Managed Long Term Care-MEDS Readiness Reviews

Tom LoGalbo
Managed Care
IPRO
November 13, 2013

MEDS Readiness Reviews

  • Why?
    • Encounter data submitted via MEDS is used by the NYSDOH for a variety of purposes and activities including:
      • Risk adjustment rate payment methodology
      • Service utilization monitoring
      • Fraud and abuse monitoring
      • Disease identification and monitoring
    • The MLTC program has been steadily expanding, across the various plan types.
      • A number of new MLTC plans have either recently commenced operations and have not yet submitted MEDS data, or have very recently started MEDS reporting.
    • Therefore:
      • IPRO, in conjunction with the DOH, developed a readiness review project for the MLTC plans, to address the components, steps, and corporate infrastructure considered necessary for comprehensive and accurate MEDS reporting.
      • The principal component of the project was a survey, administered to a sample of new MLTC plans, and to those plans experiencing problems with MEDS submissions.
  • Survey components
    • The survey included components on the following topics:
      • Claims/encounter processing
      • Claims/encounter lag time
      • A breakout of services and how each are provided (internally or through vendors/subcontractors)
      • Mapping/conversion process to insure proper mapping to MEDS specifications (where necessary and if applicable)
      • Process for insuring that all pertinent data is uploaded to the MEDS system
  • Claims/Encounter Processing
    • The survey addressed questions regarding:
      • Process for tracking service authorizations
      • Process for reconciling service authorizations to claims/encounters
      • Claims "time to process" results
      • Average claims/encounter lag time
      • Claims/encounter data completeness studies
  • MEDS Data Capture
    • The survey addressed the services specified in the MEDS MLTC Reporting Guide, and for each, asked for plans' responses to the following:
      1. Service coverage (yes/no)
      2. How is the service provided (e.g. internally, vendor)
      3. How documented (e.g. claim, encounter, internal log)
      4. How invoiced (e.g. hours, visits)
      5. Are Category of Service codes, Provider Specialty Codes, Procedure Codes captured for MEDS reporting?
  • MEDS Reporting Process
    • The survey addressed the following related to the MEDS reporting process:
      1. The number of staff members involved in the process
      2. Staff´s level of familiarity with the MEDS reporting requirements and the MEDS MLTC reporting guide
      3. Software utilized in the process
      4. The role of subcontractors/vendors (if applicable)
      5. Is the process different for each of the managed long term care reporting lines?
    • The survey also addressed:
      1. Letters /notifications from the NYSDOH regarding encounter data reporting issues
      2. Problems/concerns with MEDS submissions
  • Summary of Findings
    • Internal Systems
      1. All of the plans had established processes in place for tracking service authorizations and reconciling authorizations to claims
      2. Almost all of the surveyed plans were able to provide time to process (TTP) results for claims and encounters. Average TTP was calculated to be approximately 25 days from receipt of claim/encounter.
      3. Most of the plans were able to provide claims/encounter lag results. Average lag was calculated to be 40-45 days from service date.
      4. Several of the newer plans were unable to provide claims lag calculations.
      5. Almost all of the surveyed plans indicated that claims quality audits are conducted.
        • Audit results were generally favorable
    • MEDS Data Capture, MEDS Reporting
      1. Some plans commented on specific provider issues (e.g. not reporting with national standard billing codes, not submitting DOH compliant reporting codes)
      2. Smaller plans expressed concerns with MEDS data to the level of detail necessary to fulfill required reporting requirements
      3. Plans expressed challenges with capturing third party vendor data (e.g. vision, dental, pharmacy) in a way that can be reported for MEDS
      4. Newer plans expressed the need for assistance in interpreting and understanding the response files generated from MEDS submissions
      5. IPRO and the DOH observed that a number of plans were not aware of the DOH generated validation reports, or, were not reviewing these reports on a regular basis.

For more information

Tom LoGalbo
(516) 326-7767 ext. 349
tlogalbo@ipro.org

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