QI Corner

If you provide services to individuals involved in Medicaid programs within the State of Indiana, you should know that the State of Indiana is requiring both Managed Care and Managed Behavioral Healthcare contractors to be accredited by the National Committee for Quality Assurance (known as NCQA). The reason that this is important to know is that if you are providing services to members who are affiliated with the Hoosier Healthwise, Care Select or HIP programs there are certain NCQA standards that providers are expected to meet.

The State of Indiana FSSA/Office of Medicaid Policy and Planning Division requires the Hoosier Healthwise Managed Care Organizations to submit NCQA HEDIS reports to OMPP on an annual basis. Although MRO services are not reimbursed by the MCOs, the HEDIS measure allows for some of these services to be included when calculating follow-up rates after inpatient mental health admission. The State provides the MCOs with quarterly MRO claims data for the MCO’s membership in order for the MCOs to calculate HEDIS rates. The MCOs merge the MRO data with MCO and MBHO data and calculate follow-up rates using the HEDIS specifications. It is important to the State that members receive follow-up after hospitalization for mental health disorders and outpatient providers are encouraged to make sure newly discharged patients are seen within 7-days of discharge from the inpatient facility.

The HEDIS measure states that “for members being discharged from an inpatient psychiatric hospitalization, they must be seen for an outpatient follow up appointment within seven (7) calendar days from the date of the member’s discharge.”

In order to assess that members are receiving follow up care within seven (7) calendar days following a psychiatric hospitalization, Managed Care and Managed Behavioral Healthcare organizations use claims data. This will tell them the date of discharge from the inpatient facility along with the first allowed claims code for an outpatient visit (e.g. CPT Code 90801).

Some examples of service types that meet the requirement for the follow up measure are psychological assessments; individual psychotherapy; family/group therapy; and medication management visits with a behavioral healthcare provider. In addition, the following MRO services are allowed as follow-up services: H0004 – Individual Counseling and Therapy, per 15 minutes; H2011 – Crisis Intervention; H2014 – Skills Training and Development. Please note that Case Management Services are excluded per NCQA guidelines.

The State has identified Follow-up After Hospitalization for Mental Illness as a need for improvement due to fewer than 50% of members hospitalized for mental illness receive a follow-up visit within 7 calendar days of discharge. The State is tracking follow-up rates by region. Preliminary results show a notable increase in follow-up rates between 2008 (41.4%) and 2009 (47.4%). Still fewer than 50% of Medicaid members are receiving appropriate follow-up after discharge from inpatient mental health stays. These follow-up rates are influenced by services provided by outpatient providers, especially Community Mental Health Centers.

The State goal for this improvement project is “to improve the rate of follow-up at seven (7) calendar days to NCQA Medicaid 75th (57.4%) percentile for services incurred during CY2009. The final measurement data for CY2009 should be available in July 2010.

The official description for the measure is “the rate of follow-up after discharge from an acute inpatient admission for behavioral health diagnosis, with the follow-up rate at seven (7) calendar days post-discharge is reported. The member must have been enrolled in the program at time of discharge and for 30 calendar days post discharge to be included in the denominator. The member age on the date of discharge determines the age groupings.”

Many organizations and groups have initiated different programs and processes in order to improve access at their service locations. If you have developed a process that has improved access rates for persons being discharged from an Acute hospital at your facility or group, and are willing to share this with others within our Network, please contact us and we will publish your program in our next Provider Newsletter.

If you have any questions about this project, or NCQA standards, and/or are willing to share your successful interventions to improve access please contact Becca Sigafus at (317) 237-5773 or by email at Bsigafus@intecare.org.