TEXAS DSRIP COMPLIANCE MONITORINGPresented by Myers and Stauffer LC

Tamara Hunter, MBA, CGAPAlisha Larson Gallmeier, MPAMay 7, 2018

AGENDA

DY7 GUIDANCE

FOR PROVIDERS: KEY ISSUES & OTHER CONSIDERATIONSABOUT MYERS AND STAUFFER LC

MSLC TEXAS DSRIP MONITORING2

3

4

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About Myers and Stauffer

Office Locations and Contracts

18 Offices Nationwide

Over 800 employees

Contracts in 49 states and with Federal Government

FULL-SPECTRUM PARTNER

AUDIT

CONSULTING

RATE SETTING

PROGRAM INTEGRITY

AUDIT AND ACCOUNTING PROFESSIONALS

PHYSICIANS AND NURSING PROFESSIONALS

HEALTHCARE ADMINISTRATION PROFESSIONALSCERTIFIED PROFESSIONAL CODERS

HEALTH INFORMATION MANAGEMENT PROFESSIONALS

ABOUT MYERS AND STAUFFERWHO WE ARE

HEALTHCARE POLICY EXPERTS

Texas DSRIP Compliance Monitoring

TEXAS ADMINISTRATIVE CODE

15 TAC §354.1602 (11) Independent assessor--An entity contracted with HHSC to provide assistance with the mid-point assessment and

ongoing compliance monitoring.

15 TAC §354.1624 (a) Mid-Point Assessment - An independent assessor will initiate a mid-point assessment of DSRIP projects prior to the

fourth demonstration year, consistent with the requirements of the PFM Protocol.

(b) Compliance Monitoring – Independent assessor will continually monitor DSRIP projects and may:

• Make recommendations regarding DSRIP project values

• Provide recommendations regarding use of achievement target that varies from the standard methodology

• Provide secondary review of reduction in project scope through plan modification

ROLE OF THE INDEPENDENT ASSESSOR

15 TAC §354.1703 Independent Assessor continually monitors DSRIP performers in DY7-DY8• Plan updates are subject to potential audits

• DSRIP performers must have supporting data and back-up documentation available for review upon request

• Failure to provide, in a timely manner, supporting documentation that demonstrates performance may result in recoupment or withholding of

future payments

AUG 2014

OCT 2014

APR 2015

MAY 2015

JAN 2016

JUN 2016

SEP 2016 2017 SPRING

2018

CAT 3 PERFORMANCEREVIEWS START

CATEGORY 4 REPORT

CAT B & C DATA SUPPORTGUIDANCE

MID-POINT ASSESSMENT BEGINS• Review of project metric status

and risk; site visits

• Plan modification reviews and project valuation

MID-POINT ASSESSMENT REPORT

OVERVIEW OF MSLC TEXAS DSRIP ACTIVITIES

CAT 3 BASELINEREVIEW STARTS

CAT 1&2 VALIDATIONSTARTS

DESK REVIEW OF DY3

SUMMER 2018

UPCOMING MSLC DSRIP ACTIVITIESDY7-DY8

CAT C BASELINE REVIEW CAT C DY7ACHIEVEMENT REVIEW

CAT B & C DATA SUPPORT GUIDANCE

CAT 1&2 and CAT 3 DY6 REVIEWS

FALL 2018 WINTER & SPRING 2019

SUMMER 2019

MAY 2018 WINTER & SPRING 2020

FINISH DY6 REVIEWS

CAT B AND C FLAGGED REVIEWS

TEXAS DSRIP MONITORING PROCESSOBJECTIVES

ACCURACY

• To verify that the provider’s reported information is supported by back-up documentation.

COMPLIANCE

• To determine if the reported information is in compliance with the approved specifications.

CONSISTENCY

• To ensure that no variances exist among measurement periods unless approved by HHSC.

GOAL ACHIEVEMENT

• To determine if any revised performance meets the target goal.

TEXAS DSRIP MONITORING PROCESSWORKFLOW PROCESS

PROVIDER NOTIFICATION OF

REVIEW

REQUEST FOR SUPPORTING DATA

AND DOCUMENTATION

PRELIMINARY REVIEW OF DATA

REQUEST FOR ADDITIONAL

INFORMATION OR CLARIFICATION &

FOLLOW-UP

MSLC ANALYSIS OF DATA AND ADDITIONAL

INFORMATION. FOLLOW UP FOR ADDITIONAL INFO

IF NEEDED.

1) SUBMISSION OF CORRECTIVE

ACTION PLAN (CAP)2) IF NO CAP,

SUBMISSION OF PRELIMINARY RESULTS TO PROVIDER

MSLC REVIEW OF CORRECTED DATA

REPORTING OF FINAL RESULTS TO

HHSC AND PROVIDERS

For Providers:Key Issues & Considerations

DATA RETENTIONEXTREMELY IMPORTANT TO KEEP INFORMATION THROUGHOUT THE MEASUREMENT AND REPORTING PROCESS

Providers should be able to show documentation that supports the reported information and measure specifications, including:

• All data fields required by the measure and support guide

• Any formulas and source data for calculations

• Query language or screenshots of system query

• Data dictionary for codes, such as payer

• Vendor reports and data submitted to or accessed by vendors

DATA RETENTION EXAMPLEFORMULAS AND CALCULATIONS

CALCULATION OF TIME FROM ADMIT DECISION TO ED DEPARTURE

CALCULATION OF MEDIAN DECISION TIME

DATA RETENTION EXAMPLESCREENSHOT OF QUERY TO

SUPPORT A DATA FIELD

HbA1c Test Date Range

HbA1c Test Results for each patient

DATA RETENTION EXAMPLEDATA DICTIONARY – PAYER

CODES

DATA RETENTION EXAMPLEVENDOR REPORT

NAME OF VENDOR

NAME OF FACILITY

TABLE OF ALL VALUES (NUMERATOR & DENOMINATOR) AND FINAL RATES

DATE OF REPORT

VENDOR REPORT

A CHANGE IN THE ELIGIBLE POPULATION CHANGES THE FINAL RATE…

DATA RETENTIONINFORMATION IN E.H.R. SYSTEMS MAY

CHANGE, SO RETAIN DATA IN REAL TIME, OTHERWISE…

…WHICH COULD ALSO CHANGE THE FINAL ACHIEVEMENT

DON’T WAIT FOR AN MSLC REQUEST

TO GATHER DOCUMENTATION!

INTENT OF THE MEASUREIT’S EASY TO GET BOGGED DOWN IN DATA AND DETAILS, BUT REMEMBER THE BIG PICTURE

When determining the data needed to support the measure or when unsure about measure interpretation, always remember the intent of the measure.

What is this measure trying to accomplish?EXAMPLE 1: 30 day Risk-Adjusted Readmissions –

Measurement of Index Admissions and Readmissions can’t end on the same day…index admission needs at least 30 days to allow for measurement of a POTENTIAL readmission.

EXAMPLE 2: Depression Remission at 12 months –

Follow-up PHQ-9 must occur at 12 months. It is possible for earlier remission, but the patient could relapse. The intent is to show that the patient is still in remission at 12 months.

SYSTEM LIMITATIONSWHAT TO DO IF DATA ELEMENTS ARE NOT AVAILABLE OR NOT PART OF A QUERY

Consider alternate approaches for supporting and providing documentation of a data field.

EXAMPLE: If a provider must complete a manual review for a data element that cannot be queried, retain copies of the data and maintain a description of the process undertaken.

REPORTING & DATA SUBMISSIONMAKE QUALITY CONTROL PART OF THE PROCESS

DATA SUBMISSIONPROVIDER CHECKLIST

PROVIDER CHECKLIST YES NO

ALL DATA FIELDS ARE PRESENT

DATA FIELDS HAVE A VALID ENTRY

DATES DO NOT CONTAIN LETTERS

TEST FIELDS HAVE BEEN REMOVED

NUMERATOR AND DENOMINATOR PATIENTS/ENCOUNTERS ARE INDICATED

CORRECT UNIT OF MEASURE HAS BEEN USED & DUPLICATES REMOVED

(PATIENT IDs vs ENCOUNTER IDs)

DATA SUBMISSIONREQUIRED DATA FIELDS

Select Bundle Select Measure IDBundleA2 509

Rate of ED utilization for CHF, Angina, and Hypertension

Bundle DescriptionImproved Chronic Disease Management: Heart Disease

Measure NameReduce Rate of Emergency Department visits for CHF, Angina, and Hypertension

Measure Description

MSLC Requested Data FieldsDenominator Numerator

Bundle A2 Target Population* a) Unique Encounter Identifierb) Unique Patient Identifierc) Date of Birthd) Encounter Datee) Diagnosis Code for Heart Failure and pulmonary edema, Hypertension, or Anginaf) ICD-10-PCS Procedure Codesg) Payer for all encounters

DATA SUBMISSIONEXAMPLE – WHAT NOT TO SUBMIT

a) Unique Encounter Identifier

b) Unique Patient Identifier

c) Date of Birth d) Encounter Date

e) Diagnosis Code for Heart Failure and

pulmonary edema, Hypertension, or

Angina

f) ICD-10-PCS Procedure Codes

g) PayerFlag for Numerator

Inclusion

1 1001 1/1/2017 Medicaid2 1002 1/2/2017 I10 4A02X4A Medicaid3 1003 1/3/2017 I10 N/A Medicaid4 1004 1/4/2017 I50.9 N/A Medicaid5 1005 1/5/2017 I10 N/A Medicaid6 1006 1/6/20177 1007 2/31/2017 Medicaid8 1008 3/9/2017 Medicaid9 1009 3/10/2017 I10 N/A Medicaid

10 1010 3/13/2017 Medicaid11 1011 3/14/2017 Medicaid12 1012 5/6/2017 I50.9 4A02XCZ Medicaid13 1013 5//2017 I10 N/A Medicaid14 1014 5/9/2017 I10 N/A Medicaid15 1015 5/10/2017 Medicaid16 1016 6/1/2017 Medicaid16 1016 6/1/2017 Medicaid18 1018 8/1/2017 Medicaid19 1019 9/10/2017 Medicaid20 1020 9/111/2017 N/A Medicaid21 1021 9/12/2017 I10 4A02XPZ 22 1022 9/13/2017 I50.9 N/A Medicaid23 1023 10/1/2017 I10 N/A Medicaid24 1024 11/15/2017 Medicaid25 1025 12/31/2017 Medicaid

Duplicate Visits

Invalid Date

Invalid Date

Invalid Date

Missing Data Field

Blank Cell

Blank Cell

No Indication of Encounters in the Numerator

DATA SUBMISSIONEXAMPLE – THE RIGHT WAY!

a) Unique Encounter Identifier

b) Unique Patient Identifier

c) Date of Birth d) Encounter Date

e) Diagnosis Code for Heart Failure and

pulmonary edema, Hypertension, or

Angina

f) ICD-10-PCS Procedure Codes

g) PayerFlag for Numerator

Inclusion

1 1001 1/1/1960 1/1/2017 Medicaid 02 1002 1/1/1961 1/2/2017 I10 4A02X4A Medicaid 13 1003 1/1/1962 1/3/2017 I10 N/A Medicaid 14 1004 1/1/1963 1/4/2017 I50.9 N/A Medicaid 15 1005 1/1/1964 1/5/2017 I10 N/A Medicaid 16 1006 1/1/1965 1/6/2017 Medicaid 07 1007 1/1/1966 3/8/2017 Medicaid 08 1008 1/1/1967 3/9/2017 Medicaid 09 1009 1/1/1968 3/10/2017 I10 N/A Medicaid 1

10 1010 1/1/1969 3/13/2017 Medicaid 011 1011 1/1/1970 3/14/2017 Medicaid 012 1012 1/1/1971 5/6/2017 I50.9 4A02XCZ Medicaid 113 1013 1/1/1972 5/8/2017 I10 N/A Medicaid 114 1014 1/1/1973 5/9/2017 I10 N/A Medicaid 115 1015 1/1/1974 5/10/2017 Medicaid 016 1016 1/1/1975 6/1/2017 Medicaid 017 1017 1/1/1976 7/1/2017 Medicaid 018 1018 1/1/1977 8/1/2017 Medicaid 019 1019 1/1/1978 9/10/2017 Medicaid 020 1020 1/1/1979 9/11/2017 I10 N/A Medicaid 121 1021 1/1/1980 9/12/2017 I10 4A02XPZ Medicaid 122 1022 1/1/1981 9/13/2017 I50.9 N/A Medicaid 123 1023 1/1/1982 10/1/2017 I10 N/A Medicaid 1

DATA RETENTION AND SUBMISSIONHOW IT ALL FITS TOGETHER TO ACHIEVE A FINAL SUPPORTED RATE

MEANINGFUL DATA

Does the data support the intent of the measure and

the final rate?

DATA VALIDITY

Is the data free from erroneous entries?

COMPLETENESSOF DATA

Are all the required data fields filled in?

MSLC Prepared DY7 Guidance

CATEGORY C

List of data elements for each measure that

providers should retain when calculating the

rate. There is also additional guidance

regarding situations in which the specific data

element is not available.

DATA SUPPORT GUIDERISK-ADJUSTING

Guidance regarding measure calculation,

methodology, normative values, and data

sources (vendor, indirect standardization, etc.)

Calculation template provides a simple way for

providers to calculate the final observed and

expected rates using the HHSC-approved

methodology.

GUIDANCE & RATE CALCULATION TEMPLATECATEGORY B

Guidance for providers on the type of

documentation to retain while determining the

DSRIP attributed population.

SYSTEM DEFINITION GUIDE

DY7 GUIDANCE DOCUMENTS

SYSTEM DEFINITION GUIDECONTENT AND USER INFO

SELECTION BY PROVIDER TYPE

REQUIRED COMPONENTS

OPTIONAL COMPONENTS

DATA FIELDS TO RETAIN AND THE PURPOSE OF EACH FIELD

ADDITIONAL NOTES AND RECOMMENDED FORMATS

GUIDANCE FOR DATA RETENTION

CATEGORY C DATA SUPPORT GUIDECONTENT AND USER INFO

BUNDLE/MEASURE SELECTION

MEASURE DESCRIPTION

DENOMINATOR DATA FIELDSLIST OF DATA FIELDS REQUIRED FOR THE MEASURE DENOMINATOR. IF THE DENOMINATOR IS THE BUNDLE TARGET POPULATION, THOSE FIELDS ARE ALSO LISTED.

NUMERATOR DATA FIELDSLIST OF DATA FIELDS REQUIRED FOR THE MEASURE NUMERATOR.

BUNDLE SUPPORT TOOLLISTS DATA FIELDS TO MAINTAIN FOR THE BUNDLE TARGET POPULATIONS.

ALTERNATIVE DATA SOURCES & RECOMMENDED FORMATADDITIONAL GUIDANCE AND EXAMPLES IF A DATA FIELD IS NOT AVAILABLE. SUGGESTIONS ONLY - NOT A COMPLETE LIST.

RISK-ADJUSTING GUIDANCECONTENT AND USER INFO

OVERVIEW OF RISK-ADJUSTED MEASURES

DESCRIPTION OF DATA SOURCES AND METHODOLOGY

RECORDKEEPING GUIDANCE

GUIDANCE ON THE USE OF INDIRECT STANDARDIZATIONINCLUDING USE OF TEXAS PPR MEDICAID NORMS AND PROVIDER-LEVEL HISTORICAL DATA

RISK-ADJUSTED MEASURE TEMPLATETO ASSIST IN THE CALCULATION OF THE OBSERVED AND EXPECTED RATES

Q&A

www.mslc.com

11044 Research Blvd.Suite C-500Austin, TX 78759

512.342.0800855.252.3177

CONTACT USTamara Hunter, Senior Manager

thunter@mslc.com

Alisha Gallmeier, Manager agallmeier@mslc.com