Best Practices in Medicaid - North Dakota

Consumer-directed care demonstrations (include number of beneficiaries served now and in any expansion plans)

The Center for Medicaid Services approved North Dakota’s request to implement Independence Plus Self-Directed Support waivers for children and adults with mental retardation and developmental disabilities effective April 1, 2006. Self-directed supports will give people with developmental disabilities and their families greater choice and control in making decisions and obtaining support, and allow them the option of directing a fixed amount of public dollars through an individual budget. The Self-Directed Supports waivers are based upon the belief that in order for eligible individuals with developmental disabilities and their families to fully participate in their community, they must define the life they seek and be supported as they direct a mixture of generic and formal supports that will help them achieve their personally defined outcomes.

Self-Directed Supports for Families

Self-Directed Supports for Adults

The Home & Community Based Services Medicaid Waiver for the Aged and Disabled, the Medicaid Waiver for the Traumatic Brain Injured, and the Medicaid State Plan Personal Care Services do not currently offer consumer (self) directed services.

The State of ND is pursuing the option of offering consumer directed services within the next Medicaid Waiver for the Aged and Disabled renewal.

Delivering high quality, coordinated, long term care for the disabled and/or the infirm

The following is taken from the Center for Medicaid Services final report of North Dakota’s Home and Community-Based Services Waiver for Individuals with Developmental Disabilities/Mental Retardation for the 5-year period

April 1, 1999 through March 31, 2004.

• North Dakota Department of Human Services, Medical Services Division (HCBS unit) has strengthened the audit process by incorporating additional questions during Case Management audits, client interviews, and provider reviews. Additional measures have been taken to gather input and feedback from consumers, provider groups, and advocates.
• Continue efforts to retain and recruit service providers by offering competitive rates and by working with the ND legislature to replace the current provider payment system.
• Frequently re-evaluating the HCBS quality assurance/quality improvement plan. Implementation of the Medicaid State Plan, Personal Care Service.

EXEMPLARY PRACTICES

The State of North Dakota has developed an effective quality enhancement process that ensures the health and welfare of the consumers who are served on this waiver. The Disability Services Division (DSD) team has implemented a system that holds each individual accountable for providing a safe environment for this vulnerable population. The State of North Dakota has evolved their quality assurance system into a system that is now a quality improvement/enhancement system. During our review CMS reviewers questioned the direct care staff regarding the State’s policies for abuse, neglect, exploitation, incident reports and medication errors. All of the staff interviewed was able to describe the system and their role in reporting these activities. The staff were aware of how important their role was in maintaining a safe environment and ensuring these vulnerable individuals have quality of life. Our review reflected an overall system that is operating effectively and efficiently in providing quality waiver services.

The State of North Dakota has set a standard for their providers that provide them with clear guidance and expectations from DSD. The providers who decide to provide services under this waiver understand their responsibilities to the DSD for ensuring the health and welfare of each consumer. The DSD understands how critical it is for these providers to report incidences of alleged abuse, neglect, exploitation and medication errors. The DSD requires providers to report all of these incidents but realizes incidents do occur. The DSD’s philosophy encourages the providers to report these incidents, thus discouraging underreporting.

The State has developed an incentive program for the providers regarding the training of their staff. The program benefits the provider and the employee as the employee has expectations for meeting their training requirements and can obtain more education with a monetary incentive available. The consumer ultimately benefits from having staff that understands how to meet their needs and encourage/provide support towards a life that is as independent as possible, which enhances their self-esteem.

In addition, the consumers on this waiver were very happy with their services. The consumers knew who their case managers were, had the people who were important in their lives at their yearly ISP meeting, were able to make choices, take risks and feel a part of the community. During our interviews the consumers praised their caregivers and individuals that assisted them at the day habilitation centers or in their jobs. The individuals who provided the services to the people on the waiver, knew each individual’s unique needs, knew how to communicate with them and assisted them in maintaining their independence and gaining new skills to live as independent as possible.

Overall, this waiver provides valuable services to each individual and reassures the family that their loved one is prospering in the community. The DSD’s team composition appears to work well for this waiver. The regional managers monitor the providers and provide training as needed. These managers provide the DSD central office with valuable feedback regarding the operational status of the waiver. The collaborative work between the DSD central office team, regional managers and case managers has provided an environment for this vulnerable population to be safe, have quality of life and live in the community.

Use of health information technology (electronic health records, e-prescribing, electronic billing, etc)

The Administrative Simplification section of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandates that the North Dakota Department of Human Services (DHS) adopt standards for health care information.

North Dakota has implemented these standards and is in compliance with the HIPAA regulation.

North Dakota does not currently use electronic health records or e-prescribing.

Transparent and publicly-accessible measurements of patient outcomes and/or quality improvements

North Dakota Medicaid has completed extensive research on other State Medicaid disease management programs and has released an RFP to allow for proposals from either Disease Management Organizations or local entities.

The health management program will be available to ND Medicaid Recipients with select chronic conditions (diabetes, asthma, chronic obstructive pulmonary disease and congestive heart failure) depending on the number of conditions the vendor will be able to include in the program within the available budget. These conditions were identified among the conditions resulting in the highest Medicaid costs.

Recipients enrolled in the health management program will receive disease management services at an appropriate level based upon their need (as determined through a claims-driven risk stratification process) and will have access to nurse case managers through a telephone health information line available during and after clinic hours. All activities will be conducted within evidence-based clinical practice guidelines and with physician oversight.

• Enhancement and strengthen provider and case management review process; 
• Increased staff time devoted to audit process;
• Use of technology to aid in review process;
• Focused on audit process for the quality assurance plan

Efforts to combat fraud and abuse

NDDHS and Medicaid have a Fraud and Abuse - Surveillance/Utilization Review Unit. The Department’s Surveillance/Utilization Review Section (SURS) is a federally mandated program that performs retrospective review of paid claims. SURS is required to safeguard against unnecessary and inappropriate use of Medicaid services and against excess payments. If the Department pays a claim and later discovers that the service was incorrectly billed or the claim was erroneously paid, the Department is required by federal regulation to recover any overpayment. Referrals are received from the following sources or processes: Providers, Clients, Departmental staff, Other agencies such as Medicare, Legislators, Private citizens, Internal data reports

When a desk audit is completed, SURS will determine the corrective action to stop an activity and recoup any overpayments. The process of a desk audit is: 

• Complaint or referral is received from one of the sources above.
• Analyst determines what time frame to review paid claims, i.e., 6 months, 12 months, 18 months, etc.
• History is pulled from paid claims data bank.
• Payment history is reviewed for patterns of misuse, over utilization or fraud. Services are reviewed for correctness and continuity for quality care issues. Professional consultants are used for quality, standards, appropriateness and ethics issues.
• Some cases may require obtaining records from a provider for further review. Some cases require on-site visits and audits.
• The SURS administrator normally will conduct the audits and reviews on-site, accompanied by other specialists, i.e., nurses, coding specialist, program administrators and consultants as needed.
• If the audit/review indicates a problem with quality care, procedures or policy issues without overpayment, the appropriate specialist or SURS administrator will talk to the provider/recipient to correct the problem.
• If there is an overpayment, the SURS administrator or analyst will calculate the overpayment.
• The administrator will process any forms, notices and other documents needed to notify the provider/recipient of the problem.
• The SURS administrator will compose a demand letter for recouping the overpayment.
• The SURS administrator will determine the cost effectiveness of pursuing claims under $50.
• Under the SURS administrator’s direction, provider overpayments can be recouped by adjusting current and future claims.
• The SURS administrator will set up a payment plan if full recoupment is not possible in one lump payment.
• The SURS administrator will determine if a case is to be turned over to a collection agency or legal entity for civil or criminal processing.
• The SURS section will track all payments and cases and update as needed.
• The SURS administrator acts as a consultant to the Medicaid Director advising him/her on penalties, sanctions, and corrective actions to take based on review outcomes.
• Medicaid and Medicare programs fall under the Office of Inspector General (OIG) and various regulations found in section 14 of Public Law 100-93 lists specific business practices that are allowed and are not subject to penalties. “Safe Harbor” provisions are codified at 42 CFR 1001.952.

What changes would you make to the federal Title XIX so that you could provide better services to individuals and families on Medicaid in your state?

• Allow for the focus on prevention and wellness of recipients. 
• Support the use of technology and compensate for the integration modern information technology systems.
• Empower individuals to take part in their own healthcare decisions. Emphasis on personal responsibility for individual behaviors and health status.
• Create incentives or requirements when appropriate for individuals to try home and community-based care before seeking care in an institutional setting.

What are your future plans?

• Offer a skilled (medical) service in the Medicaid Waiver for the Aged & Disabled; Adding additional (social) services to the Medicaid Waiver for the Aged & Disabled, if appropriation allows;
• Reviewing and/or implementing outcomes from Real-Choice Systems Change grant;
• Pursue consumer (self) directed care services;
• Continuous re-evaluation of quality assurance/quality improvement plan;
• Strengthen and streamline provider enrollment process