Behavioral Health Claims Denial Root Cause Analysis Focused Surveys

• SOF also available in Portable Document Format (PDF)

Statement of Findings
Affinity Health Plan, Inc.
Behavioral Health Root Cause Analysis
December 1, 2017 – May 31, 2018
Survey ID# 1558031150

10.21 Mental Health Services
d) The Contractor shall reimburse any OMH licensed provider, including out of network providers, at Medicaid Fee for Service rates for 24 months from the effective date of the Behavioral Health Benefit Inclusion in each geographic service area for ambulatory mental health services provided to Enrollees.

Finding:

Based on the review of Plan-submitted monthly claims reports which demonstrated persistently high claim denials for behavioral health services (ACT, PROS, HCBS, Partial Hospitalization, and CPEP) over a period of six months from 12/1/17-5/31/18, as well as information contained in the subsequent August and December 2018 Root-Cause analysis submissions which were requested by New York State to explain the reasons for such high denial rates, the Plan failed to reimburse providers at Medicaid Fee for Service and/or APG rates for ambulatory behavioral health services due to a configuration error in their Behavioral Health vendor Beacon´s FlexCare claims platform which led to the inappropriate set-up of provider profiles.

Plan Response

As part of Beacon´s plan of correction, Beacon updated 536 provider fee schedules for all Diversionary Services. Beacon utilized the NY Office of Mental Health (OMH) "Government Rate Services Table" in conjunction with rates listed on the OMH "Medicaid Reimbursement Rates" to define established government rates for each of the diversionary services. Beacon cross-referenced contracted providers with the "Government Rates Service Table" to ensure that contracted providers had rates loaded for the sites and services listed on this table and the Beacon claims system will appropriately pay NYS mandated government rates for applicable behavioral health services without requiring manual intervention. Beacon also cross-referenced the rates with the "Medicaid Reimbursement Rates" page to ensure that rates matched for each timeframe. Rates were updated from 10/1/15 to current, including 1/1/19 rate increases. Beacon reviewed provider contracts to ensure that the correct contracted benefits were loaded to the provider profile. In addition, Beacon has updated its policies and procedures, including enhancing its testing, to ensure that any future NYS government rate update to mandated government rate changes is implemented timely. As of January 11, 2019, all Diversionary Services (ACT, PROS, HCBS, Partial Hospitalization, CPEP) have correct codes and rates for all providers.

The claims for the period in question of 12/1/17-5/31/18 have been reprocessed and paid. Diversionary claims have been paying correctly since 1/11/19. As part of the claims reprocessing, Beacon developed reconciliation reporting to track how many of the Diversionary Services claims had been remediated out of the original claims in question. Reprocessing for 100% of all the dollars in question for Diversionary Services is complete.

During the course of remediation activities from Dec 2018 through April 2019, Beacon implemented the State-directed Advanced Payment Program (APP) to fund providers who had claims concerns for Diversionary Services affected by inappropriate denials or payment with incorrect rates. Beacon was able to remediate and reprocess 100% of the Diversionary claims in scope for the APP. No advanced payments were required.

In order to ensure providers are reimbursed at the correct rates and as part of Affinity´s enhanced vendor oversight activities, an Affinity team with representatives from Vendor Oversight, Medical Management, and the Office of the Medical Director has been reviewing via webinar a weekly sample of denied claims which requires Beacon to demonstrate the claims have been adjudicated correctly by its claims adjudication system as per the provider profile set up. During this weekly sample review, Affinity is auditing the rates being paid and denial rationale applied to ensure proper adjudication of claims in accordance with the NYS Health and Recovery Plan (HARP) / Mainstream Behavioral Health Billing and Coding Manual and Affinity´s policies. This includes ensuring that claims for diversionary services are not denied due to the absence of a prior authorization.    The enhanced monitoring efforts adds an additional layer of oversight to ensure proper claim adjudication and will continue until Beacon can demonstrate a consistent level of 99% accuracy and for a minimum of 6 months.

The person responsible for this plan of correction is Lisa Mingione, VP- Chief Compliance Officer. The expected completion date of this plan of correction is December 31, 2019.