Contract Monitoring

Contract MonitoringContract Monitoring
Who, what, when and why?Who, what, when and why?

Contract Monitoring DefinedContract Monitoring Defined
 ContinualContinual processprocess ensuringensuring
compliance with the terms andcompliance with the terms and
conditions of the contact -conditions of the contact -
arrangement; typically consisting ofarrangement; typically consisting of
three components;three components;
 AdministrativeAdministrative
 Terms/conditions of contract (insurance,Terms/conditions of contract (insurance,
internal processes, HR)internal processes, HR)
 FiscalFiscal
 Invoices; billed amount within contract,Invoices; billed amount within contract,
 ProgramProgram
 Client eligibility, medical necessity,Client eligibility, medical necessity,
outcomesoutcomes

What’s new, we already do this…What’s new, we already do this…
 [I think] most experience is in[I think] most experience is in
managing contracts for discreet fee-managing contracts for discreet fee-
for-service arrangements; psychiatricfor-service arrangements; psychiatric
services and one payer…State/GR.services and one payer…State/GR.
 Sub-Contracting federallySub-Contracting federally
reimbursed services [with statereimbursed services [with state
match] adds a whole new dimensionmatch] adds a whole new dimension
to contract management.to contract management.

Give me one good reason forGive me one good reason for
Monitoring & Managing Contracts!Monitoring & Managing Contracts!

Ok, seriously, why?Ok, seriously, why?

Case & PointCase & Point
Krizek, MD (psychiatrist) (1997):Krizek, MD (psychiatrist) (1997):
 1986 to 1992 submitted 8,002 false1986 to 1992 submitted 8,002 false
claims resulting in $245,392claims resulting in $245,392
overpayment. Wife was billing.overpayment. Wife was billing.
 False claims: two issues; medicallyFalse claims: two issues; medically
unnecessary and up-coded.unnecessary and up-coded.
 90844 versus 9084390844 versus 90843
 ““Seriously deficient” record keepingSeriously deficient” record keeping
 Some claims over 21 hours.Some claims over 21 hours.
 ““Failed utterly” to review bills submittedFailed utterly” to review bills submitted
on his behalf…reckless disregard.on his behalf…reckless disregard.
 $5,745,000.$5,745,000.

Really…are they serious?Really…are they serious?
 TheThe
American Recovery and Reinvestment Act of 2American Recovery and Reinvestment Act of 2
(Recovery Act) provides the Department(Recovery Act) provides the Department
of Health and Human Services (HHS),of Health and Human Services (HHS),
Office of Inspector General (OIG), with $17Office of Inspector General (OIG), with $17
million in funding for oversight and review.million in funding for oversight and review.
The Recovery Act provided an additionalThe Recovery Act provided an additional
$31,250,000 to OIG for the purpose of$31,250,000 to OIG for the purpose of
ensuring the proper expenditure of fundsensuring the proper expenditure of funds
under Medicaid.under Medicaid.
 OIG will assess whether HHS is using theOIG will assess whether HHS is using the
$165.4 billion in Recovery Act funds in$165.4 billion in Recovery Act funds in
accordance with legal and administrativeaccordance with legal and administrative
requirements and is meeting therequirements and is meeting the
accountability objectives defined by theaccountability objectives defined by the
Office of Management and Budget.Office of Management and Budget.

Back to “what’s new?”Back to “what’s new?”
 We have traditionally been inWe have traditionally been in
the role of proving up our goodthe role of proving up our good
work. Our contract monitoringwork. Our contract monitoring
process focused on internalprocess focused on internal
controls; QM, Finance etc.controls; QM, Finance etc.
 LPND puts us in the role ofLPND puts us in the role of
proving up ‘their’ work.proving up ‘their’ work.
 Again, we take the money.Again, we take the money.

Come on…it is just DSHS!Come on…it is just DSHS!
 Who paid you toWho paid you to
do what and whatdo what and what
do they expect indo they expect in
return?return?
 PrivatePrivate
FoundationsFoundations
 StateState
 IRSIRS
 DOJDOJ
 GAOGAO
 OIGOIG
 CMSCMS
 Hi-Tech ActHi-Tech Act
 HIPPAHIPPA
 FCAFCA
 STARKSTARK

What needs monitoring?What needs monitoring?
 RelationsRelations
 Performance to include;Performance to include;
 Program/service deliverablesProgram/service deliverables
 Fiscal/financialFiscal/financial
 Record – keepingRecord – keeping
 BillingBilling
 SystemsSystems
 Quality ManagementQuality Management
 Utilization ManagementUtilization Management
 Human Resource ManagementHuman Resource Management
 Corporate ComplianceCorporate Compliance

How are other folks doing?How are other folks doing?
 March 2004; OIG assess the RyanMarch 2004; OIG assess the Ryan
White Care Act Title I & Title IIWhite Care Act Title I & Title II
[HRSA] grantees’ monitoring of ‘sub-[HRSA] grantees’ monitoring of ‘sub-
grantees’grantees’
 Findings:Findings: monitoring is limitedmonitoring is limited, 15, 15
of 20 granteesof 20 grantees did not havedid not have
comprehensive documentationcomprehensive documentation
demonstrating consistentdemonstrating consistent
monitoring activities.monitoring activities.

OIG recommended HRSA…OIG recommended HRSA…
 Set standards for monitoring sub-Set standards for monitoring sub-
grantees that, at a minimum requiregrantees that, at a minimum require
a formal agreement, program report,a formal agreement, program report,
fiscal report and schedule of sitefiscal report and schedule of site
visits.visits.
 Require grantees to report how theyRequire grantees to report how they
monitor their sub-grantees inmonitor their sub-grantees in
accordance with these standards asaccordance with these standards as
part of every applicationpart of every application
 Increase efforts to monitor granteesIncrease efforts to monitor grantees
oversight of sub-grantees…oversight of sub-grantees…

OIG Grants OversightOIG Grants Oversight
FrameworkFramework
 RequirementsRequirements
 ReportsReports
 ReviewsReviews
 EnforcementEnforcement

Who: What does a contractWho: What does a contract
manager look like?manager look like?

Is there a job title?Is there a job title?
 Should not beShould not be
one person butone person but
a coordinateda coordinated
effort to include;effort to include;
 RelationsRelations
 QMQM
 FinanceFinance
 ComplianceCompliance
 It is not a job, itIt is not a job, it
is a processis a process

EqualityEquality
 All providers within a network are reviewedAll providers within a network are reviewed
and treated the same by the LMHA/QM.and treated the same by the LMHA/QM.
 The same measures used for one providerThe same measures used for one provider
is used for the provider of the same serviceis used for the provider of the same service
whether they are external or internal.whether they are external or internal.
 If a provider is accredited or licensed byIf a provider is accredited or licensed by
another regulatory authority the scope ofanother regulatory authority the scope of
the authority review may change.the authority review may change.
 Can the provider demonstrate goodCan the provider demonstrate good
standing with an accrediting and/orstanding with an accrediting and/or
licensing body? If so, can all or some oflicensing body? If so, can all or some of
the provider services be ‘deemed’?the provider services be ‘deemed’?

WhenWhen
 Reviews may occur pre andReviews may occur pre and
post contract/opening.post contract/opening.
 Reviews occur postReviews occur post
contract/opening as regularlycontract/opening as regularly
scheduled reviews,scheduled reviews,
unannounced reviews or focusunannounced reviews or focus
reviews.reviews.

MonitoringMonitoring
 All materials required of the RFP haveAll materials required of the RFP have
been received and reviewed by the centerbeen received and reviewed by the center
contract holder. The proposal is complete.contract holder. The proposal is complete.
 Financial stability of the potential providerFinancial stability of the potential provider
has been reviewed and determined to behas been reviewed and determined to be
sound.sound.
 The contract holder notifies QM that aThe contract holder notifies QM that a
preliminary review of the provider capacitypreliminary review of the provider capacity
to meet standards and contractto meet standards and contract
requirements may be scheduled.requirements may be scheduled.
 QM assigns the contract review andQM assigns the contract review and
schedules with the provider a date andschedules with the provider a date and
time to conduct the review.time to conduct the review.
 The purpose of the review is twofold:The purpose of the review is twofold:
 Basic structure exists to meet contract?Basic structure exists to meet contract?
 Willingness to meet contract?Willingness to meet contract?

Post Contract ReviewPost Contract Review
 Immediate responsibility for compliance rests withImmediate responsibility for compliance rests with
the provider. All providers are required tothe provider. All providers are required to
demonstrate a process for internal accountability ofdemonstrate a process for internal accountability of
data and fidelity to service provision. This processdata and fidelity to service provision. This process
is shared with the provider’s contract holder,is shared with the provider’s contract holder,
manager and QM.manager and QM.
 All provider services should be reviewed on anAll provider services should be reviewed on an
ongoing basis by their manager and contract holder.ongoing basis by their manager and contract holder.
 All providers are placed on the QM review scheduleAll providers are placed on the QM review schedule
for external validation of internal methods offor external validation of internal methods of
accountability and service fidelityaccountability and service fidelity
 All reviews are conducted with an establishedAll reviews are conducted with an established
protocol developed by QM which may also be usedprotocol developed by QM which may also be used
by the provider, the provider’s manager/contractby the provider, the provider’s manager/contract
holder for internal management purposes.holder for internal management purposes.
 On at least an annual basis the provider’sOn at least an annual basis the provider’s
compliance with service standards, recordscompliance with service standards, records
standards, training, health, safety and advocacystandards, training, health, safety and advocacy
standards is verified by QMstandards is verified by QM

Post Contract contPost Contract cont
 Reviews may be triggered by dataReviews may be triggered by data
reviewed of ongoing service informationreviewed of ongoing service information
received by the manager and QM from thereceived by the manager and QM from the
provider.provider.
 High risk or persistent questions of serviceHigh risk or persistent questions of service
compliance may warrant an unannouncedcompliance may warrant an unannounced
or focus review of the provider.or focus review of the provider.
 Focus review are normally conducted byFocus review are normally conducted by
QM, however, a focus review may beQM, however, a focus review may be
requested of the provider as formatted byrequested of the provider as formatted by
QM or the manager.QM or the manager.

Integrate: Internal & ExternalIntegrate: Internal & External
 Ideally, the same process of review occurs forIdeally, the same process of review occurs for
internal and external monitors.internal and external monitors.
 The contract holder would monitor the provider’sThe contract holder would monitor the provider’s
adherence to contract requirements as an internaladherence to contract requirements as an internal
manager would monitor the compliance of anmanager would monitor the compliance of an
internal provider’s adherence to performanceinternal provider’s adherence to performance
contract requirements.contract requirements.
 Oversight and validation of this process isOversight and validation of this process is
conducted through QM. Risks to performanceconducted through QM. Risks to performance
contract requirements are identified as arecontract requirements are identified as are
corporate program compliance risks associated withcorporate program compliance risks associated with
state and federal healthcare compliancestate and federal healthcare compliance
requirements.requirements.
 The summary of data and reviews is collated,The summary of data and reviews is collated,
analyzed and shared with the Executive Director,analyzed and shared with the Executive Director,
Executive Staff and Center Board on a quarterlyExecutive Staff and Center Board on a quarterly
and annual basis.and annual basis.

What to monitor.What to monitor.
 The review process is formatted and has aThe review process is formatted and has a
protocol.protocol.
 The review process includes:The review process includes:
 Physical site reviewPhysical site review
 Policy and procedures reviewPolicy and procedures review
 Record structure reviewRecord structure review
 Staff training and credentialing reviewStaff training and credentialing review
 Debriefing with potential providerDebriefing with potential provider
 Plan of Improvement if neededPlan of Improvement if needed
 Scheduling technical assistanceScheduling technical assistance
 Formal review report to potential provider andFormal review report to potential provider and
contract holder recommending LMHA action.contract holder recommending LMHA action.

Steps to take:Steps to take:
 Develop policy – procedureDevelop policy – procedure
 Designate coordinator andDesignate coordinator and
appropriate department/staffappropriate department/staff
 Designate provider relationsDesignate provider relations
 Develop audit instrumentsDevelop audit instruments
 Develop monitoring calendarDevelop monitoring calendar
 Credentialing process toolCredentialing process tool
[initial][initial]

Contract Monitoring

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