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Targeted Medicaid Assessment
The following information is presented for the purpose of identifying gains made, to date, in the implementation of the strategies generated in the Targeted Medicaid Assessment Report. Please be advised that while this initial presentation reflects the implementation of many of the recommendations, however, it is anticipated that the results will be easier quantified in a year to year comparison of Medicaid activity.
Finding #1. Standardizing of Team Practices
The recommendation in this area references the inconsistence with case processing between supervisory staff, and identifies an opportunity for improvement in consistent application of practices.
To advance this recommendation, the supervisory team has taken the opportunity to review intake and recertification processes, as well as those processes for resource recovery activity. Attempts have been made to identify those areas where differences in interpretation governed activity. Specific attention has been paid to the processing of cases with disability income, as suggested in the recommendations.
The following activities are directly attributed to this finding:
- The 2003 Social Security Mass-Rebudgeting was also completed in standardized format this year. Information was electronically gathered from the Social Security Administration and provided to staff for the purpose of identifying changes in benefit levels. As a result of this unified process, all Medicaid cases were re-computed without the need to incur overtime for Medicaid staff.
- Review of the cases where disability income and wages are reported, to assure income is correctly determined and accounted for.
- The local burial process is currently under review to resolve discrepant payment patterns, and eliminate potential overpayments for services.
To date at least one case, that of a client in receipt of disability assistance has been re-reviewed for eligibility determination. The result has been case closure and a resource recovery referral for $2400.00.
It should be noted that trends in case applications continue to increase slightly. A sample period in 2002 identified an average number of 128 Medicaid applications filed per month. That number has increased to 130 applications filed in the current year. Action taken on those applications supports the appliance of Altreya recommendations. Currently, roughly 20% of applications filed resulted in a denial of benefits, as compared to 17% prior to the study. In addition, the number of closings at recertification has increased from an average of fourteen cases per month to nineteen cases per month.
While the implementation of the recommendations included in the report will have little impact on the increasing availability of State mandated programs, or the trends in the community that dictate the need for Medicaid, the Department is committed to applying those recommendations identified to force denials or closings for cases as appropriate.
Finding #2. Centralization of Regulation Interpretation:
This finding references the manner in which regulations are interpreted, and information specific to the implementation of regulations is provided to staff.
Staff has been linked with electronic files for regulations and state communications. With the onset of 2004, each communication is tagged with a brief summary identifying local impact/application, and maintained for individual reference. Team meeting have been conducted to review the communication reviewed. Time has been made available at full staff meetings to address the impact of the regulations.
This process was successfully utilized with the 2004 MRB case activity. The directive administered by the state was disseminated in the above reference manner, and a follow-up meeting was held. As a result, the MRB was uniformly conducted across all programs, including chronic care.
Finding #3 Measure for Desired Performance
This finding addresses the ability of the Department to identify, track and predict trends in Medicaid case loads.
The following activity supports the advancement of this finding:
- Supervisory staff has participated in training for the developed EMEDNY. Intake and undercare supervisors review participation on a monthly basis in order to identify trends in participation, and identify areas of opportunity.
- Supervisory staff represents the agency at the State-wide Medicaid forum in order to become aware early on of changes in the Medicaid program, allowing the opportunity to anticipate local impact and plan for effective implementation.
- Cases with excessive payment histories are reviewed for category appropriateness and the possible need for provider or pharmacy restriction.
To date one new case has been restricted for both provider and pharmacy services.
Finding #4 Leveraging and Optimizing the Organization:
This finding addresses the effective use of staffing patterns, and appropriate delegation of assignments within the department.
Following the completion of the Targeted Medicaid Assessment Report, this department had realized turnover in two very necessary clerical positions. While vacant, the department drew from additional clerical resources, in an attempt to not pull examining staff from their case responsibilities. The Department is once again at full staff, and anticipates to be very shortly functioning at full operational capacity.
In the interim, the department has acted upon the following recommendations associated with this finding, including:
- Eliminating the requirement that all staff participate in Medicaid Technical Assistance Group conference calls
- Increase efficiency in those tasks related to document preparation and receipt
- Purging of files as appropriate, to eliminate the time burden associated with file retrieval
- Re-emphasis on obtaining of clearance information necessary to support case determination
- Assignment of DMV inquiries to clerical staff in order to expedited identification of possible resources
The application of this finding has resulted in the identification of financial institution accounts that could be identified as a resource. The resulting adverse action taking on that case is currently pending fair hearing
Finding #5 Intensify Intake/Eligibility Interviews:
This finding addressed the process we employ to render eligibility determinations, interviewing to determine eligible rather than identify opportunities to render adverse decisions.
The supervisory staff has targeted key areas of the interview and recertification process to provide opportunities to challenge eligibility. Those areas include available spousal support, cost effectiveness, and the appropriate category assignment.
To date, the following actions can be attributed to this finding:
- Four referrals to the legal department to challenge reported lack of spousal support. Greater than $300,00.00 combined resources had been identified. At least one denial has been challenged in a fair hearing, no decision has yet been rendered.
- The review of cost effectiveness for TPHI payment has resulted in a $700.00/month savings for one case. The district has been covering private insurance at over 800.00/month. (An annual savings of $8400.00)
- Identification of possible third party health insurance for minors with absent parents. The department has strengthened cooperation with Support Collection and has established a means of communicating with SCU at each client eligibility contact.
- Inclusion of facilitated enrollers at staff meetings to increase awareness of comprehensive interview techniques.
Finding #6.Tighten Screen for Out of District/State Residency:
This finding speaks to the nature is which we question the residency of applicants for assistance.
Supervisory staff has reviewed possible indicators of alternate residency with staff. A review of the residency regulations has been conducted.
To further support correct determinations, collateral inquiry documents have been revised to include verification of permanent addresses on file with employers, educational institutions and others.
As a result one case has been denied due to non-residency. The client has requested a fair hearing. The resulting cost avoidance is approximately $8000.00 this year. A second case remains undetermined pending further investigation.
Finding #7. Tighten Screen for Self-Employed and Not Claiming Income:
This finding speaks to the need to identify, deny or close cases for applicants who fail to report income.
The Department has taken aggressive steps to identify and utilize all tools available to advance this finding. This does include the review of lines of credit, advanced payments on annuities, and the income tax forms filed by the applicant in addition to the review of self-employment worksheets. This process has been implemented for all new interviews, and will be completed at recertification for existing undercare cases.
The aggressive investigation of self employment has resulted in the closing of one case, with an anticipated savings of approximately $8,000.00 annually.
Finding #8. Make the Front End Detection System more Systematic:
This finding identifies the need for targeted referrals to the Resource Recovery Unit, eliminating the inclusion of random application investigation.
Random FEDS referrals were eliminated in mid-2003. As a result, the Department has realized a timely resolution of targeted referrals.
The result of the implementation of targeted referrals has been a Medicaid cost avoidance of $4000.00
Finding #9. Advancing the Timing of Recertification Process
This finding suggests the financial saving possible for re-evaluating eligibility one month in advance of the State-generated recertification interview.
Beginning in January 2004, recertification interviews were scheduled one month earlier. The savings from this finding have yet to be calculated.
Finding #10. Lower the County-Operated Transportation Costs
This finding addresses the need for the County to identify and implement the most cost effective transportation system. The finding suggested expansion of the existing system to take advantage of economy of scale principles, or contract out full delivery of services.
The County has taken aggressive steps to establish a county-wide public transportation system. This is recognized as the most cost effective means of meeting obligations with regards to the Medicaid population as well as meeting the needs of the general citizenry. Negotiations have been successful with the Rochester Genesee Regional Transit Authority, and the system will be operational by year’s end.
In the interim, the Division of Human Services has taken steps to streamline the delivery of Medicaid transportation services.
To date, the findings have been implemented as follows:
- Reduction in driver transport hours from an average of 188 per week prior to the report to an average of 134.25 hours per week since implementation.
- Reduction in the average transport time from 3.4 hours to 2.9 hours. This has been accomplished by minimizing idle wait time, and coordinating trips to common destinations.
- The savings realized to date in the provision of transportation services total $8243.00.
Finding #11 Tighten County-Operated Transportation Approvals:
This finding addresses the need to review requests for County provided transportation for appropriateness.
The following steps have been implemented to assure the appropriateness of transports:
- Limit prior approval for long term transports to six months or through the coverage authorization date, which ever is shorter
- Review of long distance transportation requests to determine that services are not available within our general medical market area
- Review of transportation request to client application, to determine that client owned means of transportation are not available
Finding #12 Reduce Transportation Service Levels to the Appropriate Level:
This finding addresses the minimum level of transport provided based on client diagnosis.
Prior approval staff has put in place a process to review transportation requests to define the minimum level of transport. This does include requesting doctor verification if necessary, and the identification of lower level transports where appropriate.
To date, staff has been successful in linking local transports with existing agency trips. In addition, we have begun to review long term transport requests on a case by case basis for appropriateness.
The process of implementing the recommendations of the Targeted Medicaid Assessment Report has provided an opportunity to heighten the awareness of staff with regards to their role in providing a cost effective delivery of the Medicaid Program. The successes, thus far, are in many ways attributed to their diligent efforts in conducting comprehensive interviews, and their willingness to apply the recommendations provided in the Targeted Medicaid Assessment Report. As we continue to implement the suggestions of Altreya Consulting and to locally identify opportunities for improvement, the potential for increasingly quantifiable cost avoidance and savings is genuine.