi湥⁥ f散瑩v攠牥e敤i慴ao渻



F潬low⁵瀠p漠v敲楦y⁰牯扬敭s⁡牥⁦ix敤㬠;nd



䍡Cry畴uim灲潶敭敮琠tff潲瑳⁥ 敮⁩n⁡ se湣攠ef⁩d敮tifi敤⁰牯扬敭s.

䵃M⁥ s畲敳⁴桡琠慳s敳sm敮瑳⁡ 搠d慲攠灬慮s⁡牥⁴ m敬y⁡湤 潦⁨ gh
-
煵ality


瑨潵琠th散ki湧
潲⁰oi潲⁡灰roval⁦r潭
䑈a
.

䵃M⁤ t敲ei湥sⰠ,潣畭敮瑳Ⱐ,湤⁲e灯r瑳⁩瑳w渠灥rf潲o慮c攠⡥⹧eⰠ,mm畮iz慴io渠牡瑥n)

䵃M⁰ 慮s⁡湤⁣慲ai敳 琠瑩杨瑬y⁦潣畳敤⁩m灲潶敭敮琠tr潪散瑳.





NOTE: This document is not a definitive checklist of MCO certification requirements. It describes the developmental tasks th
at
must be accomplished before any organization begins to op
erate as a MCO.


6