Document type sign claim connecticut fast
(upbeat music) - So the question, the sort of
broad, beginning question is why did you use a state plan
amendment to do what you did? - We amended our state plan because we were already in the state plan. What we had to do recently
was change the state plan from a bundled rate to
a fee-for-service rate. But we had been in our
state plan since the 90s. - And who made that decision or who did you have to
work with or convince, to move in that direction? - So we really didn't
know what we were gonna do when we were told that we needed to move to a fee-for-service system. We put it off. I don't know if you remember
or not, but there was that 2010 letter that basically
told to everybody to unbundle. And then, finally, our general assembly and the office of the
governor tried to put birth to three in our
Medicaid lead agency. And they didn't do that. But what they did do was
they moved the funding a portion of the funding
into (missing audio) match. And in that scenario, it was you are getting this
funding moved over here because you are going to fee-for-service. And we hemmed in hot and finally discovered that,
okay, they're not kidding. We absolutely have to do this. And we approached our
colleagues over at DSS which is our Department
of Social Services. They're the lead agency for
Medicaid in Connecticut. And the attorney on the team,
his name is Joel Norwood. And what a helpful guy, he
just said, you know what? We just have to amend your state plan. And it's like, okay, what does that mean? I mean, really, we just we kind of didn't even know anything. And they just walked
us through the process which is remarkably complicated. And then we gave them the
information they needed to be able to put the wording
into the state plan. - And so they, Medicaid
actually executed that for you. - Yeah, they did. Oh, I mean, honestly, it's
funny because you know there's lore and then there's reality. And the lore was don't
talk to DSS, you know they're Medicaid, but in
reality, these people were great. They were so helpful to work with because they could explain things to us. The process of getting CMS approval of a state plan is one thing. But we also discovered that when you go to fee for service, we went different approaches
and decided to use EPSDT. And with EPSDT there can't be an age limit
because it's really birth to 21. So we had to figure out how to word that. And then we also realized that there's any willing
provider provisions in Medicaid that we did not want. So not only did we have to
do a state plan amendment we had to do something
called a 1915 before waiver which allowed us to waive the any willing provider
provisions and do an RFP so that we could select qualified
birth to three programs. We wouldn't have known any of this if we didn't have our DSS
team leading us really. - And was there any concern,
I guess, by anyone involved in this process at the
higher levels or not? And correct me if I'm wrong, but when you do a state plan amendment it theoretically can
open the whole state plan up for other amendments that
someone would like to bring into that process. And that's why some
people don't choose to go in that direction. Was that ever an issue? - I honestly never heard that. In fact, I think our state plan is being amended all the time. They did an amendment for
autism supports for children over three there's, all sorts
of amendments being done. In fact, the attorney that we worked with that's his job really is
amending the state plan and working it through the system. - But those are not
those typical of things that the Medicaid agency wants to do. I was told they must do. And I asked that in
context of other States that may want to go in this direction where it's not in essence being told to do from above. So you're not going to get much pushback, but if it changes other
options that a state has that other people want to push it's always been my understanding
that provides a vehicle for someone to try to do other things that someone might not want to take place. - And there is a public hearing component to the CMS approval process. So absolutely it could. I would say the fact that ours was coming from the office of the governor down and CMS that our Medicaid
agency was the one really driving the bus. You know, they were
saying, we got to do this. You've got to go to fee for service. We can't do bundled rate. Because also I think
given the 2010 letter, our state plan was so old it was probably out of compliance
with CMS and other ways. And our Department of Social Services just wanted to clean it up to begin with. So I think they were highly
motivated on many levels. And when you've got that kind of top down and grassroots support
from your Medicaid lead, it's much easier. But yeah, I would say a
state trying to do this on their own would need to start with whoever can influence the
Medicaid lead commissioner because that's where it
needs to come from first. So that potentially (indistinct) why your state agencies, might it not? - It might, you know, I mean really it even came down to
programming the software at DXC formerly Hewlett Packard enterprises, DXE is who administers the MMIS system coming up with all of
the tiny little rules. So there's many, many layers to this onion and you definitely want to start at all of them at the same time so that you could make sure that you're not missing anything. - Well, let me go back. I know this is sort of
right in your wheelhouse that you will want to talk about a lot, which is was there additional data in this whole process
that you had together and kind of coupled with that. Were there any expectations for you or your team to calculate
costs of making the change? I mean, with some of this the ability to generate additional revenue or was it very specifically
decided because of the moving away from
bundle to a fee for service? I think the, the real motivation to get us from bundled to fee for service was because we were experiencing
annual deficits. Just with the growth of part C. And it looked like we were
leaving money on the table. We did have a governor's
office and office of policy and management who
realized that this might be a way to bring more federal
dollars into the state. So if your executive, chief executive doesn't want to bring more
federal money into the state it's a harder battle, right? We had a governor who supported bringing more federal dollars into the state. So we knew that that was going to happen. We helped our department
of social services by using the utilization data that we had, hours of service and numbers
of children and all of that to be able to project, you know, well if we're currently
getting this much money and this percentage of children
are insured by Medicaid what happens when all of the children, I'm sorry my phone's ringing in the back. - I think anything where you gathered data that helps move this along and forward that people want you to have. There's a second question embedded in that of how much revenue additional revenue do you
think you did generate and did that have impact on
state match in terms of what how the state was
putting through Medicaid? How were they putting their state match into the process? - All right, so we knew that switching to a fee for service model was going to generate more revenue because when you're paid at bundled rate, fine if there's only
one service in the month you might get $800 or whatever it is. But for children who are
receiving intensive services or families who are
getting intensive supports, you are looking at a total loss. They might be getting 10 hours a week and you're still only getting $800 from Medicaid for that
40 hours of service. So all we had to do was go into the service
utilization data we had for children with autism and show them what that would
look like in fee for service. And it was a huge selling point. As far as the budget makers go. Now our Department of Social Services, they realized that it was
gonna end up costing more in the match but little tiny birth to three was just put into the
Medicaid budget line, along with the hospitals. You know, so they kept saying, please, your funding is not even a rounding error for some of these other people. And I think that's important
to have that context to be able to say, we're not
talking about a lot of money. It's still a lot of money but relative to the
overall Medicaid budget it was not a significant impact. - Very good. So I'm assuming from what
you've described to this point there was no opposition
really to this action unless there was opposition
from the provider community. And if you could speak to that if there was opposition and
how did you address that? Yes, the opposition was
from the provider community. They were very unhappy about the idea of moving
to fee for service. For many, many reasons, we lost a couple of really high quality programs because they just didn't
want to bill Medicaid. They did not want to be
part of the Medicaid system. And so they dropped out. And that was hard crushing, you know, to actually lose programs
that you've been working with for 25 years. So the remaining programs
continually pursued, we went through three
commissioners during this period. And each new commissioner
got the same argument, which was don't make us
move to fee for service. We don't want to go to fee for service. And the commissioner would get up to speed very quickly and
say, we don't have a choice. We are doing this. It's the right thing to do. You know, it was hard because on some degree we do like a bundled rate, a bundled rate gives our
programs more flexibility. It supports the practices that we want that may or may not actually be billable. But at the same time, I
think it might've been the past Massachusetts
part C coordinator who said that providers actually need
to have some skin in the game. And I do believe that, I think there's an aspect
of having providers participate in billing
that made a difference. We did find a contractor. We went out to RFP. We found a contractor who was
willing to do the middle work. You know, all of the
electronic file transfers. And that made it more palatable. But we had to have
regular meetings, you know talk about leading by convening. We were just absolutely in the faces of our providers constantly
with updates and information and there couldn't have
been enough communication to help with the anxiety
basically of the shift. - And I think you would probably suggest that anybody who was wanting
to do something similar significant changes in a billing system based on this action or private insurance. You're likely if people have
not been billing third parties or their lead, their lead agencies the providers lead agencies
have not been billing to do third-party payments, public or private people
are going to push back. - And, and not only will they push back the programs will push back. So they may, the birth to three providers in Connecticut actually
originally did their own, not Medicaid but they did their own commercial insurance billing back in the nineties and the
early two thousands. And then we found that some are doing really
good job in some work. So we centralized it. And when we centralized it, we discovered that we still
weren't getting the kind of numbers that we wanted. So we use this as an opportunity to just redo the billing
vendor completely. So it was a combination of fee for service and we need a better
approach to commercial. But not only will the
programs or the entities who are going to be responsible for doing the billing pushback, they're going to, it's going to get out to their families. And we had families that were
calling their representatives saying, don't close birth to three. And it was like, are you
closing birth to three? It's like, no, we're not
closing birth to three. That one program is closing because that one program
doesn't want to Medicaid, but no the system is fine. We had to do a lot of public relations work
with referral sources who thought that the birth
to three system was closing. I mean, there was just a lot
of misinformation out there. So we had to work around that as well. - And did that have any implication? This is a little more in the weeds. But did any of this have
implications for family fees? Because, correct me if I'm wrong you do have a family fee system or not? - Yes, we do. We instituted family cost
participation fees back in 2003. And, we did have to change our
system of payment procedure only because there was
some language in there about how claims and services
were going to be paid for. But the actual family
cause participation fee process did not change at all. - And I assume very little
of the family fee system would have applied for the most part for Medicaid eligible families. - Right, we have currently $45,000 adjusted gross income entry amount. And so anyone who is insured by Medicaid or anyone who makes less than 45,000 doesn't pay family
cost participation fees. And we're hoping to get
that up to the Alice levels but that's another budget
discussion for another time. - So it sounds like in
your overarching process that you went through, you hadn't tried this before because you wouldn't
necessarily have wanted to. So it really was the downward pressure from those above you
that sort of drove this as opposed to having a
change that you asked for, and then continued to
ask for sort of building on a case-by-case basis. But instead it was, it was
sort of all kind of all or nothing, but, you know,
it was going to be all of something because the people who were driving the bus were saying, this has to take place with a lot of mixed
metaphors in there, so. (laughing) - Yes, we absolutely, our lying was we have no choice in this matter. We have to go to fee for service. What's interesting is that currently, remember that letter was 2010, you know we're now, when was this all started? It was seven years later. We noticed that Medicaid started shifting back to what they're calling event rates. And we were thinking, you know, are we gonna un-bundle
just to have them tell us to go back and re-bundle? And we talked with our
Medicaid folks about this. A rate setter folks in particular. And they said, we don't have the data
to create an event rate because you've never done fee for service since Part C started. So we have to do fee for
service for several years before we're even going
to have a conversation about event rates. But yes, eventually down the line we could look at event rates. So right now we were able to convince them that an evaluation is an event and they paid for the
eligibility evaluation. But as far as trying to
come up with an event rate for an early intervention, monthly type fee we have to collect this micro fee for service data first. And absolutely we had no choice. - And that's so variable. That is so (indistinct) of the issues that a child would be presenting with of quote unquote, how many sub events are taking place within a given month. - Yeah, and we just had no, no data. I mean, even when it came to rate setting, our Department of Social Services looked to us for a year's
worth of service delivery data. Actually they needed two full years worth of service delivery data. And they used that for rate setting. They tried doing a cost report but they all came in different and it wasn't clean or good data. So instead they ended up using our utilization
data to set the rates. - And I know you're
recognized across the parts of the world is around
your expertise around data. Is there anything you would want to say other to the individual
States that are applying for this activity or more
directed to the entire community about what people need to be collecting should they want to try to
either do a state plan amendment or access Medicaid? What do people really need to be paying attention to data wise? - You know, that's like when
you're swimming in the ocean and someone wants to ask you
a question about the fish. It's like, ah, so you
know, to me it seems like, well of course anybody would
want to be able to know how many hours of service are in an IFSP for any
given child Medicaid commercial diagnosis codes, all of the things that we look to for representativeness equity. Absolutely, but you can't
just stop at the IFSP the have to take it that next step into, okay, so what's actually happening. And then you have to be
able to compare the two and say did what was planned get provided and was the argument
that we were able to make that roughly about 65 to 75% of what was planned got
delivered that pushed this along? Interestingly, since we
went to fee for service that rate went up because if they don't
provide the services, they don't get paid. So, it's kind of interesting. - And it clearly does
have implications relative to productivity expectations. I would assume. - Absolutely, you know,
particularly, even right now during the COVID public health emergency, our providers going into
this realized very quickly that if they don't provide
some kind of visit, they don't get paid at all. So we were very quick to work with our Medicaid lead agency again and get, they're called
provider bulletins. But also we amended our procedure to allow for remote early
intervention to bill Medicaid the same way as in-person does. And that helped to keep
the programs afloat because it is just another way of providing EPSDT early
intervention services. So actually I think had we
not gone to fee for service this might've even been harder but the utilization is very
important to the programs. Let me shift gears a
little bit here and ask you coming out of this in terms
of both the process of the how and then the execution of
the, I guess of the what. What has the implication been for your private insurance billing or participation in the program? - Well, previously the billing
of Medicaid and the billing of commercial insurance were
two totally separate processes. Even when we had a billing contractor, he only did third-party. His company only did third-party
commercial insurance. Our department of administrative services was who billed Medicaid on our behalf when we had a bundled rate. This shift helped us to find a contractor through an RFP process that
was able to do both pieces. So the process is exactly the same regardless of which third-party
payer is being billed. And that also allows
us greater efficiencies and it took some of the
weight off of the programs. And we now have this
combined data, you know before trying to report on utilization or Medicaid payments under
a bundled rate through DAS as opposed to the commercial
insurance, it was just a mess. Now it's nice and tidy. We also got them to
pick up our family cost participation fee administration, which was yet another
thing that the lead agency had been doing. But as we've lost staff,
we contracted it out. And really now all of that is under one
house, it's really helpful. - And have you seen increases on your private insurance side? - Not really, you know. - Let me rephrase the question, have you seen changes in
your private insurance side, pre pre COVID as opposed to during the
current period that we're in? - You know, I'm not sure that we've had enough
time go by to actually compare COVID to pre COVID
when it comes to that because it took a little, you know a month or two for services to get up. We saw a huge drop in referrals and a huge drop in utilization
because remember 50% of our state part C funds
go to supporting children and families when the child has
an autism spectrum disorder. And they're not sitting
in front of laptops for 10 hours a week. So they saw the biggest decline. Anyway, then the claims go
out to the third party payers and with the exception of Medicaid who has their two week cycle which is very nice, the commercial
payers are taking longer and we had to get an executive order to extend it beyond three cause we started doing that. I think after a couple of more
months then the summer came. So it'll be really interesting
to see the difference separating it out from the
overall drop in services. You know, we don't really look to our commercial insurance for much. I think it was our insurance
commission who told us that about 97% of the families
in Connecticut are insured by self-funded plans,
which means they're not required to follow the state statute. So if they are paying for
it, they're doing it because it's what's right for
their clients, I guess. But it's not like they're required to. So, we're still tackling that. We're going to start with the autism and then move on from there. - I think an awful
(indistinct) is also directly towards the employer who
is making the decision to self-insure and essentially saying to their clients, meaning
the agent, the lead agencies at the program level, you know,
you don't have to do this. And I think that's an ongoing challenge with across the country for any early intervention
system is you're, you know sometimes you're not sure who it is we're trying to organize this around. And I'm hesitant to say against, but with because someone may not just
simply not want to do it or an insurer might be someone in the insurance plan itself who has kids in the eye and really
benefit from it and likes it. But that becomes its own challenge. So we're getting, we're not
like super close to time but I guess I wanted to ask you if there are questions
that I have not asked you that you would like me to ask you to be able to sort of
more fully or round out the conversation if you feel that I haven't asked you
something that's important. - I think I would stress the importance of thinking through every piece of it before you take the first step
to the extent that you can. I mean, I mentioned the 1915 before waiver but that was massive because
had we not been able to do that or were that not even an option. I think we would have
fought it a little bit more because we would have
said we cannot open this up to any willing provider. But if you don't even know
that that's an issue to address then you don't know whether
or not to have the battle. We then, of course for the first couple of years
have to renew the waiver. The waiver has a legislative process. We had to explain it. They were mixing up the 1915 B4 waiver with the waiver that they may be asking for Medicaid managed care or other waivers like in adult DD ID services. So you end up just
asking a lot of questions trying to get as informed as you can but the minute you hear something
that doesn't sound right like, well of course, you know they can't bill for more
than one service per day. It's like, no, no, no, no, no, wait, wait we have to fix that because
they have to be able to bill for more than one service on one day. In fact, one practitioner
might need to go to the home have a conversation with mom, have mom raise up something that she would like to
talk about with dad. The practitioner leaves
goes home, eats dinner and comes back that evening
to have a conversation with dad and to show dad
some of the activities or hear from dad what
he wants to focus on. And that has to be billable. And the other thing I think was critical was the role of our ICC and
our providers in advocating. Once they got off the, we don't want to do this
train, there was the, okay if we're going to do it we're gonna do it right approach. And so they testified
at the public hearings and because of the two ICC members that are also providers who testified at DSS's public hearings
about the state plan amendment we got joint visits covered but we also got transition
conferences and attending PPTs which is our version of
a IEP meeting covered. And it all came down to how we defined what an
early intervention visit was. And those little things
make a big difference as you move along. - So this is my last question
that I would want to ask is, it's (indistinct). One is, how long have you been in the implementation stage of this? And two, I think you've
partially answered this just now is what has the relationship
with the provider community, how has that evolved given what the sort of opposition to it in the beginning? - Okay, so when this whole
thing was supposed to start it was supposed to be April of 2017. Well, that didn't happen. And it was July of 17, then
it was September, October. It ended up being November of 17. By the time we got the state
plan amendment approved by CMS and we got the vendor contracted with the state and we
got the data systems. I have to tell you, that's another piece of this that I absolutely
didn't anticipate. We've got one, two, three four different data systems
in four different entities. So the birth to three data system, the private contractor
billing data system, the MMIS data system interface and change healthcare which
is the healthcare exchange that our third party biller uses. One little data glitch in any of those can cause a whole batch of claims to deny. So really the first, probably
six months was just testing and testing and testing. But then on November 1st, we switched and it wasn't until April of 18 that the programs could
actually see their billing data in the third-party billing
vendors data system because of a glitch on our end. And it was an absolute nightmare. So I remember Maureen Greer saying, "you need to have a
least a six to nine month pool of funds available to
push out to the programs before this shift happens as cash advances just to tide them over." And boy did we need that? We also got our Medicaid lead
agency to do the same thing. They put forward cash advances and then withheld 20% from each payment once the or per month, once
the billing actually started. But the data systems were
amazingly complicated. We didn't, we had a developer who was not in the right country. You know, I mean he just literally he wasn't in the right field. So anyway, after the data started flowing that was now April, 2018. It still took a while for
the programs to get used to looking at their own data, running their own reports, understanding, many of
them had to hire people specifically for working claims. They didn't even really know
what working claims meant. So they had to hire
specific people to do this. We had early adopters
are doing much better. Our larger agencies who
maybe are doing this for other lines of
work, doing much better. That's still took a while. And every time there was a bug or a glitch or a payment or
an overpayment and a take back it just ended up continuing to be messy. Throw into this, we were required to do
a request for proposals to open up the procurement
of birth to three because we had not done
so in about six years. And we were able to convince
our office of policy management that now is not the right time for this RFP. We don't even know how
we're paying programs or if we're paying programs let alone how they're going
to get paid once this is done. So that delayed us even further. We finally did the RFP. It went out to the public
in December of 2019. And prior to, no actually it was
published in October of 19. So prior to that RFP being published, one of the things that the
programs kept saying is this fee for service model
is going to make through, so you don't have enough programs and nobody's gonna apply to be a provider and families are gonna have to wait. When in fact every single program that
was providing services in September applied to
provide services in October. So we thought that was a statement. The fact that the transition
had been successful. And then as a result of the RFP we actually went from about
27, 28 programs down to 19. And we're just seeing
greater efficiencies, bigger programs managing it. And even through COVID some are having a hard time, but at most, a lot of
the programs are like, no, actually we're fine. So the relationships are with the ones who are going to be with us longterm are fine.
