Comment #1: Concerns with MCOs Increasing Power of Oversight with Little Protection for Providers

Thank you for the opportunity to share feedback on the most recent draft of CPST - Community regulations. We appreciate several of the changes made including the provision allowing certain LMHP-Types to act as supervisors for a time and raising the number of units permitted each month for non-licensed staff. While we acknowledge that some beneficial changes for providers were made, our agency also has several concerns with some of the changes that were made, particularly the increased regulations surrounding MCO communication and oversight and the number of separate agencies who have been given regulatory power.

Concerns with increased requirements and regulations for interactions with MCOs

The increased requirements to contact and update MCOs (sections 3.2.3, 5.3.2, 5.5) are concerning due to the level of difficulty we have experienced attempting to contact and communicate with MCOs as well as the significant increase in documentation and administrative burden that this will add for staff. Often, providers are stuck in never ending phone trees that result in dropped calls, voicemails that are never returned, or overall inability to get ahold of MCOs (and specifically, Care Coordinators). We have also experienced where MCOs will not divulge Care Coordinator’s contact information until an authorization is in place due to confidentiality. 

Providers and MCOs will need a better plan for how to get ahold of MCOs, including increased accountability on MCOs to participate in this process. Please ensure that providers can contact MCO care managers in efficient ways to honor provider’s time and to specify that providers will not be held accountable by the MCOs if we cannot get hold of them. If contact with MCOs is not improved, this will negatively impact both providers and clients as it can lead to a delay in getting services started (especially if CPST providers must now also contact MCOs to explore EBP availability with other providers), and providers do not have an avenue for reimbursement for the time spent coordinating and attempting referrals. 

Additionally, the comment  in section 10.1 #6 about service authorizations potentially being removed as a requirement (similar to outpatient therapy where no pre-auth is required) is concerning, especially if the MCO can claim in a future audit or when reimbursement is submitted that an authorization was never in place. 

Here are the specific areas that we believe need to be addressed:

• Responsibility for securing referrals to EBPs should either be placed on the MCOs 

• -OR- CPST providers should be provided with efficient methods for securing reimbursement for the administrative time spent on care coordination as the reimbursement listed in the rate study is not sufficient for the requirements listed in the draft regulations.

• There needs to be a streamlined process for MCOs to be efficiently contacted for CPST and EBP referrals specifically. MCOs need additional accountability for providing efficient contact methods and ensuring appropriate response times for providers.

• To make coordinating services easier, MCOs should provide Care Coordinator information for CPST clients on the front end rather than requiring that an authorization be in place -OR- should have a dedicated CPST referral contact person (MCOs should not be permitted to gatekeep the Care Coordinator contact info until an authorization is in place). 

• If pre-authorizations are removed as a requirement, a registration process should still occur where providers can get an Authorization # and Units approved to help avoid lack of reimbursement during future audits or billing issues with MCOs. The agreement should document that providers are approved and authorized to bill for services.

DBHDS CAPS Submitted to MCOS (Section 7.1)

There are issues with the requirement that DBHDS CAPs must be sent to MCOs. This is concerning on multiple levels including but not limited to:

• DBHDS has a core focus on quality management and enforcing fidelity of services provisions, and CAPs are currently used to improve the quality of services. However, having every CAP reported to MCOs will lead to a lack of trust and fear between providers and DBHDS and likely decrease reporting areas of improvement needed and action planning to improve those areas. 

• Also, from experience with a variety of Licensing Specialists, the level of audits and attention to details varies greatly where some Licensing Specialists are more detailed and others are less. So, some agencies may receive CAPs from a more detailed auditor, while other agencies could have similar areas for improvement overlooked.

• Currently, we have a great licensing specialist who has used CAPs to help us improve our services and support clients better, but if there is now a fear of MCO involvement, it breaches that trust. The focus changes from improving services and recognizing areas of potential deficiency to preventing loss of funding (recoupments, additional audits from MCOs), that could negatively impact the stability of community programs for clients, staff, and agencies. Providers need close, safe, and trust-based working relationships with their DBHDS Licensing Specialists that can help find areas needing improvement without fear of MCO retribution. 

• Since DMAS is in control of funding and coordinating more closely with MCOs, it would feel more appropriate for DMAS auditors to issue CAPs that go to MCOs rather than DBHDS audits.

• MCOs will not use CAPs to help providers improve their services. It will only be setting up MCOs to find more ways to recoup funding and take back money than they already do currently. This is only harmful for providers, specifically those who are striving for compliance and who are actively making corrections.

Here are the specific areas that we believe need to be addressed:

• Only CAPS issued by DMAS should be sent to MCOs -OR- 

• Allow “good faith” and discernment for Licensing Specialists to decide if CAPs should be sent to MCOs. For example, severe compliance issues or fraud should be sent to MCOs, but areas where providers are showing “good faith” and attempting to abide by regulations, those CAPs should not be sent to MCOs.

Conclusion and Summary

At this time, it feels that significant power has been given to MCOs as many small requirements have been added onto providers, any of which can be used by MCOs to deny payments or justify audits. It does not seem like very many protections have been put into place for providers who are providing quality services. Even the CANs - Lifetime assessment, which was meant to offer standardized units and authorizations for providers and clients, has many potential issues with obtaining the assessment between agencies, accuracy, and frequency of recompletion without guaranteed reimbursement (Specifics will be listed in another comment from our agency). Please add more accountability for MCOs and protection for providers.