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June 2019 A DMHC Timely Access Reporting Requirement MY 2019 PROVIDER APPOINTMENT AVAILABILITY SURVEY (PAAS) METHODOLOGY REVIEW
June 2019
A DMHC Timely Access Reporting Requirement
MY 2019 PROVIDER APPOINTMENT AVAILABILITY SURVEY (PAAS)
METHODOLOGY REVIEW
TODAY’S OBJECTIVES
About QMetrics• Key Personnel
• Background, Qualifications, & Services
Overview of PAAS Requirements
Highlight MY 2019 Methodology Changes
Review Key Milestone and Deadlines
Discuss Health Plan and QMetrics Responsibilities
Naming Conventions & Data Exchange Requirements
Identify Important Resources
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KEY PERSONNEL
Suzan Mora Dalen, MPA, CHCA - Principal & HEDIS Auditor• Executive Lead / Sponsor
Jim Dalen, MA – Chief Health Economist• Programming/Analytics Lead
Stacy Baker, JD – Compliance Officer & VP Regulatory Affairs• Regulatory Advisor & Oversight
Erin McGlone, MPH – Survey Program Administrator
Robb O’Brien, MA – Senior Programmer & Data Engineer
Jeff Lucas, MA – Senior Data Analyst
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BACKGROUND & QUALIFICATIONS
We are a California based audit and consultancy firm working with health plans and provider groups
We have a thorough understanding of the challenges and barriers in meeting NCQA, State and Federal requirements
We are seasoned healthcare and health plan operations executives with experience across the full spectrum of managed care; working in health plans, consulting for health plans, overseeing and auditing health plans.
We are a Woman minority-owned business
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AREAS OF EXPERTISE
HEDIS® & STARS Improvement
Encounter DataCompleteness Assessment
& Improvement
Advanced Analytics Managed Care Data & Reporting
Pay for Performance(Align.Measure.Perform)
Predictive Modeling Provider Appointment Availability Surveys (PAAS)
Provider Satisfaction &After Hours Surveys
Quality ReportingRegulatory Compliance &
Oversight Risk Score Optimization Supplemental DataCapture & Review
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Advanced Analytics Risk Score Improvement
Quality Measure Improvement
ADVANCED ANALYTICS
Predictive Modeling Tailored creation of new predictive
models
Refinement and enhancement of existing models
Risk Score Optimization Optimize retrospective and prospective
member risk score improvement activities
Ensure the maximum ROI for Medicare Advantage, Commercial Exchange, and Medicaid models
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Encounter Data Completeness Assessment & Improvement
Identify encounter data leakage points and implement process improvements
Reduce encounter rejection rates by submitting trading partners, both incoming and outgoing
MANAGED CARE DATA & REPORTING
Managed Care Data & Reporting
Detailed analysis of data to support analytical decision making
Develop customized reporting with targeted data marts and dashboards
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Quality Reporting Develop and/or audit quality metric
calculations and reporting
Evaluate accuracy and completeness of patient care reporting
QUALITY & VALUE BASED PERFORMANCE REPORTING
HEDIS® & STARS Improvement
Evaluate the root causes contributing to low performing measures
Apply expertise from having conducted hundreds of HEDIS and Performance Measure Validation audits for performance improvement
® HEDIS is a Registered Trademark of the National Committee for Quality Assurance (NCQA)
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QUALITY & VALUE BASED PERFORMANCE REPORTING
Supplemental Data Capture & Review
Assess supplemental data availability, maintenance, measure-use, and reporting
Integrate the use of supplemental data with the Plan’s overall reporting and performance improvement program
Determine ROI for each supplemental data source
Pay for Performance (Align.Measure.Perform)
Ensure thorough preparation for participation and compliance in the AMP program by educating staff, reviewing documentation, and/or conducting an audit preparedness review
Conduct an evaluation of data gaps and/or low performing measures and issue improvement recommendations
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Regulatory Compliance & Oversight
Compliance assessment, development & training
Implementation plans for new laws
Regulatory filing assistance
REGULATORY COMPLIANCE & OVERSIGHT
Provider Appointment Availability Surveys (PAAS)
Full survey administration, including dedicated domestic call center partner
Survey validation by experienced HEDIS compliance auditors and compliance & regulatory affairs professionals
Provider Satisfaction & After Hours Survey
Administration, analysis and report development
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TAR Compliance Assessment & Data Validation
Comprehensive document and data review of A – F Timely Access Report (TAR) Compliance Report Requirements
Third-party unbiased quality review of Plan’s TAR submission
REGULATORY COMPLIANCE & OVERSIGHT
Qualitative and quantitative review of all documents and data prior to submission
Review of G Data submission for completeness, formatting, and adherence to DMHC requirements
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PAAS BACKGROUND & QUALIFICATIONS
MY 2016 Validation
MY 2017 PAAS Administration, Validation & Provider Satisfaction Survey
MY 2018 PAAS Administration, Validation, Provider Satisfaction and After-Hours Surveys• 100,000+ provider survey outreaches: fax, online, telephonic
Full Knox Keene and Limited Knox Keene Licensed Health Plan Clients
Wide Range in Plan Membership, Single and Multiple Networks, Multi-County Service Areas
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MY 2019 Methodology and Key Changes
1. MY 2019 Survey Structure2. Provider Contact Lists3. Sample and Oversample Sizes4. Random Sample Selection5. Survey Tool & Questions6. Survey Administration7. Provider Dispositions8. Plan-to-Plan Agreements9. Template Changes
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SURVEY STRUCTURE
Primary Changes Overall similar approach to MY 2018
Requirement to survey contracted providers outside of the plan’s service area
Inclusion of Telehealth and Advanced Access providers
Provider specialties to include in each Provider Survey Type
Target Sample Sizes – one chart (for single and multiple counties), applicability to census approach
Contact List, Raw Data file and Results file Template changes
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PROVIDER CONTACT LISTS
Providers Outside of Service Area
The MY 2019 Methodology requires plans to report rates of compliance for all counties in which contracted providers are located. Therefore the plans must include contracted providers that are located outside of the plan’s service area on the plan’s Contact Lists. [see MY 2019 Methodology Footnotes #3, and #5]
Selection Date
Must include all providers in the plan’s network as of December 31, 2018
Plans are permitted to omit providers no longer in the plan network as of March 31, 2019 when creating the Contact Lists (per DMHC email clarification on 6/18/2019)
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PROVIDER CONTACT LISTS
Deemed Ineligible Providers
For providers already on the Contact List and selected to be surveyed: if a provider is discovered to be ineligible prior to initiating the survey, the provider may be deemed ineligible on the Raw Data Template (without having to initiate the survey) and replaced by another provider from the oversample. [see FAQ #1 and MY 2019 Methodology Footnote #15]
Pediatric Providers
For MY 2019 the Department is requiring health plans to include all specialty physicians and psychiatrists that fall under industry standards for the corresponding provider type, without a distinction being made as to whether it is adult or pediatric. [see FAQ #38]
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PROVIDER CONTACT LISTS
Provider Contact List – PCPs Added the following provider types to the definition of a PCP
• Physician Assistants• Nurse Practitioners
Provider Contact List – Other Provider Types DMHC added more detail in the methodology footnotes as to the
provider types to include for each specialty type
Provider Survey Types
MY 2019 Requirements and Notable Changes
Primary Care Providers
Primary Care Physicians and Non-Physician Medical Practitioners (NPMP - Nurse Practitioners and Physician Assistants)
Advanced Access PCPs
Specialist Physicians
Cardiovascular Disease, Endocrinology, and Gastroenterology Same three provider types as in MY 2018 but does not narrow to specific specialty/subspecialty
types as in MY 2018
Psychiatrists Reported on its own separate Contact List template
Non-Physician Mental Health
Providers (NPMH)
Licensed Professional Clinical Counselor (LPCC), Psychologist (PhD-Level), Marriage and Family Therapist/Licensed Marriage and Family Therapist and Master of Social Work/Licensed Clinical Social Worker
4 provider licensure types rather than the 14 possible provider types in MY 2018 Behavioral Health/Autism (BCBA) licensed providers no longer included (among others) [See
DMHC FAQ #7 & #45]
Ancillary Service Providers
Facilities or entities providing mammogram or physical therapy appointments MRI entities no longer included
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PROVIDER CONTACT LISTS
De-duplicating the Provider Contact List Duplicate entries are rows where the same provider name appears more
than once in a single county for a single network.
De-duplications rules for all Provider Survey Types: • Last Name and First Name (ANC – Facility Name)• FQHC/RHC Name• NPI • County• Name of Network
FQHC/RHCs – NPI is now taken into consideration (unlike in MY 2018)
The MY 2019 Contact List Template has a “Unique Provider” field that plans must populate
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PROVIDER CONTACT LISTS
If providers meet all of the applicable requirements to be included in the Contact List, the Contact List shall also include: Federally Qualified Health Clinics (FQHCs) and Rural Health Clinics (RHCs)
• RHCs were not specifically mentioned in MY 2018
• Contact List includes a separate field to enter the FQHC/RHC name (rather than entering the name on the provider group field as in MY 2018)
Providers offering in-person and/or telehealth appointments to enrollees • Plans shall treat “telehealth” as a single virtual county for survey fielding purposes and enter
“Telehealth” in the County field on the Contact List.
Primary Care Providers participating in the plan’s Verified Advanced Access Program• Program for provider offices that provide same day or next business day enrollee appointments.
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SAMPLE AND OVERSAMPLE SIZES
Determine Sample Size For each Provider Survey Type in each Network/County, plans shall either survey:
• A sample of providers until the target sample size has been met; or• All providers in the County/Network (census)
Oversample for Replacements (for sample approach) No minimum threshold outlined as was for MY 2018
If the initial oversample is exhausted and additional providers remain in the County/Network, plans must continue to add additional providers from the Contact List using the random sample selection process until either the target sample size is reached or all providers have been contacted.
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SAMPLE AND OVERSAMPLE SIZES
Target Sample Sizes The MY 2019 Methodology only includes one Target Sample Size chart instead of
two as was used in MY 2018
The MY 2019 Target Sample Sizes align with the thresholds from the MY 2018 Single County Chart
The Methodology applies the Target Sample Size requirements regardless of whether a sample or census is surveyed.
• Footnote 12 - “Unless the health plan is unable to meet the target sample size due solely to ineligible providers, it must obtain enough valid survey responses to meet the target sample size regardless of whether a sample or census is surveyed.”
• QMetrics is seeking DMHC confirmation and clarification on this element.
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RANDOM SAMPLE SELECTION
Counties with Multiple Networks Similar approach as in MY 2018
Apply the responses from the providers sampled from the largest network to all of the smaller networks in which the sampled provider participates.
• The provider is surveyed once and the response is applied to all relevant overlapping smaller networks
• Note - there may be some additional sampling of non-overlapping providers needed.
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SURVEY TOOL & QUESTIONS
Survey Script Content Continues to include only two appointment date/time questions (one
for ancillary)
Providers on Leave of Absence (and not scheduling appointments)• Enter “NA” in the appointment date/time fields
• Enter “N” in the compliance calculation field for that appointment
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SURVEY ADMINISTRATION
Timeframe All surveys must occur between April 1, 2019 and December 31, 2019
Waves Two waves – 50% (and no more than 60%) of providers in each survey
type to be surveyed in each wave
Waves must be spaced at least 3 weeks apart• Second Wave shall begin no sooner than 3 weeks after the final survey of
the 1st wave has been completed.
Waves may be staggered by Provider Survey Type
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SURVEY ADMINISTRATION
Plans are permitted to administer the surveys using one or a combination a the three administration modalities: (1) Extraction, (2) Three Step Protocol, or (3) Verified Advanced Access Program
Option 1 – Extraction (Manual or Electronic)
Plans may extract the next available appointment from the provider’s practice management software or conduct the extraction manually.
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SURVEY ADMINISTRATION
Option 2 – Three-Step Protocol
STEP 1: Survey: Fax or Email 5 business day response deadline Responses permitted via fax, email or online portal
STEP 2: Survey Reminder Optional Within 2 business days of initial survey invitation
STEP 3: Telephone Follow-up
Health Plan
Outreach
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SURVEY ADMINISTRATION
Option 2 – Three-Step Protocol
STEP 3: Telephone Follow-Up Survey
Contact providers that have not responded to initial survey invitation within 5 business days
Initiate phone survey 6 – 15 business days of sending the initial survey attempt conducted via email or fax• If a provider responds to the email/fax survey prior to the initiation of the phone survey,
the response can be entered into the Raw Data Template and a call will not be needed.
Provider willing to complete at a later date/time – scheduled or unscheduled agent call-back within 2 business days of message• If provider does not respond within 2 business days Non-Responder
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SURVEY ADMINISTRATION
Option 3 – Verified Advanced Access Program (PCPs only) Providers may be included on the Raw Data and Results Templates and
automatically counted as compliant without requiring any survey outreach.
May only include providers that have been verified by the plan’s Access and Availability Quality Assurance System as meeting the criteria of §1300.67.2.2(b)(1) (program that provides for same or next business day enrollee appointments)
QMetrics will request a plan attestation for any Advanced Access providers listed on the PCP Contact List to confirm providers are appropriately classified.
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SURVEY ADMINISTRATION
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PROVIDER DISPOSITIONS
Replacement of Ineligible Providers – Ineligible providers are to be entered on the Raw Data Template with one of the following dispositions and replaced with a provider from the oversample (if sampling was used):
MY 2019 Reasons for Ineligibility (same as MY 2018):
• Provider not in Plan Network - Provider no longer participates in the health plan network• Provider not in County - Provider does not practice in that county• Provider retired or ceasing to practice - Provider retried or no longer practicing• Provider Listed under Incorrect Specialty – Listed in Contact List under wrong Provider
Survey Type• Contact Information Issue (Incorrect Phone or Fax Number/Email) - Provider listed with
incorrect contact information that cannot be corrected• Provider does not offer Appointments - Provider does not offer enrollee appointments (e.g.,
provides only hospital-based or peer-to-peer services)
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PROVIDER DISPOSITIONS
Replacement of Non-Responding Providers • A non-responding provider is a provider that does not respond to one or
more applicable items within the required time-frame or that declines to participate in the survey.
• Non-responding providers are to be entered on the Raw Data Template with either of the following dispositions and replaced with a provider from the oversample (if sampling was used):
o "Refused – Refused/Declined to Respond“
o "Refused – No Response"
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SURVEY ADMINISTRATION NOTES
If provider report date/time of next available appointment depends upon whether patient is new or existing
• Request dates for both and use the earlier date (shorter duration)
If provider reports patients are served on walk-in or same data basis, provider to provide date and approximate time that patient walking in at time would be seen.
• Appointment cannot be prior to date/time of the call
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SURVEY ADMINISTRATION NOTES
Referral of patient to different provider (covering provider) cannot be recorded as initially surveyed provider providing appointment Appointment offered at different office in same county with same
provider can be recorded as available appointment with initially surveyed provider
For FQHC/RHCs, appointment availability at separate site with any provider of that provider survey type within FQHC/RHC qualifies as available appointment
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SURVEY ADMINISTRATION NOTES
If provider office indicates urgent appointments are not offered:• Record “NA” in appointment date and time fields
• Record “NA” in compliance calculation field
If provider is not scheduling appointment at the time of the survey because out of the office on leave or vacation:
• Record “NA” in appointment date and time fields
• Record “N” in compliance calculation field
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PLAN-TO-PLAN AGREEMENTS
A. Secondary Plan also submits a Timely Access Compliance Report Both plans indicate relationship in the Timely Access Portal Plan
Profile.
Secondary Plan surveys and submits separate PAAS Templates for the Primary Plan to file in its Other Plan Network tab of the Portal.
B. Secondary Plan does NOT submit a Timely Access Compliance Report Primary Plan is to include the data for the relevant providers from the
Secondary Plan in the Primary Plan’s own PAAS Templates.
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TEMPLATE CHANGES: CONTACT LIST
New Fields• FQHC/RHC Name
• Non-California Licenses
• Non-California State
• Telehealth
• Unique Provider
• Advanced Access Program
• Terminology Tab
Removed Fields• Network Name 2-20 (only one Network Name permitted per row)
• Clinic Name
• Health Plan ID for Plan-to-Plan Contract
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TEMPLATE CHANGES: RAW DATA
Raw Data Files
New Fields• Other than those already noted as changes to the MY 2019 Contact
List fieldso Sample Type (Random Sample or Census)
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TEMPLATE CHANGES: RESULTS DATA
Results Data File Final Template released by the DMHC on Friday, June 14th
Combined Template – each Provider Survey Type has a separate tab in one template
Includes weighted rates of compliance in a new “Summary of ROC” tab.
Plans may no longer enter “NA” under “Target Sample Size Achieved” field when the census approach is used as in MY 2018.
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WAVE & DARK PERIOD APPROACH
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OUR APPROACH
Thorough knowledge of Methodology, FAQs, and Regulatory Requirements
Survey Administrator and Validator
Kick-Off Call / Educational Webinar
Pre-Validation of Data• Formatting and Field Completeness of Contact Lists
• Reconciliation of Contact Lists Against G Data / Annual Network Filing
Interim Reporting
Comprehensive QA program
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OPERATIONAL PROCEDURES
Lessons Learned Meeting Target Sample Size
Census Approach
Contact Attempts• Fax – 3 Attempts if busy (For each unique telephone number provided)
• Email – includes provider inquiry inbox (monitored daily)
• Telephonic - 3 attempts (busy, disconnected/hang up, no answer, exceeded hold time) – 30 minutes between attempts per number on file.
“White Glove” Outreach for High Volume Provider Offices
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QMetrics “White Glove” Outreach Approach
Applicable to high volume provider offices to minimize provider burden• Defined generally as (can be customized)
o 10 or more providers with the same FAX Numbero 10 or more providers with the same Email Addresso 10 or more providers with the same Telephone number
Identified during the pre-validation process
Custom approach designed collaboratively with Health Plan to minimize provider burden, while maximizing response rate
Can be applied to any survey mode
Special care taken to maintain full compliance with all DMHC methodology requirements The 50/50 wave requirement compliance can be challenging for these instances
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OPERATIONAL PROCEDURES
Interim Reports Interim reports provide a snapshot of how plan is progressing toward
meeting the target sample size for each Provider Survey Type during the survey fielding campaign.
Plans should review the interim reports and conduct additional provider education and/or work with QMetrics to discuss possible ways to increase response rates if they are low in a particular area.
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TECHNOLOGY
FAX• High Resolution FAX out
• OCR & ICR of FAX Images for data capture
EMAIL• Email sent with unique link to online survey for each provider
• User friendly online survey process
TELEPHONIC• Computer Assisted Technology Interviews (CATI) for FAX/Online non-
responders
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QUALITY PROGRAMS & PROCEDURES
Quality Assessment is Performed Throughout the Process Pre-survey Administration: Validation of Contact Lists
Comparison to DMHC specifications
Reconciliation of Contact Lists to Network Filing (‘G’ Data)
Comparison to expected
Throughout Survey Administration Programmatic evaluation of survey results from each modality done as data is collected to
ensure compliance to DMHC Specifications
Post-Survey Administration Programmatic evaluation of survey results ensuring compliance with all specifications
Reconciliation of Raw Data to Contact Lists
Reconciliation of Results to Raw Data
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CLIENT QUESTIONNAIRE CHECKLIST ATTESTATION
Initiates the contracting / re-contracting process
Provide health plan profile information
Identifies scope of work• PAAS, validation, Provider Satisfaction Survey, After-Hours, customization,
other services
Checklist• Identifies required documentation to assess provider counts, networks, and
work estimates for resource allocation
Attestation• Identifies executive level sign-on off of organizational profile that drive key
factors in survey administration, i.e. FQHC, networks, products, etc.
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PAAS KEY DATES & DELIVERABLES
Plan (May – July)
ANR as of Dec 31, 2018
Crosswalk
Contact Lists
Client Questionnaire
Primary / Secondary Contacts
QMetrics (June – July)
Pre-validation• Contact Lists
• Reconciliation against ANR
Pre-validation findings / communication to Plans
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PAAS KEY DATES & DELIVERABLES
Plan (June – July)
Review, response, and correction of data, as needed
Pre-survey invitation to providers / provider network
QMetrics (June – July)
Pre-validation• Contact Lists
• Reconciliation against ANR
Pre-validation findings
Testing & Configurations
QA
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PAAS KEY DATES & DELIVERABLES
Plan (August – December)
Review interim reporting
Provider / Location Issues
Special Handling White Glove processes
Updated outreach to providers regarding ongoing survey
QMetrics (August – December)
Survey administration
Interim reporting
Ongoing QA processes
Conference Calls with Plans as needed
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PAAS KEY DATES & DELIVERABLES
Plan (January – March 2020)
Review of templates
Template inquiry and verification
Validation findings review and response
QMetrics (January – March 2020)
Final data aggregation
Template completion
Validation of compliance rates
Executive Summary Report
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NAMING CONVENTIONS
For Contact Lists:• MY19_CL_<Survey type>_<Plan Abbreviation>.xlsx
Survey type• PCP = PCP• SCP = Specialist Providers• PSY = Psychiatrists• NPMH = Non-Physician Mental Health• ANC = Ancillary
For returned / corrected pre-validation reports save as:• (YYYYMMDD) at the end of file name
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DATA EXCHANGE REQUIREMENTS
Health Plan Specific Timeline• Exhibit A of Contract – Deliverable Due Dates and Responsibilities
Box Account• Secure and HIPAA compliant
• Client-specific
Version Control and Date Stamping
All Files, Templates, and Documents Should be Posted on Box in Respective Folders
Identify Plan Representatives Who Should Have Access and Permissions
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IMPORTANT RESOURCES
MY 2019 documents are posted on the “Resources” section of the DMHC Timely Access Compliance Reporting Web Portal (log-in required)
• Methodology• Survey Tool• Contact Lists• Vendor Checklist• All Plan Letter• FAQs
DMHC website (historical docs only) http://dmhc.ca.gov/LicensingReporting/SubmitHealthPlanFilings/TimelyAccessReport.aspx#.WMC8wTvyu01
DMHC Timely Access Email Notifications
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Contact information
Suzan Mora Dalen, MPA, CHCA
Direct: (888) 388-9111 (ext. 1)
Email: [email protected]
Stacy Baker, JD
Direct: (888) 388-9111 (ext. 2)
Email: [email protected]
MAIN PAAS CONTACT :Erin McGlone, MPH – Survey Program Administrator
Direct: (888) 388-9111 (ext. 120)
Email: [email protected]
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QUESTIONS
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THANK YOU
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