Medical Services

Managed Care

State Plan Amendment - Title XIX of the Social Security Act

Supplement 9 - Monitoring Activities

The State utilizes a number of resources to monitor program compliance and operation as listed below. The State will assert its authority to utilize interventions as listed in Supplement 10 to correct any identified issues and ensure the standards listed below are maintained. It is the State’s policy to utilize the least intrusive (for both beneficiaries and providers) intervention(s) to achieve the desired result. However, the State will utilize any of the interventions available when, and if needed.

Standards

  • Access - The State ensures that managed care beneficiaries have appropriate access to covered services. Access is monitored through complaint resolution, surveys, change request reasons, and caseload monitoring.
  • Enrollee Rights - Beneficiaries are guaranteed rights as described in Supplement 4. Adherence to enrollee rights is monitored through complaint resolution, surveys and change request reasons.
  • Time and Distance Limits to PCP - All beneficiaries have a choice of at least two PCPs within 75 miles or 90 minutes. Beneficiaries may be removed from managed care restrictions if they do not meet these limits or demonstrate that time or distance factors limit their access to PCP services. Time and distance is monitored through surveys, change request reasons, and caseload monitoring.
  • Twenty-four Hour Access - Twenty-four hour accessibility to the PCP or designated covering provider must be available to all beneficiaries. Twenty-four hour access is monitored through complaint resolution, twenty-four hour surveys and change request reasons.
  • Appointments - Appointments for PCP services must be available to beneficiaries within reasonable waiting periods. Waiting periods for appointments are monitored through complaint resolution, surveys and change request reasons. Interventions are implemented when standards are not met.
  • In-Office Waiting Times - In-office waiting times for PCP appointments must be reasonable and should not be greater than waiting times for other patients. Waiting times are monitored through complaint resolution, surveys and change request reasons. Interventions are implemented when standards are not met.
  • Quality of Care - PCCM beneficiaries deserve the same quality services as all other patients. The State ensures this through the Methods listed below. Interventions are implemented when quality issues are discovered.

Methods

  • Quality of Care Studies - Effectiveness of Care Measures are utilized to evaluate and monitor a number of clinical standards such as but not limited to: immunization status, mammography screening rates, asthma control and follow-up after hospitalization for mental illness. The State utilizes the results of these studies to determine if quality interventions are needed.
  • Special Projects - The State periodically conducts projects to measure and improve access and quality of care. These projects are usually designed to determine the current status of a particular outcome or service, determine a goal for improvement, implement quality interventions to reach the goal and then measure the outcome. Projects differ from studies mainly by the longer duration, in-depth monitoring and aggressive and persistent interventions. An example of a special project is the GRPA immunization project which runs (ran) for four years from 2000 – 2004.
  • Complaint Resolution - The State utilizes the complaint resolution process to identify quality and (or) access issues. Most issues are specific to particular PCPs or recipients but some are more global in nature. The State applies interventions as needed to address the issues.
  • Recipient Surveys - The State surveys samples of managed care families regarding their general satisfaction of the program and specific information regarding their PCP. Approximately 1000 surveys are mailed per calendar year with historic response rates of approximately 40%. Interventions are implemented to address identified issues of concern.
  • Twenty-four Hour Access Surveys - The State makes telephone calls to PCPs during non-business hours on at least an annual basis. Follow-up calls are conducted for providers identified as deficient. Interventions (usually in the form of a corrective action plan) are implemented for providers identified as “not available” after two unsuccessful attempts to reach them. Further interventions are conducted for providers who continue to remain non-compliant.
  • Provider Surveys - Surveys are sent annually to PCPs and other providers requesting their views of the program. Information from these surveys helps the State with policy formation and the design of both provider and recipient educational material.
  • Caseload Monitoring - The State monitors PCP enrollment data each month utilizing a unique identifer to insure that capacity limits (750 per practitioner) are not exceeded, to ensure that recipients have appropriate providers and to ensure that sufficient numbers of PCPs are available within travel and distance limits. Interventions are implemented to correct any identified issues.
  • Change Request Monitoring - The State monitors all reasons beneficiaries give for changing their PCPs. This information is received via Change Forms. Although this SPA is removing mandatory lock-in provisions for all but a few beneficiaries, the State will request, but will not require, that beneficiaries list their reasons for changing PCPs. The State handles negative responses similar to the “complaint resolution” process by utilizing appropriate interventions.
  • Service Reviews - Selected inpatient claims are reviewed on a monthly basis by the South Dakota Foundation for Medical Care (SDFMC). This peer review organization conducts reviews to ensure appropriateness of admission, length of stay and discharge as well as DRG validation and the quality of care provided. Our consulting physician also conducts monthly reviews to validate the DRG assignment.

    The Surveillance Utilization and Review Sub-System (SURS) conducts reviews of billing and medical records to assure appropriate payment, ascertain compliance with rules and regulation, and detect fraud and abuse. Any quality of care issues that are identified or suspected are referred to the peer review organization for review and follow-up.
  • Additional Record Reviews - The State reserves the right to request billing and medical records when quality or payment concerns arise. The State may utilize medical and administrative staff to review the requested information to ensure that quality and billing standards are met. Interventions are utilized to correct any identified issues.